Report on Hospital Accreditation 2011-2013_Final

Chapter 6 | Recommendations and Improvements6.2.6 Review on the Use of High Strength Alcohol Solution for Cleaning Metal Surface It is a common hospital practice to use high strength alcohol solution for cleaning metal trolleys. The surveyors pointed out that high strength alcohol solution was a hazardous (volatile) chemical which posed occupational health and safety risk, and taking up valuable pharmacy time and space. There were alternatives which could be considered such as disposable alcohol wipe and detergent wipe. The TFIC advised that alcohol solution could be used for disinfection but not cleaning purpose. For cleaning of the metal surface, detergent and water could be used. Along the same line, Occupation Safety and Health (OSH) Team in Head Office commented that high strength alcohol had relatively low flash point and gave off inflammable vapours. Extensive use of alcohol spray / swab might expose staff to inflammable vapours over the statutory occupational exposure limit. To control the possible fire hazard and prevent over exposure, the use of spray bottle to generate alcoholic aerosol in general clinical setting should be avoided. As an improvement initiative, some hospitals have stopped the use of high strength alcohol solution or spray for cleaning metal surface and replaced with the disposal neutral detergent wipe or alcohol wipe.QUALITY TIMES • Issue 12 • Aug 2013 The Hospital Authority Periodic Publication on Quality Improvement for Healthcare ProfessionalsImprovement through Accreditation:Use of High Strength Alcohol SolutionCommon Practice vs Survey RecommendationsUse of high strength alcohol for “cleaning” the metal surface of trolleys is quite common in hospitals. Recently,accreditation surveyors have recommended replacing it with neutral detergent or disposal cleaning wipes for cleaningmetal surface in ward areas.Overseas Rationale and Local Advice STOPInternationally, use of high strength alcohol solution to “clean” metal surface liketrolleys is not recommended. Unnecessary use of alcohol for general “cleaningpurpose” poses occupational safety & health (OSH) risk of aerosol inhalation.Local experts came up with similar advice. The Chief Infection Control Office (CICO)said that alcohol solution should be used for disinfection but not cleaning purpose.Head Office OSH advised that high strength alcohol has relatively low flash pointand gives off inflammable vapour. Hence, extensive use of alcohol spray / swab mayresult in staff being exposed to the inflammable vapour over the statutory occupationalexposure limit. Also, to mitigate possible fire hazard and prevent over exposure, the use ofspray bottle to generate alcoholic aerosol in general clinical setting should be avoided.Examples of Initiatives in HospitalsPWH QMHWith the recommendation from Gap Analysis, PWH has For disinfection purpose:developed a poster to educate frontline staff for the useof alcohol only for disinfection purpose Replace high strength alcohol swab and spay with alcohol wipe for disinfecting dressing trolley. For cleaning purpose: Use neutral wipe for cleaning purpose. Editorial CommentsTake Home Messages With input of ACHS surveyors, infection control and occupational safety experts, we are now able to identify the most appropriate• Use high strength alcohol only for disinfection purpose, substance or method for cleaning and disinfection. We always not for cleaning. tend to believe that common practice, such as using high strength alcohol for cleaning metal surface, is the right practice. It is always• Do not use alcohol swab and spray, even for disinfection. difficult for us to critically examine or change a common practice if we believe that it is right. Fortunately, the accreditation survey conducted by independent external peers can help to achieve this “impossible goal” of discontinuing the improper use of high strength alcohol for cleaning purpose. Mr. Daniel LO Senior Manager (Allied Health), HAHO Full report is accessible at HA intranet (under “Highlights”)Editorial Board Members: Dr K S LIU SD(Q&S), HKEC Advisor: Dr K H LAU ASD(Q&S), HKWC Dr Lawrence LAIDr Alexander CHIU CM(Q&St), HAHO Dr Y W TSANG Con(Path), QEH Hon. Senior Advisor(Q&S), HAHODr Ian CHEUNG CM(CE&TM), HAHO Dr N C SIN CSD(Q&S), KECMs Susanna LEE M(N)/CNO, HAHO Ms K P WONG CM(Q&S), KWC Comments are welcomeMr Daniel Lo SM(AH), HAHO Dr Michael CHEUNG C(CS), NDHMr William CHUI Hon Assoc Prof/CSC(PHAR), HKWC Ms Bonnie WONG CM(Q&S), NTWC Please email us through HA intranet at address: HO Quality & Standards Department 49

Chapter 6 | Recommendations and Improvements 6.2.7 Review on the Practice of Multi-dose Medication It was noted that some medications like insulin and eye drops were multi-dose for multi patients. Surveyors commented that such practice presented infection control risk. The international best practice recommended no multi-dosing of medication between patients. If single dose vials were not readily available, the medication should be dispensed for individual patients and discarded on discharge. Local expert advice from TFIC opined that sharing vials or topical eye medication between patients was not recommended as it might increase the risk of cross contamination. Single use medication or use for the same patient was preferred. However, the cost implications and practicability of single dose medication had to be considered. In view of the significant organisation and financial implications, Department of Quality & Standards, HA Head Office would further liaise with stakeholders, including TFIC, Medication Safety Committee, Chief Pharmacist Office and hospitals to deliberate the current practice of multi-dose medication and propose the corporate direction for HA. 6.2.8 Minimising Misidentification Risk – Using Full Term for Booking Operations To enhance patient safety, clear documentation and minimal abbreviation is encouraged. As the Operating Theater Management System (OTMS) is allowing free text entry, it is difficult to enforce no abbreviation in the entry, especially the operation name and the side indicator. The OTMS Committee was liaised and initial enhancement was done to ensure the side indicator of operation should be printed in full term, i.e. Left/Right/Bilateral instead of L/R/B. Continued efforts will be made to encourage input of preoperative diagnosis or procedure in full description.50

CCREDITATIONACCREDITATIONTPATITIOANLTATIO CHAPTER 7 ACCREDITATION Hospitals SharingHOSPITAL ACCREDITATIONTION HOSPITA7L.1 Caritas Medical Centre HOSPITAL ACCREDITATIONITAL ACCREDITATION 7.2 Kowloon HospitalN 7.3 North District HospitalL ACCREDITATIONEDITATION 7.4 Our Lady of Maryknoll HospitalCCREDITATION 7.5 Pok Oi HospitalAL ACCREDITATION ACCREDITATIONDITATION 7.6 HPrOinScePoITf AWLaleAsCHCoRspEitDalITATION HOSPITAL ACCREDITATION 7.7 Pamela YHouOdSePNIeTtAheLrsoAlCe CEaRsEteDrnITATIONCREDITATION Hospital HOSPITAL ACCREDITATION 7.8 HQOuSeAePCnCIRTEElAAiDzLIaTCAbTACeItOChRNCHERHoEDsOpDIitSITaTlPAATITTIOIAONL HOSPITAL ACCREDITATION 7.9H OSQPueITeAn LMaAryCHCoRsEpiDtaIlTATION ACCREHOSPITAL ACCREDITATION HOSPI ATION HOSPITAL ACCRED 7.10 Tuen Mun HHoOspSitaPl ITAL ACCREDITAAL ACCREDITATION HOSPITALACCREDITATION 7.11 Tung Wah Hospital 7.12 United CHhHOriOSstPSiaITPnAIHLToAAsCLpCitRAaElCDCITRAETIDOINTATIONL ACCREDITATION HOSPITAL ACCREDITATIONEDITATION HOSPITAL ACCREDITATION ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCREDITATIONHOSPITAL ACCREDITATION HOSPITAL ACCRE HOSPITAL ACCRALTCATACIOCRNCERHEDODISITTPAATITTIOIAONL ACCREDITATIONACCREDITATION HOSPITAL ACCREDITATION

