Abstract
Over the past two years, the Department of Sexually Transmitted Infection Control Clinic (DSC) in Singapore has embarked on a programme to review and enhance its quality improvement programmes. A thorough review of its day-to-day operations was conducted, infection control processes and standard operating procedures. It capitalized on its use of computerized medical records to improve documentation and patient screening. DSC introduced risk-management protocols and revised patient, staff and workplace safety guidelines. These measures have resulted in benefits such as reduced prescription errors, fewer patient complaints and active clinical practice improvement programmes. In January 2008, DSC, along with its parent hospital the National Skin Centre, became the first ambulatory healthcare facility in Singapore, and also among the first few outside the United States to be accredited by the Joint Commission International.
Introduction
The Department of Sexually Transmitted Infections Control (DSC) is a public clinic that provides specialist care in the screening and management of patients with sexually transmitted infections (STIs) in Singapore. It was opened in 1991 and it plans and implements the National STI Control Programme. DSC is a division of the National Skin Centre (NSC), and also reports to the Ministry of Health (MoH). In 2007, the clinic had 29,650 attendances, 8972 of whom were new patients. 1
Joint Commission International (JCI) is a division of Joint Commission Resources (JCR), a not-for-profit affiliate of The Joint Commission. For more than 50 years, the Joint Commission and its predecessor organization have worked to improve the quality and safety of healthcare services.
Today, the Joint Commission is the largest surveyor of healthcare organizations in the United States, surveying nearly 20,000 healthcare programmes through a voluntary accreditation process. 2 The approach of the JCI is an organizational one with analysis of all systems of a healthcare organization. This approach has been compared and contrasted with four European-based quality assessment programmes.3,4
Previously quality assurance programmes have been focussed mainly on hospitals and nursing homes. With ambulatory care gaining prominence in most areas, implementing performance measurements in these settings has gained importance and urgency. 5
In2006, DSC embarked on a programme to review and enhance its quality improvement programmes. We completed a thorough review of our day-to-day operations, infection control processes, updated standard operating manuals and procedures, introduced documentation where needed, undertook extensive training and drills for staff, introduced risk management protocols and revised patient, staff and workplace safety guidelines.
In January 2008, the DSC and NSC became the first ambulatory healthcare facilities in Singapore, and also among the first few outside the USA to be accredited by the JCI.
Rationale for Clinical Excellence and Quality Programmes
There are many reasons for a healthcare organization to embark on a clinical excellence and quality accreditation programme.
Achieving accreditation is a strong validation that an organization has taken the extra steps to meet high levels of safety and quality. Achieving accreditation strengthens public confidence and is a clear demonstration to patients and community that an organization is committed to providing highest quality services. Such programmes help the organization strengthen improvement efforts by including principles and practices that help to continuously improve quality. They may improve access to, or reduce the cost of liability coverage by enhancing risk management efforts. Staff education is enhanced, as is the development of a culture where near misses are identified and analysed to prevent small errors from becoming tragedies, and enables a change of ingrained habits and behaviours. Accreditation programmes promote team building for staff and facilitates staff recruitment. Last, but not least, clinical excellence and quality programmes give a competitive advantage to an accredited organization and assists recognition from insurers, employers and other stakeholders. 6
This paper highlights the quality improvement measures introduced by DSC in its quality journey. It will focus on key aspects of patient-centred as well as management standards.
Ensuring Access to Care and Continuity of Care, and Safeguarding Patient and Family Rights
The DSC patient's charter was introduced to ensure access to and appropriateness of care and treatment irrespective of the patient's ability to pay, his or her social status, race, religion, sexual orientation, age or gender.
All patients, whether local or foreign, are charged the same subsidized rates for their consultation, investigations and treatment. Access and facilities for the disabled and elderly are readily available in the clinic and special operational guidelines are established within the clinic to ensure that they receive the necessary assistance during their time in the clinic.
DSC functions as a walk-in clinic in order to be accessible to the general public, and the clinic opens till late on certain evenings to cater to patients who are unwilling to take time off from work because of the nature of their medical problem. The clinic caters to sensitivities of females by running special clinics for women. Special physical arrangements and manpower resources are deployed to offer a private experience for the women attending the clinic.
The Electronic Medical Records (EMR) system was introduced in NSC and DSC in 2004 and was the first fully integrated EMR in Singapore. The system enables seamless and paperless patient care that has helped to improve coordination of care among healthcare providers, increased productivity and reduced medical errors.