CHAPTER 7 Hospitals Sharing This chapter is contributed by hospitals which had their surveys during the report period from April 2011 to March 2013. Their sharings focus on three areas: recommendation and improvements, staff engagement and communication; and learning and sharing. 7.1 Caritas Medical Centre 7.1.1 Recommendations and Improvements CRITERION RECOMMENDATIONS IMPROVEMENTS 1.1.3 CMC develop a practical Consumers/ guide to define procedures • Implemented the HA Policy on Safety Bedside patients are and interventions that can informed of be performed in wards Procedure in August 2011. Compliance audit the consent and specialist outpatient of the Safe Surgery Practice on Interventional process, departments for which (Department of Radiology and Combined understand and documented consent is Endoscopy Unit) and bedside procedures (in provide consent required. wards) were conducted in April 2012, with overall for their health CMC should work with HA to compliance rate 95% and 98% respectively. care identify the best practice for documentation of the name • Developed and implemented a “Guideline on and site of the operation/ procedure on consent management of abbreviations in CMC” on 30 August forms, working towards the 2012. All clinical departments including Allied Health elimination of the use of also developed their Departmental Abbreviation abbreviations on the consent Lists. Subject officers of respective departments/units forms. This applies to both are responsible for updating the list periodically. operative site and the name of the procedure. • Department of Medicine and Geriatrics had developed and piloted seven types of pre-filled consent forms in Chinese and English versions, namely (1) Blood transfusion; (2) Computed tomography with contrast; (3) Oesophagogastroduodenoscopy; (4) Colonoscopy; (5) Endoscopic retrograde cholangiopancreatography, (6) Endoscopic ultrasound; and (7) Transcatheter arterial chemoembolization. Contents of pre-filled information include full name and site of procedure; potential risks; alternative option(s) and title of the respective patient pamphlet / fact sheet. The captioned forms will be implemented in the whole hospital in 3Q 2013.52

Chapter 7 | Hospitals SharingCRITERION RECOMMENDATIONS IMPROVEMENTS1.5.1. Work towards increasing theMedication medications managed by • Pharmacists had reviewed the ward drug stock itemssafety Pharmacy in wards so that storage, labeling and alerts for a number of wards/ units, including Emergency are consistently managed. and Medicine ward, Operating Theatre, Surgical wards, Pediatric wards, Orthopedic ward, and Developmental and Disability Unit. Up to March 2013, 17% (73 out of 428) ward stock items were reduced in these wards. • Alert labels for High Risk Medications & warning labels for Penicillin-group allergy were standardised in Department of Emergency and Accident, Emergency and Medicine ward, Operating Theatre, Surgical wards, and one Paediatric ward. Tall Man Lettering DOPamine Inj. 40mg/ml in 5ml DOBUTamine Inj. 12.5mg/ml in 20ml Adhere to Plastic Bag Label ALERT ! High Risk Medication Alert labels and Tall Man Lettering for High Risk Medications1.5.2 While there is still a need • Upgraded low-tempInfection to continue high levelcontrol disinfection of items used for sterilizer and sterilizer & sterile cavities, ensure that washer disinfector. the most effective and safe method is being used e.g. Steris vs. Cidex. Low-temp sterilizer 53

Chapter 7 | Hospitals SharingCRITERION RECOMMENDATIONS IMPROVEMENTS1.5.2 Develop a plan to eliminateInfection the use of Cidex in all but • Installed an Automatic Endoscope Reprocessor (AER)control closed systems. device for OT. • An AER (closed system) is available in CEU for reprocessing endoscopes by Cidex OPA. The elimination of flash • Total eliminate of flash sterilization of implant and sterilisation. The reduction of the use of related instruments. linen for wrapping trays and bundles. • Piloted \"KIMGUARD\" wrapping paper for instruments lighter than 2.72kg in OT with satisfactory outcome. • Trial on users’ handling and logistic process of non-woven fabric packs is satisfactory. Complete replacement of reusable Linen Wrapper 122x122cm with single-use non-woven fabric of 10 items will take effect starting 1 May 2013. Develop and implement a • Renovation work was done in Dental Unit, EDS and plan to separate the clean and dirty areas in Eye Day Surgery CEU to divide the clean from dirty area. (EDS), the Dental Clinic and Combined Endoscopy unit (CEU). Renovation works done in CEU54

Chapter 7 | Hospitals Sharing7.1.2 Staff Engagement and Communication Briefings were conducted for CMC staff in preparing for the Periodic Review (PR) 2012, including PR timeline, OWS recommendations and follow up improvements taken, standards and elements of 15 mandatory criteria.To boost staff morale in preparing for PR, hospital executives including Dr. H C Ma, HCE, Ms.Wena Pang, GM(AS), and Mr. Andrew Yeung, GM(N) paid a visit to all wards/departments/units to deliver a souvenir (new ‘Staff ID card holder’) to all CMC staff.Staff ID card Development Disability Unit Department of Pharmacy 55

Chapter 7 | Hospitals Sharing Department of Surgery A ‘Celebration Party for ACHS PR Survey cum Mid-Autumn Festival 2012’ was launched to commemorate CMC’s achievements and express gratitude to all staff for their hard works and commitment in the PR. 7.1.3 Learning and Sharing CMC Q&S Newsletter was published quarterly to share about the ACHS survey, for examples: • Major changes of ACHS EQuIP 5 • Introduce the HA e-CQI system for registry of improvement projects • Message from Dr. H C Ma, HCE to thank all CMC staff for their dedication and efforts in achieving the gratifying result in the ACHS PR survey • Key improvement plans following PR Caritas Medical Centre Caritas Medical Centre Caritas Medical Centre Quality and Safety Newsletter Quality and Safety Newsletter 17th Issue published in August 2012 Editorial Board: Dr. Y K Chan, Hospital Coordinator, Q&S, Ms. Betty Au Yeung, SNO, Q&S, Ms. Cecilia Yeung, HA (P&C) & Ms. Jessica Kong, APN, Q&S. 15th issue (Publish in December 2011) 18th issue (publish in January 2013) Editorial Board Editorial Board: Dr. Y K CHAN, Hospital Coordinator, Q&S; Ms. Betty AU YEUNG, SNO, Q&S; Ms. Cecilia YEUNG, HA (P&C); Ms. Jessica Dr. Y K CHAN, Hospital Coordinator (Q&S) Ms. Cecilia YEUNG, HA (P&C) KONG, APN, Q&S; Ms. Evelyn HO, APN, Q&S; Ms. Teresa CHAN, RN, Q&S; Ms. Klasse LAM, CMC EOII(PRO) Ms. Betty AU YEUNG, SNO (Q&S) Ms. Fanny NG, SNO (PRO) Key Improvement Plans following ACHS Periodic Review 2012 Ms. Teresa CHAN, RN (Q&S) Enquiry / Feedback: Ext. 7990 (OSH) 1.1.3. Consent Process • Use separate consent form for blood transfusion prior to operation Ms. Melody CHAN, RN (Q&S) 7890 (PRO) • Explore the use of pre-printed consent form for selected high volume procedures 7969 (Q&S) to improve documentation and eliminate the use of abbreviations in consent form The ACHS Periodical Review 1.1.8. Health Record Documentation Dear Colleagues, Message from HCE (PR) will be conducted in CMC • Conduct audit on patient medical record, including content and use of staff chop from 30th July to 3rd August What is HA CQIs? • Develop departmental abbreviation list (for clinical documentation) including Allied Health I am glad to inform you that after the concerted effort by all staff in preparing for the ACHS 2012 by 6 ACHS surveyors periodic review, CMC has been granted 11 Marked Achievements (MA) and 4 Extensive (including local surveyors). It is an electronic Continuous Quality Departments Achievements (EA) on the 15 mandatory criteria following comprehensive scrutiny of the Improvement Initiative System (CQIs) Hospital by the surveyor team. Starting from January 2012, ACHS will base developed by HAHO for users to input their 1.1.5. Clinical Handover, Discharge and Transfer on the EQuIP 5 to conduct hospital survey. improvement projects. The system enables • Pilot the use of action slip for clinical handover in acute wards I would like to thank all staff for your dedication and efforts in achieving this gratifying result The key revisions are as follows: users to track, monitor the progress their for the Hospital. I am very proud of you all and I think you deserve the credits made by the projects and serves as a sharing platform of 1.5.1. Medication Safety surveyors on various aspects of our hospital’s services. Just like to re-quote the following 1.5.1 “Medication safety” - change to good practices amongst HA hospitals. The • Review the ward drug stock management slogans as my token of appreciation: “當年認証顯眾志，今日覆核更齊心”. mandatory criterion. system has been interfaced with the HA • Repeat the documentation audit of MAR forms Convention website for submission of abstract • Develop a new CMC guideline on handling of dangerous drugs for the whole hospital, including Dr H C Ma, HCE 1.5.7 “Nutritional need” - new criterion paper. Starting from 2012, all survey documents will have to be submitted to ACHS Operation Theatre (O.T.) 2.1.3 Split into two separate criteria. via this local platform. 各位同事 醫院行政總監的話 2.3.1 2.1.3 “Incident Management” 1.5.2. Infection Control 2.1.4 “Complaint Management” • Eliminate linen wrapper for O.T. instrument sets • Explore the use of multi-dose vial for individual patient 我高興地告知大家，經全體員工的共同努力去準備今年的澳洲 Split into two separate criteria. • Eliminate the use of alcohol for swabbing dressing trolley 醫療服務標準認證中期覆核後，明愛醫院在十五條必達準則 2.3.1 “Health Records” (Mandatory Criteria) 中 共 有 四 條 準 則 獲 評 定 為 優 異 級 別 2.3.2 “Corporate Records”. 1.5.6. Correct Surgery [Extensive Achievement (EA)] 。 • Develop a new generic O.T. count sheet in line with international (ACORN) standard 2.3.2 Combine into one criterion - & 2.3.3 “Data & information”. 3.1.3. Credentialing • Review CMC policy or Committee terms of reference so as to clarify the respective roles and 2.3.3 responsibilities of COS, MAC and HR in the area of monitoring and review of clinicians’ performance Access to HA CQIs and the system for defining the scope of clinical practices 我感謝所有員工為本院所付出的奉獻和努力,從而取得可喜的成果。我很為你們感到 From CMC intranet website: 3.2.4. Emergency and Disaster 驕傲。評審員在本院各方面的服務評價甚高，相信大家的努力是實至明歸。我再次 1. Click ACHS at Quick Links • Implement a guideline that defines the accountability of staff supervising the NEATS 引述口號 “當年認証顯眾志，今日覆核更齊心”以作謝意。 2. Click CMC transport waiting room and which includes the roles of the porters 3. Click CQIs (Quality Initatives) • Standardize the content and layout of emergency trolley and transfer bag 醫院行政總監 馬學章醫生 • Establish dedicated systems for adult and Paediatric resuscitation equipment From HA Internet website: to ensure that required resuscitation equipments are readily available in all 1. Click HAHO emergencies 2. Click Quality and Safety 3. Click CQIs (Quality Initiatives) Login ID & password as your email account56

Chapter 7 | Hospitals Sharing7.2 Kowloon Hospital7.2.1 Recommendations and Improvements Five priority areas were identified during the accreditation journey in Kowloon Hospital (KH). Improvement projects were initiated to close the gaps. (i) Lack of Document Control System for Policies and Guidelines • Key improvement: –– Establishment of KH document control system in accordance withprevailing document control policy in Kowloon Central Cluster (KCC). • Follow-up actions: –– Set up of Document Control Committee (DCC) co-chaired by the Director of Q&S and the SNO(NS&A and Q&S) and comprised of clinical and non-clinical representatives. –– Appointment of the Hospital Information & Records Manager as the Administrator of the KH Document Control Centre to manage the ‘Public Controlled Documents’. –– Appointment of Document Control Officers from various departments to help to maintain the departmental documentation system. Training was provided to equip them with the skill and knowledge to upload and edit information from the document centre. –– Briefing sessions were organised to introduce the document control system to frontline staff. • Progress & outcome: –– A governance system regarding documentation was formulated. The KH DCC was set up in November 2012 with its Terms of Reference endorsed by KH Quality & Safety (Q&S) Committee. –– A document control system in accordance with the KCC Document Control Policy was established in March 2013. The KH Document Control Centre was developed in April 2013 and served as a platform to facilitate staff in uploading and retrieving information of various types for clinical and administrative service needs. 57

Chapter 7 | Hospitals Sharing • Future plan for improvement: –– Compliance audit on controlled document would be arranged according to hospital audit plan. (ii) Lack of Standardised Practice of Documenting Open Disclosure of the Incident in the AIRS Report • Key improvement: –– Standardised practice of documenting open disclosure of the incident in the AIRS report. • Follow-up actions: –– KH Q&S Office to review all available guidelines and standard operating procedure in HAHO related to the subject. –– KH Q&S Office to develop KH guidelines in accordance with the KCC ‘Guidelines in Open Disclosure of Incidents’ included in the KCC Patient Safety Program 2012. –– Training sessions with demonstration of documentation on AIRS regarding open disclosure were organised to frontline staff. –– CQI Forum on incident management and open disclosure was conducted and related information was provided during staff orientation.58