All patient transactions are performed electronically from registration to pharmacy and billing. The electronic case file is accessible at all clinical stations. Clinical notes, order entries and laboratory results are updated in real time, facilitating a smooth flow of information between the various points of contacts that the patient has to make in a typical clinic visit.
The clinical management system allows clinical staff to monitor patient load and waiting times, staff workload/productivity, and there is a job stack module for the doctors. Clinical modules are integrated with backroom administration modules including inventories, purchase orders and the financial system.
Prescriptions are sent electronically to the pharmacy. The system alerts the physician to any possible allergies and also displays the price of medications. Critical medical information like chronic illnesses and drug allergies, are integrated and shared with all other public healthcare hospitals and clinics in the country.
Management of information policies are in place to ensure the security of the EMR system, and a security matrix coupled with regular audits ensures that only authorized personnel are able to access the EMR.
Assessment and Care of Patients
In reviewing the needs of our patients, the clinic revised its policy so that every new patient, in addition to having a history and physical examination that focussed on their presenting complaints, is also routinely assessed for the presence of pain, psychological needs, social and economic factors, educational needs, as well as nutritional and functional status.
Standard clinical templates are used for case-clerking, counselling and contact-tracing. DSC also adopts a standard abbreviations list on STI and medical terms. Defaulters can be easily tracked through, as follow-up dates are generated using the system.
For STIs that are painful, e.g. genital herpes, pain scores are documented, and a pain management plan is in place to deal with the pain, whether from disease or following investigation or treatment procedures. STIs are often associated with psychological distress and patients are routinely assessed on their response to their illness, and if they have any particular worries. A simple psychological assessment is done through a set of screening questions. Social and economic concerns, educational needs as well as functional and nutritional status are also assessed in this manner.
In view of the sensitivity that is often associated with a STI, the clinic provides patients an environment that respects their privacy and personal space. These include having notices to inform patients that they can request for added privacy anytime they feel uncomfortable. Queue numbers are used to identify patients, rather than calling them by name, in order to maintain anonymity. The physical layout of the clinic is designed to enhance patient privacy, such as the use of poster boards and well-spaced out seats to provide patients with adequate personal space. Staff are trained to speak in soft tones when attending to patients.
The clinic has protocols in place for patients deemed to require urgent medical attention. There is a triage and monitoring system to ensure that these patients, such as those with symptoms of pelvic inflammatory disease and epididymo-orchitis, severe genital herpes, or fever and pain are assigned priority numbers and their waiting time to see a doctor is maintained at less than two hours. Audits conducted in the last two years showed that 75% of all patients who are defined as requiring urgent medical attention are seen within 40 minutes, while the rest are seen within an hour. Operational guidelines including the allocation of specific room facilities for the care of different groups of vulnerable patients have also been established within the clinic. One example is the management of patients in police custody who wait in private areas. Another is the assessment of young patients, which involves assessing their ability to understand and give consent to investigations and treatment, and a one-on-one counselling on various aspects of sexual health and teaching negotiation skills.
Patient and Family Education
Barriers to learning are bridged as far as possible. Patient information leaflets (PILs) on some common infections, procedures and medications are made available in English, Chinese, Malay, Tamil and Bengali at the clinic waiting areas. PILs in Bengali were introduced as Singapore has a large population of foreign workers from Bangladesh. There are also Bengali translations on some commonly asked questions and answers for use in the clinic. Interpreters of various regional languages and Chinese dialects are also available to patients upon request. The clinic also captures the language spoken by patients, which is readily reflected in the computer system when staff is attending to these patients.
Counselling and contact-tracing remain integral aspects of overall patient care at DSC. They provide a valuable opportunity for patients to be actively involved in their plan of care, and instil in them a responsibility towards themselves and others. This is done in a friendly, non-confrontational manner by trained health advisors. DSC also maintains a list of relevant community resources that can be tapped upon for socioecono-mical and psychological support. This is to ensure that there is a continuous process of care provided to patients even when they become well.
Quality and Patient Safety
The Quality and Audit Committee was formed to oversee and direct quality programmes in the clinic. This committee reviews quality and appropriateness of clinical care, pharmacy practices, nursing care and laboratory procedures through Clinical Performance Indicators. It monitors and reviews adverse events, incident reports and near-misses through reporting systems and databases, nosocomial infections and medication errors.
The committee identifies system deficiencies and gaps in the delivery of patient care, develops strategies to prevent recurrence of adverse events, and ensures that corrective and preventive measures are properly instituted. It also directs periodic audits for key clinical procedures and areas of medical care and benchmarking processes of care with other reputable centres.