Chapter 7 | Hospitals Sharing • Progress & outcome: –– KH Guideline on Clinical Risk Management was developed in March 2013 and a section on open disclosure was included. –– Process and content of communication on open disclosure are documented in patient’s record. –– Outcomes of incident investigation were shared amongst staff during department meeting, nursing meeting, CQI Forum, cluster Q&S officer meeting, etc. –– Strengthening of the culture of open disclosure amongst KH staff. • Future plan for improvement: –– Compliance audit on open disclosure will be arranged according to hospital audit plan.(iii) Lack of Comprehensive Nursing Assessment and Care Plans to Address Patient’s Needs Upon Admission and During Hospitalisation • Key improvement: –– Development of a generic nursing assessment form and care plan which includes assessment of 12 dimensions of patient’s needs in accordance with KCC Policy on Patient Assessment. • Follow-up actions: –– A nursing task group was formed with representatives from clinical departments in the design and implementation of the generic and specific nursing assessment and care plans. –– Briefing sessions were conducted to introduce the generic nursing assessment form and care plan to frontline nurses. –– Audit to evaluate the effectiveness and staff competency in completing the generic nursing assessment form and care plan was conducted in December 2012. 59

Chapter 7 | Hospitals Sharing –– Feedback from frontline nurses on the generic nursing assessment form and care plan was collected. • Progress & outcome: –– Audit result showed over 90% of compliance rate for each dimension indicating good applicability of the generic nursing assessment form and care plan. Overall, positive feedbacks were collected from nurses. –– Areas of non-compliance were addressed and the generic nursing assessment form and care plan were reviewed in March 2013 according to the feedbacks. • Future plan for improvement: –– The revised generic nursing assessment form and care plan were endorsed in KH Nursing Committee in August 2013. On-going staff compliance audit will be conducted to evaluate the effectiveness of the revised form and care plan. –– Development of specific nursing care plans for particular patient groups was underway and 5 nursing care plans for patients having halo jacket, low back pain, lower limb amputation, hip operation and stroke had been drafted.60

Chapter 7 | Hospitals Sharing(iv) Lack of Standardisation of Medical Record Forms in Clinical Departments • Key improvement: –– Standardisation of medical record forms in clinical departments in accordance with HAHO Manual of Good Practices in Medical Record Management. • Follow-up actions: –– A task group was formed with representatives from clinical departments. –– Stocktaking of all medical record forms was conducted to eliminate obsolete forms. –– Generic medical record forms were formulated for use across departments to reduce numbers of forms. –– Re-sequencing of the medical record forms by type and category. –– Consolidation of the medical record forms and a master list was kept by KH Medical Record Office (MRO). • Progress & outcome: –– Implementation plan by 3 phases were worked out with clinical departments in January 2013. –– Approval obtained from hospital management for funding support to outsource contractor for form design and printing logistics. • Future plan for improvement: –– All KH medical record forms will be centralised and stored under management of KH MRO. 61

Chapter 7 | Hospitals Sharing (v) Lack of Physical Demarcation of the Clean and Dirty Zone in the Bronchoscopy Room • Key improvement: –– Improving the physical demarcation of the clean and dirty zone in the bronchoscopy room in accord with prevailing infection control standards. • Follow-up actions: –– Submission of project for funding support by CWRF Head 708 SH8100MX in July 2012. –– Approval of funding was obtained in March 2013. –– Work improvement plan was submitted to KH Facility Management Section for discussion with contractor and relevant parties. –– Work improvement plan was confirmed and renovation plan was worked out with COS and concerned staff. • Progress & outcome: –– Improvement works for physical demarcation of the clean and dirty zone to be commenced on 30 September 2013 and will last to 17 November 2013.62

Chapter 7 | Hospitals Sharing7.2.2 Engagement and Communication Since the kick-off ceremony for hospital accreditation of KH ( 承先啟後 , 薪火相傳 ) was launched in February 2012, a series of staff engagement activities for the KH Quality Journey have been organised in various departments. The aim is to improve patient care through hospital accreditation. Our slogan for hospital accreditation (in Chinese: 醫院認證齊 做好，服務市民質素高 ) has been selected among hundreds of participants to raise staff awareness of the purpose of hospital accreditation. Staff engagement activities include talks, seminars, department visits by Accreditation Project Team (APT) members ( 建立團隊，上下一心 ), CQI sharing forums ( 互相欣賞，分享成果 ), meetings, and carnivals. Through these events, staff members are better informed of the EQuIP standards. Trust and mutual understandings are cultivated through these activities. Guests from other hospitals which have gone through hospital accreditation are invited to share their experience. We have learnt much from them in our preparation for hospital accreditation. Furthermore, top management in KH has been invited to participate in several role plays to promote knowledge on work safety in particular for the supporting staff group. The video clips of the role plays are shared during the staff engagement activities. After much preparation, the Gap Analysis by ACHS Consultants ( 謙卑學習，努力改進 ) was carried out in October 2012. Feedback from various staff after Gap Analysis were encouraging and positive. They shared the understanding and enthusiasm that KH Quality Journey towards hospital accreditation would ultimately improve patient care. Staff have become more confident in preparing the coming Organisation Wide Survey ( 專業水 平，邁向國際 ) which would be conducted from 18 to 22 November 2013. 63

Chapter 7 | Hospitals Sharing Summary of Quality Journey towards Hospital Accreditation in Kowloon Hospital: 承先啟後，薪火相傳 (through kick-off ceremony for hospital accreditation ) 建立團隊，上下一心 (through department visits and support by APT members) 互相欣賞，分享成果 (through CQI Sharing Forums) 謙卑學習，努力改進 (through Guests Sharing and Report of Gap Analysis) 專業水平，邁向國際 (through Organisation Wide Survey) 7.2.3 Learning and Sharing Since the kick-off ceremony for hospital accreditation of KH in February 2012, a series of events have been organised by various departments to raise staff awareness and to engage staff for hospital accreditation. These activities include department visits by APT members, CQI forums and staff briefings. After much preparation, the Gap Analysis by ACHS Consultants was carried out in October 2012. Staff feedback was collected using a questionnaire and a video clip was taken to share staff feelings and experience about gap analysis. Some staff expressed that they felt worried, excited and a bit nervous because of the increased workload and lack of understanding of the EQuIP Standards. Others thought that hospital accreditation was worthwhile for quality and service improvement. It was also interesting to find that staff had good impression of the ACHS Consultants and see them to be friendly, nice, practical, realistic, reasonable and professional. Overall, the feedbacks from various staff was encouraging and positive. After receiving the Gap Analysis report of KH, we held several staff briefing sessions to explain the findings, mainly for learning purposes. All rank of staff were better informed of the suggestions and recommendations given by the ACHS Consultants and better prepared for the coming Organisation-wide Survey which would be conducted in November 2013. Culture building and staff engagement ( 薪火相傳 ) Accreditation Project Team & Quality Champions64

Chapter 7 | Hospitals SharingTo sustain the momentum, staff engagement activities will be continued for the KH QualityJourney. A summary of the events and number of participants is listed in the table.EVENTS (December 2011 to March 2013) NUMBER OF ACTIVITIES NUMBER OF PARTICIPANTSKick-off Ceremony 1 100Department Visit 13 347CQI Forum 8 596Staff Briefing before Gap Analysis 22 1009Staff Briefing after Gap Analysis 60 994Visit to Department of Respiratory Medicine Hospital Visit by ACHSGap Analysis CQI Sharing Forum 65

Chapter 7 | Hospitals Sharing 7.3 North District Hospital 7.3.1 Recommendations and Improvements (i) Clinical Handover & MEWS To enhance continuity of care and maintain patient safety, the importance of shift-to-shift clinical handover within healthcare professionals has been recognised in North District Hospital (NDH). In September 2012, a taskforce of clinical handover consisting of doctors and nurses was set up to review current practice and identify the barriers to effective intra-departmental handover. Several pilot surveys were conducted in medicine, surgery and orthopaediac departments. As a result, the flow of communication on handover among clinicians was revised and redesigned, and the mechanism was tailored to suit the needs of the clinical characteristics of individual department. In addition, tools for clinical handover, like specific record and white board were developed to enhance effective and formal communication between doctors and nurses. Content of clinical handover was clearly defined, which included important items like existing problems/ potential risks; treatment/care plan as well as follow- up arrangement. Moreover, Modified Early Warning Score (MEWS) was implemented in all clinical wards for early detection of the deteriorating patients. NDH recognised the importance of cultural cultivation in service improvement, and a conscious effort was made to promulgate the concepts and framework of the new clinical handover process. It was done through staff engagement activities, such as road show and game booth. Feedback and comment from frontline doctors on clinical handover was collected and analysed to allow better execution of the practice under daily clinical settings. Knowledge on MEWS was also enhanced through these events. Effectiveness of the new clinical handover practice was constantly reviewed and improved as required at individual departmental and hospital management level. The next step would be the interdepartmental handover (A&E – general ward – ICU), and it would be reviewed and piloted in 3Q 2013. Bedside handover with the aid of handheld device as well as advanced staff training workshop in clinical handover communication skills would be explored.66

Chapter 7 | Hospitals Sharing(ii) Clinical Documentation and Medical Records Maintaining accurate and reliable clinical documentation is one of the core professional responsibilities. It is the central platform for record keeping of diagnosis, symptoms, treatment plans, arranging procedures as well as serving as a host of a countless list of care process. Good clinical documentation allows healthcare providers to have effective intra/inter-disciplinary communication, clearer picture for data reviewing, more accurate coding, and facilitates adherence to protocol and tracking of progress in clinical research. A good practice of documentation is essential in quality patient management. Hence, a series of clinical documentation improvement programs was implemented from 2011 to 2013. First of all, NDH clinical standard of Intermittent Peritoneal Dialysis (IPD) was revised in 2013. Secondly, staff engagement activities like game booth was held to enhance staff awareness of the importance of good practice on clinical documentation as well as the introduction of the new standard. Thirdly, quality of clinical documentation was annually assessed through retrospective audit by the Integrated Clinical Standard and Audit Committee as well as Health Information Record Department to monitor compliance. Areas of weakness were identified and actions were taken. The audit results were also shared among healthcare professionals at open forums and departmental meetings. Improvement projects, which included re-designing staff name chop was launched to meet the standard of documentation. On the other hand, training and education were provided nowadays through electronic platform. The newly launched i-Learn website in i-NTEC was designed for new comers and professional frontlines to enhance their knowledge and skills in clinical documentation. Through the procurement of new patient record trolley with lockable compartments, confidentiality, privacy and security for health record keeping was enhanced in ward areas. Needless to say, complete electronic medical record is our future goal, and there would be a pilot project jointly with HA IT team on exploring electronic storage of special invasive investigations like lung function test, treadmill electrocardiography, nerve conduction tests, etc., which electronic transfer of results at the moment is lacking. 67

Chapter 7 | Hospitals Sharing (iii) Care of Deceased Persons Caring for a deceased patient is an intricate task for healthcare providers. A dignified environment should be maintained at mortuary where staff are courteous and display respect towards the deceased and their families at all times. Mortality management should be provided to the customers with dignity, comfort and support through effective housekeeping and the provision of physical and emotional care when needed. To implement good daily practices with a caring approach, a series of improvement programs was conducted by the Pathology Department. Firstly, the provision of facilities and equipment, especially body viewing room were ensured. Renovation of physical environment with decorum and installation of additional curtains were completed by January 2013. This improved privacy of deceased patient and family. A suitably located waiting area for families was also arranged adjoining the viewing facility. Secondly, workflow of transferring the deceased body was reviewed and revised, to ensure respect and recognition of the dignity and privacy of deceased patients. The public access was now strictly separated from body viewing room and uncoffining room. Notice was posted to remind mortuary staff and undertakers about the maintenance of privacy and respect in handling of deceased patients. Now, the transferring process had been reinforced to prevent the deceased body being seen by the public or hospital patients during the transfer. This would minimise unnecessary disturbance and distress. Finally, all mortuary staff, undertakers and Food and Health Bureau staff received special training on mortality management. Besides introduction of standards and guidelines, staff was well-informed on professional and ethical conduct, legal standard, interventions and medical information on management of the body of the deceased. Jointly with Palliative Care Team, an educational seminar was delivered in March 2013 to share and learn respectful care of the deceased, bereavement care for families, cultural and religious customs and practices as well as pastoral support in caring attitude. Staff was encouraged to share their feelings and experience during the seminar and was seen to be very engaged. In this sense, they are better prepared in the days to come for these intense roles to this special task of managing various issues of deceased patients.68

Chapter 7 | Hospitals Sharing(iv) Management of Medical Emergencies Medical emergencies occurred in hospital sporadically without prior notice. Prompt recognition and efficient management of these by a well-prepared healthcare team can increase the likelihood of survival. All healthcare providers should also be able to efficiently utilise available resources when handling these cases. NDH Hospital Resuscitation Committee was well established for years to handle this matter. First of all, policy/protocol/guidelines on medical emergencies were launched. Clinical guideline on cardiopulmonary resuscitation (CPR) that consisted of basic algorithm for managing cardiac arrest was established and distributed to frontline. CPR paging system for clinical ward was reinforced so that medical staff could response to the immediate call without unnecessary delay. Response plan for handling persons requiring emergency medical assistance in the vicinity of NDH was revised. Periodic drills were conducted in regular intervals, helping healthcare providers to identify and practice the duties and responsibilities in various emergency scenarios. Secondly, appropriate medical equipment were installed and kept. Items and quantities of equipment and medications in the emergency trolley in all general wards were standardised. Layout of items/medications in the trolley was audited with satisfactory compliance rate observed. Photo guide book was developed as a quick reference to enable healthcare providers to facilitate access. Equipment, such as automatic external defibrillators were inspected and documented on a daily basis. Finally, it is important that the healthcare providers received proper training in emergency management allowing efficient and timely treatment be delivered to patients. More than 50 medical staffs and 20 nurses have completed Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) course in 2013. Also, in-house trainings on BLS were held for allied health professionals and supporting staff to provide basic management of airway, breathing and circulation. Special course like “ECG Makes Easy for Nurses” and nurse-led defibrillation workshop was conducted. 69