This committee is assisted by the Safety Committee that works to create awareness and promote patient and workplace safety and health in DSC. It reviews incident reports on patient and workplace safety and health issues, ensure that root cause analyses are adequately carried out.
DSC's quality culture focuses on systems rather than the efforts of individuals. Reporting of untoward outcomes by DSC staff is a non-punitive process. Professional misconduct and other disciplinary processes are distinct and separate from the quality and patient safety improvement process. We have adopted the PDSA (Plan, Do, Study, Act) cycle problem-solving approach to quality improvement. This approach has been incorporated into existing training programmes and system improvement tools.
One of the key indicators that the clinic uses is the rate of medication/dispensing errors at the pharmacy. Since the implementation of the EMR, the rate of any medication/dispensing error at the clinic has consistently been below 0.3% for the last three years, compared with 0.5–0.9% in the preceding three years. The majority of these errors were due to inadequate instructions (e.g. whether to take before meals), which were corrected and intervened at pharmacy level. Notably, there have been no cases of serious medical errors (e.g. patient being prescribed a drug he was allergic to) as the EMR requires all doctors to key-in their personal passwords a second time whenever it detects patients being prescribed medications for which an allergy has been highlighted in the system. Besides this first level of checking, the pharmacist is also alerted and can over-ride the prescription while personally checking with the physician. An audit trail of any intervention is created. There are policies in place that allow the pharmacist to escalate the matter to the head of the clinic if there are concerns that the prescribing doctor is refusing to heed any absolute contraindications highlighted by the system.
The following are important components of our quality and patient safety programme.
Clinical records review
Adherence to therapeutic guidelines and maintenance of good-quality medical documentation are enhanced through the clinical records review. Medical records of patients with a specific diagnosis are periodically peer-reviewed based upon a closed patient record review form. The quality of medical record documentation by doctors is also assessed on a peer-review basis. They receive regular feedback regarding the results of this audit and discrepancies are highlighted to the respective doctors.
Clinical practice improvement programme
The clinical practice improvement programme (CPIP) is a training programme for clinical leaders and managers on the principles, concepts and tools of continuous quality improvement. Participants are required to complete a project on clinical improvement and are supported by local facilitators and faculty until project completion. The duration of the CPIP programme is six to nine months with three key learning sessions – an introductory four-day training programme, followed by mid-point project review at three months and final project review at six or nine months. One such project was the setting-up of a nurse-led clinic to reduce waiting time for patients without symptoms, who came to the clinic for STI screening. Patients are able to access the full range of screening tests without having to consult the doctor. This has improved waiting times at the clinic and led to better patient satisfaction. Since the implementation of this particular project, the clinic has consistently managed to reduce waiting times for asymptomatic patients who attend the clinic for the sole purpose of STI screening by at least 50% for the past two years. Audits are conducted quarterly to ensure that these standards are being matched.
Incident reporting
Incident reporting (IR) is a voluntary reporting system for actual incidents and near-misses. This is a non-punitive reporting system. Reporting of medical errors, treatment, investigation and procedure-related incidents, sharps injury, staff or patient fall, safety and security, and environment incidents as well as ‘near-misses’ is encouraged to facilitate identification of areas for improvement and prevention of injury to patients. Reports are generated, and tabled at the Safety Committee for review and onward dissemination of findings. Since the inception of this non-punitive reporting system, the number of reports have increased from ‘nil’ returns in 2005, to seven incidents in 2007, which included two cases of falls within the clinic, two cases of patients feeling unwell after treatment was administered, two ‘near-misses’ in which the wrong treatment was almost administered and one case of a failure to act on an abnormal Pap smear result for two months before it was discovered in an audit. We believe that this active IR occurs because staff are convinced that the processes entailed in investigating these incidents benefit the clinic and ensure better patient safety.
Work improvement teams
The work improvement teams’ (WITs) programme teaches staff skills, creativity and problem-solving methodology to resolve work-related problems. DSC WITs teams have employed information technology to implement several new patient-focused initiatives. These include the use of personalized passwords for the release of laboratory test results over the telephone to patients, the use of short message system (SMS) technology to release outcome of tests to patients in bulk and a streamlined opt-out testing workflow for HIV testing. These new initiatives have enhanced the quality of service provided to patients and increased staff productivity. The clinic is now able to deploy its health advisors to do more face-to-face counselling instead of having one person constantly manning the telephone whenever a patient calls up for results.