Chapter 7 | Hospitals Sharing 7.3.2 Staff Engagement and Communication Visit By ACHS Team •• NTEC Hospital Visit by ACHS Team  (21 November 2011) Simulation Round •• NDH Simulation Round (Mock Survey) with debriefing  (26 – 30 March 2012) Visited 15 departments/units Walkrounds •• Quality & Safety Walkrounds (criteria-based)  (16 May 2012 – 3 October 2012) Conducted 26 visits for 15 clinical departments/units70

Chapter 7 | Hospitals SharingForum• Extension of Hospital Accreditation in HA – Communication & Engagement Forum (17 October 2011) Total 115 attendants• Forum on Clinical Handover, Transfer & Discharge (Criterion 1.1.5)  (22 March 2012) Total 63 attendants• Forum on Care of the Dying Patients and their Relatives in Acute Setting at NDH (Criterion 1.1.7) (10 September 2012) Total 66 attendants 71

Chapter 7 | Hospitals Sharing Staff Engagement Activities • Promotion of “Avoid Known Drug Allergy”  (13 January 2012) Visited 15 wards/units • 醫院認證知多少 ( 前線及支援服務同事 – 攤位遊戲）(15 March 2012) Total 320 attendants Workshop • EQuIP 5 Sharing Groups for nursing staff  (18 April 2012 – 19 December 2012) Conducted 14 classes, Total 348 attendants72

Chapter 7 | Hospitals Sharing• Inter-Professional Education Workshop on High Risk Medications (Criterion 1.5.1) (28 September 2012 – 17 January 2013) 4 Sessions, Total 183 attendantsPreparatory Meeting• Pre-meetings with departments/units/committees  (November 2011 – November 2012) Conducted 26 meetings for 13 departments, 4 committees and 1 taskforce• Departmental meetings on clinical indicators  (30 July 2012 – 29 August 2012) Conducted 7 meetings for clinical departmentsGap Analysis• Gap Analysis at NDH  (5, 12 – 15 November 2012) Total 173 staff, including HA, Department of Health, Social Welfare Department, Electrical and Mechanical Services Department, patient groups & volunteers Conducted 41 criterion based interviews, 5 special meetings & 41 site visits. Total 58 Priority Action Items noted 73

Chapter 7 | Hospitals Sharing Briefing • Briefing on update of iGateway Development @ iHosp  (12 April 2011) Total 66 attendants • Briefing to Buddies  (18 October 2012) Total 5 attendants • iCQI Briefing Session to All Staff, iCQI Briefing Session to NTEC Webmasters  (6 February 2013) Total 81 attendants iHospital • iAccreditation Electronic platform to provide up-to-dated information on hospital accreditation under NDH Hospital Accreditation Steering Committee74

Chapter 7 | Hospitals Sharing7.3.3 Learning and Sharing (i) Quality Workshops (18 Sessions) (19 January 2012–26 March 2013) Total 788 Attendants (ii) Gap Analysis – Summation Conference (15 November 2012) Total 152 Attendants 75

Chapter 7 | Hospitals Sharing (iii) Debriefing Session After Gap Analysis – NDH (20 November 2012) Total 105 Attendants (iv) NDH Quality and Safety Newsletter (2Q2011– Ongoing) Total 11 Issues Published76

Chapter 7 | Hospitals Sharing7.4 Our Lady of Maryknoll Hospital7.4.1 Recommendations and Improvements (i) Consolidate the Nursing Assessment Forms on Admission Into One Comprehensive Standardised Assessment Form Across the Hospital: The previous nursing assessment on admission appeared fragmented in collating and documenting of patient’s information. A comprehensive Nursing Assessment Record on Admission was implemented in August 2012 in all clinical areas, identifying those ‘high risk’ patients. The form included the following major aspects: • Nursing assessment to identify patient at risk, e.g. falls, pressure ulcers, malnutrition, suicide attempt, psychological assessment, infection control ; and • Integrated assessment by allied health professional, e.g. physiotherapist, occupational therapist, dietitian, etc. • Initial discharge planning to enhance the timelines of patient discharge and identifying risks that may delay the discharge process, e.g. patient’s expected discharge time. A series of training sessions, on-site briefing and consultation were conducted before implementation. The last audit was conducted in January 2013 with the overall compliance rate of 93.3%. (ii) Cultivate the Near Miss Reporting Culture and Staff Awareness on Patient Safety Through Establishing a Platform on Near Miss Management and Sharing To enhance staff awareness on near miss management, a designated near miss reporting form was introduced. Staff is encouraged to report the near miss or potential risk through this designated form. Meanwhile, the collected data were analysed and monitored by Quality and Safety Committee. Results are promulgated during the near miss sharing session. Two near miss sharing sessions have been organised in 2012; more than 70 participants attended the sessions. Evaluations were conducted and 97.1% of respondents agreed the briefing content was practical to their work. 77

Chapter 7 | Hospitals Sharing (iii) Redesign the Patient Flow in Operating Theatre To minimise the risks associated with the patient privacy and infection control, the workflow of patient waiting area in the operating theatre was redesigned by • Change the location of reception area • Relocate the scrub area and replace the scrub sinks by March 2013. Further improvements were also made in order to reinforce the good practices of infection control in operating theatre. (iv) Implement the End-of-Life Care Pathway The hospital-wide End-of-Life care pathway was developed based on the Liverpool Care pathway and served as a guide in providing care for imminently dying patients with terminal malignancy. It consisted of four parts, namely medical assessment, nursing care review, psychological & spiritual needs and aftercare. Briefing session was delivered based on extensive literature review in July 2012. Then, the pathway was first launched in Palliative Care Unit as a pilot project on 5 September 2012 and initiated in 54 terminal cancer patients over a three-month period. Within 72 hours before death, 93% of patients had the pathway started. The overall compliance of drug prescription for symptom control was over 70%. Besides, non-essential drugs and unnecessary procedures were discontinued in more than 75% of patients. Palliative care nursing staff feedback was collected from 15 November 2012 to December 2012. Majority of respondents agreed or strongly agreed that the pathway had provided a practical framework for End-of-Life care and facilitated documentation of the care process. Most importantly, they did not think that it caused excessive workload.78