Patient feedback
Patient feedback represents an important opportunity for DSC to identify and rectify gaps in our services. Capture of this information and the ability to categorize, analyse and prioritize key deficiencies is the basis for the development of this system. Patient feedback comes from various sources, including letters, feedback forms, telephone calls and emails. Patient satisfaction surveys are conducted routinely by the in-house corporate communications department, monthly parent organization surveys and annual national surveys. Service quality improvement has been the focus of quarterly staff gatherings and annual retreats for several years.
Infection Control
We introduced a comprehensive policy on prevention and control of infections. An infection control (IC) senior RN was trained in IC and given the responsibility to oversee IC procedures and audits.
The clinic identifies and tracks the patients with potentially infectious conditions fast, e.g. active tuberculosis, herpes zoster, scabies and allocates a holding area for them. It has policies on employee health, management of needle stick injuries, and management of blood and body fluid spills, and terminal cleaning. There are readily available spill kits in the clinic for use and staff is trained to handle spills competently. Each consultation room also has an additional sink with a sensor tap for patients to wash their hands before exiting. Hand hygiene is an important component of IC. Alcohol hand rubs are placed prominently in all waiting areas, consultation, treatment, counselling and registration areas for both staff and patients to use. Regular hand hygiene and IC audits and competitions are carried out to create awareness among staff.
Posters on the correct hand-washing techniques are displayed at all washbasins. All staff also participates in N95 mask-fitting exercises. There are also proper biohazard waste disposal guidelines established in the clinic and the securing of the bio-hazard bins to ensure that there is no access by the general public.
Facility Management and Safety
DSC conducts fire and emergency evacuation drills twice yearly and there is an appointed fire safety team that oversees these exercises, which are essential in preparing staff for emergencies. An emergency call system connects all the consultation, treatment and counselling rooms. ‘Code blue’ drills are conducted periodically to rehearse staff for medical emergencies. Environmental safety measures such as the storage of liquid nitrogen containers in an appropriate location to minimize accessibility by patients. Staff are trained to handle the topping-up of the liquid nitrogen with adequate personal protect equipments. Sharp containers are secured to the walls as a safety precaution in the treatment rooms.
In the laboratory, a monitoring system for critical equipments with the use of SMS alerts in the event of a machine breakdown or power failure has been implemented. The ventilation in the laboratory was also improved with the installation of an additional exhaust fan. There is also general improvement in housekeeping of the clinic with the adoption of the JCI standards. Stores and computer CPUs have been elevated above ground to enable easier cleaning which is in line with IC practices. Electrical wires were tidied up to minimize potential environmental and personal hazards to staff and patients. There are clear guidelines adopted for the storage of cleansing agents and items in the sluice rooms and toilets.
Staff Qualifications and Training
The Human Resources department performs primary source verification of employee qualifications, and is also responsible for training new employees. All new staff receive on-the-job training and must be certified to meet the standard job requirements before confirmation. Every staff member receives a job description that details the scope of duties, responsibilities and expectations. Staff members are continuously assessed on their competencies based on a set of pre-existing guidelines. Key performance indices for disease incidence, rate of condom use in regulated sex workers and contact-tracing have been recently reviewed.
We conduct monthly group discussions to ensure that staff members keep abreast with the latest developments in the field of STIs/HIV. The discussion takes the form of case presentations on medical or psychosocial issues, or journal club reviews. There are also opportunities for staff to attend local and overseas conferences and attachment programmes. DSC has also embarked on an electronic learning journey, which provides staff with a systematic learning framework to acquire or familiarize themselves with STI knowledge, skills and clinic operational guidelines. We are glad to note that even older staff members, who were by their own admission not ‘computer-savvy’, were able to adapt well after some initial resistance. The organization must recognize and address the initial anxiety that some staff might feel whenever a major change occurs.
The drive towards quality care is a continuous process, and requires ongoing commitment. Leadership is important and ensures that complacency does not set in. A sense of innovation and the drive towards continuous improvement in areas important to the organization and its patients must be fostered.
Conclusions
Improving quality benefits the healthcare organization, its patients and the community. The journey towards quality improvement and JCI accreditation has made us refocus our attention on patient safety issues, it has made us review our entire clinical and management operations, embedded policies and practices that take care of patient and family rights, and health education. It has also produced the beneficial effect of improving interaction and consultation among clinic staff who have learnt to work more closely together as a team. Quality of patient care has improved, and there are objective measures of these. Sustaining this practice will stand us in good stead as we look to the future. We therefore highly recommend other healthcare organizations to embark on quality improvement programmes and accreditation exercises of their own. While the initial start-up cost might appear prohibitive, we believe that the additional income generated, and savings incurred from its added efficiencies would go a long way in helping to pay for it. This has certainly been the case in our experience.