Chapter 7 | Hospitals Sharing(v) Establish a Comprehensive System to Identify Items Included in the Preventive Maintenance Program A central computerised system to include all bio-medical equipment for preventive maintenance program was set up, in order to avoid missing to arrange the preventive maintenance before the expiry of warranty; and to ensure all high-risk equipment were under maintenance contract. A master list of data-base captured the description of equipment, asset number, acceptance dates and other relevant information under HA and other maintenance agents (Such as Electrical and Mechanical Services Department, General Electric, Hong Kong Oxygen). Spot check is conducted on bi-annual basis; the last exercise was conducted in December 2012.(vi) Benchmark with International Standard & Cultivating Safety Culture in Kowloon West Cluster (KWC), International Safe Workplace Program (ISWP) and WHO Initiative Program KWC has strived to build a safe working environment for all staff all along. The rationales of developing ISWP framework in KWC are to provide hospitals with an international recognised framework in OSH promotion and implementation. It was a collaborative effort among 7 hospitals and 19 general out-patient clinics in enhancing safety culture. To meet the requirements of ISWP, a series of cluster-wide safety programs had been completed, such as: Safety Climate Index Survey, Training Needs Analysis, Work Safe Behaviour Programs, ISWP Audit Training, Safety Plan development, Quality Improvement Plan, Internal Audit, External audit by HK Occupational Safety and Health Council, Safe workplace networks with community. ISWP had been awarded the Gold Award of Safety Promotion Award and the Bronze award of Best Presentation Award at the 10th Hong Kong Occupational Safety & Health Award held on 2 September 2011. The steering committee had also been awarded the Merit Team in the Hospital Authority Outstanding Staff & Teams Award 2012. 79

Chapter 7 | Hospitals Sharing 7.4.2 Staff Engagement and Communication (i) Staff Awareness Day and Staff Fun Day To engage staff in the hospital accreditation exercise, the Hospital Accreditation Awareness Day and Staff Fun Day were arranged on 13 April 2012 and 6 February 2013 respectively; more than 200 staff participated the game booth, questionnaire and theme talk on accreditation. (ii) Hospital Accreditation Express The Hospital Accreditation Express was regularly published, reporting the latest progress on hospital accreditation exercise. A total of 13 issues was disseminated.80

Chapter 7 | Hospitals Sharing(iii) Departmental Visits In order to preparing the gap analysis and organisation-wide survey, departmental visits were arranged in April 2012 and February 2013 respectively. The objectives of those visits were as follows • To recognise the preparation of the departments about the hospital accreditation exercise; • To enhance staff understanding for the exercise; and • To give support to staff Recommendations were given and follow up in order to enhance hospital’s service and quality safety. 81

Chapter 7 | Hospitals Sharing 7.4.3 Learning and Sharing (i) Sharing From Pilot Hospitals of Hospital Accreditation • Caritas Medical Centre (CMC), one of the accredited HA hospitals in the pilot scheme of hospital accreditation exercise, was invited to share their experience in hospital accreditation journey to standard owners and department heads. • Canossa Hospital (Caritas), one of the accredited private hospitals in the pilot scheme of hospital accreditation exercise, was invited to share the practical tips and successful experience in their hospital accreditation journey. The sharing session was held on 16 December 2011 and 37 staff participated the session. (ii) Key Improvement Sharing Session Sharing on key improvements in nursing aspects: nursing care plan, nursing care competency, fall prevention, surgical safety and psychological assessment was arranged to OLMH nursing staff on 19 July 2012; around 33 nursing staff joined the activity. (iii) Sharing of ACHS Consultancy Report The report of Gap Analysis was shared to frontline staff on 30 July and 2 August 2012, total 62 staff participated.82

Chapter 7 | Hospitals Sharing(iv) Nursing Briefing Sessions on ACHS 9 sessions of briefing sessions were conducted to nursing staff on designated criteria from 5 February 2013 to 8 March 2013; total 385 attendants within this period.(v) Sharing the Experience on Gap Analysis Invited by the HA Accreditation Project Team and hospitals of second phase of hospital accreditation exercise, sharing sessions on the preparation of OLMH gap analysis were organised as follows. • Experience Sharing to KH on 10 August 2012 and 75 staff attended; and • Sharing to Quality and Safety Coordinating Committee, Kowloon West Cluster on 8 October 2012. 83

Chapter 7 | Hospitals Sharing 7.5 Pok Oi Hospital 7.5.1 Recommendations and Improvements (i) Introduction From 10 to 12 August 2012, Gap Analysis was conducted by the ACHS Consultant Teams at Pok Oi Hospital (POH). Overview of the history of the Hospital, and its close association with the Tuen Mun Hospital was introduced, together with the corporate and clinical governance structure, quality and risk management structure and key performance activities and statistics. Four key improvement projects in POH were also presented. During those three days, the consultants discussed with the executives, medical staff, Chiefs of Service, and frontline staff who represented clinical departments, specialty outpatient centres, diagnostic, pathology, pharmacy and allied health services and the Tin Ka Ping Infirmary. In addition, volunteers had actively contributed to the process. Cluster based services serving POH such as, human resources, finance, procurement and materials management, facilities management, contract management and information technology were presented to the consultants. Department visits were also conducted to help consultants understand the physical environment and service delivery, together with relevant documentation review.84

Chapter 7 | Hospitals Sharing(ii) Findings and Recommendations The consultants provided a written assessment of their findings after the Gap Analysis that outlined the strengths against each Criterion, together with opportunities for improvement and Priority Action Items, that must be addressed prior to the Organisation-wide Survey (OWS). Main Priority Action Items to be addressed prior to the OWS are outlined as follows:(iii) Priority Action Items (PAI) and Follow-up Actions Clinical Function Criteria Criterion 1.1.1  Assessment PAI: To ensure that children admitted to or treated at the hospital are assessed using a recognised Paediatric Assessment Tool. The use of the tool should be included in the assessment evaluation program. Follow-up actions: As Accident and Emergency (AED) is the main hospital department providing service for children in POH, Paediatric Assessment Tool was devised at AED. Reference assessment tools were sent out to stakeholders in late October 2012, and eventually adopted and devised in late 2012. Criterion 1.1.2  Care Plan PAI: Develop and implement a simple nursing care plan for individual patients, and form part of the patient record. The goals of nursing care to be identified included Activities of Daily Living (ADL) and routine patient care. Follow-up actions: Nursing care plan was developed and piloted in all wards since mid- October 2012. The pilot plan was evaluated on 27 November in Medical and Geriatrics ward showed acceptable progress. The nursing care plan form was revised starting from January 2013. 85

Chapter 7 | Hospitals Sharing Criterion 1.5.1  Infection Control PAI: Dispense injectable medication such as insulin that is supplied in multi-dose containers to individual patients where possible. Follow-up actions: The issue was brought to discussion in Cluster Drug Administration Safety Committee meeting in late October. Initial direction would be sought through the accreditation project teams meetings at HA Head Office to align the practice. Proper infection control practice and principles were upheld in clinical areas. (iv) Support Function Criteria Criterion 2.1.2  Risk Management Framework PAI: Evaluate the quality and risk management framework in POH with the objective of developing a workable and integrated quality and risk management framework overseeing both clinical and non-clinical risk. Follow-up actions: A briefing session of Hospital Risk Registry development in POH was held in mid- December 2012, to engage various departments. A focused discussion session was held in mid-March 2013 by the Quality & Safety Division, whereby risks identified in individual departments, both clinical and non-clinical, were evaluated using a risk matrix. the hospital risk registry was then consolidated through prioritisation and consensus.86

Chapter 7 | Hospitals Sharing (v) Corporate Function Criteria Criterion 3.2.4  Disaster and Emergency Management PAI: E-trolley in Operating Theatre shall have the paediatric and adult airway management separated. Follow-up actions: Paediatric and adult airway management equipment were separated in different compartments of the e-trolley.7.5.2 Staff Engagement and Communication In mid-November 2011, an Engagement and Communication Forum was conducted at POH. Representatives from Q&S in HAHO and ACHS Consultancy introduced to staff in POH regarding the concept and arrangements of hospital accreditation in details. Department visits were also arranged after the forum. 87

Chapter 7 | Hospitals Sharing To engage key staff involving in accreditation processes, such as self-assessment and necessary preparation in their departments, staff were invited to attend monthly topic workshops organised by HAHO starting from February 2012. Local educational workshops were also organised, such as document control and risk management. During the period of March through July 2012, visits were arranged by POH Q&S Office to a total of 22 service departments and wards, in order to facilitate their preparation for hospital accreditation. 7.5.3 Learning and Sharing To prepare POH staff in the hospital accreditation and share updated knowledge and guidelines regarding care and safety, a total of 10 staff communication forums were organised at the POH 1/F Auditorium before the Gap Analysis, starting from February till August 2012. Experts from various fields and specialties were invited to deliver talks for sharing. The attendance of each forum is as follows.88

Chapter 7 | Hospitals SharingSchedule for Communication Forum of Gap Analysis 2012NO DATE TOPIC SPEAKER ATTENDANCE Mr Robin LI 2041 22 Feb 2012 (Wed) Medication Safety2 9 Mar 2012 (Fri) Infection Control/House-Keeping Mr C H KAN 1733 30 Mar 2012 (Fri) Quality and Risk Management Ms Bonnie WONG 1884 13 Apr 2012 (Fri) Nutrition needs of patients Ms Joanne KOO 176 Document Control Ms Bonnie WONG5 27 Apr 2012 (Fri) Clinical Documentation Debriefing Ms Esther TAN 171 on ward visits Ms Louisa LEUNG6 11 May 2012 (Fri) Resuscitation call Dr Wilson LEE 147 Inter-hospital transfer of critically ill Dr W L TONG7 1 Jun 2012 (Fri) Ventilator training Debriefing on C M MAK 132 ward visit Ms Louisa LEUNG8 8 Jun 2012 (Fri) Admin Issues / OSH Debriefing on Mr Antony LUI 139 ward visit Ms Louisa LEUNG9 6 Jul 2012 (Fri) Human Resources Issues / Mr David MAK 158 Credentialing Data privacy Mr Wallace CHENG10 3 Aug 2012 (Fri) Medication Safety Highlights Mr Robin LI 175 Before gap analysis……. Ms Louisa LEUNG 89

Chapter 7 | Hospitals Sharing 7.6 Prince of Wales Hospital 7.6.1 Recommendations and Improvements (i) Cease the use of High Strength Alcohol Solution for the Cleaning of Metal Surfaces such as Trolleys During Gap Analysis, it was found that clinical area using alcohol to clean the metal surfaces. The Surveyors recommended to cease the practice. Infection Control Team and Central Nursing Division reviewed the situation, and assessed the need and cost, then proposed to management to use the cleaning wipe for cleaning of trolleys. The proposal was supported. Pamphlet was developed and briefing was conducted to staff on changing of practice with good feedback and compliance.90

Chapter 7 | Hospitals Sharing(ii) Enhance Fire Safety As part of the annual fire safety equipment testing program, the contractor was requested to affix a label to each hose reel and hydrant to denote that it has been tested. The fire safety program was conducted regularly in hospital, including fire drill, fire talk, risk area, etc. The equipment was reviewed and checked. During Gap Analysis, surveyors suggested fixing the checking label onto the hose reel, to enhance communication. The recommendation was put at high priority and improved was completed in a short period of time.(iii) Enhance Management of Resuscitation Equipment Ensuring that where adults and paediatric patients are treated in the same area, airway management and resuscitation equipments were separated. Resuscitation Trolley setting were standardised in hospital. Most of the clinical ward/unit has only one resuscitation trolley. However, there will be adult and paediatric patients treated in some area, e.g. Accident and Emergency (A&E), Intensive Care Unit (ICU), High Dependency Unit (HDU), etc. If the equipment for adult and paediatric are grouping together, e.g. intubation and endotracheal tube, the risk for taking in-appropriate equipment will be high and would delay the resuscitation process. As such, the surveyor suggested separating the airway and resuscitation equipment for easy picking and reference. The suggestion was supported and proceeded. While A&E had designated trolley for paediatric patients, other wards used a separate bag for paediatric equipment and accessories. Feedback was good. 91

Chapter 7 | Hospitals Sharing 7.6.2 Staff Engagement and Communication (i) Strategic Retreat Four strategic retreats were organised in May 2012 and December 2012. Three of them were held before Gap Analysis, one for Prince of Wales Hospital (PWH)/Shatin Hospital (SH)/Bradbury Hospice (BBH)/Shatin Cheshire Home (SCH), one for North District Hospital (NDH), and one for Alice Ho Miu Ling Nethersole Hospital/Tai Po Hospital (AHNH/TPH), with 120 senior staff attendance. During the retreat, staff survey on participants’ engagement, acceptance, understanding and readiness for Gap Analysis as well as accreditation were conducted. Through patient journey, some gaps were identified and discussed. The fourth strategic Retreat was conducted by Quality & Safety Division after the Gap Analysis. While 60 senior colleagues were invited to review the recommendations/ PAIs from surveyors, the discussion was positive.92

Chapter 7 | Hospitals Sharing(ii) CCE Forum New Territories East Cluster (NTEC) Q&S Division promoted the accreditation concept to colleagues through a slogan “Do the basics well as part of daily life 做好基本功，融入 生活中 ”. Three Chief Cluster Executive (CCE) Forums on Accreditation was held in 2011 and 2012 with more than 670 colleagues in different ranks to participate with positive feedback. During the Forum, on site staff survey on their engagement, acceptance, understanding, and readiness were conducted too, and result showed a difference with same survey conducted to senior. 93

Chapter 7 | Hospitals Sharing (iii) Game Booth Game Booth to enhance and alert staff knowledge and awareness in general quality and safety issues via awarded games was conducted in September 2012 and February 2013. Each round was conducted twice while one session for professional staff, and one session for supporting staff (including administrative, clerical and supporting colleagues). Through multiple choice questions, the basic but important concepts on various Q&S issues such as occupational safety and health (OSH), infection control, fire safety, waste handling, confidential document handling, and medication safety, etc. were delivered. There were totally 652 professional and 1108 supporting staff (including contract out services) had participated. Onsite feedback was positive and encouraging.94

Chapter 7 | Hospitals Sharing7.6.3 Learning and Sharing (i) iQuality (A Flyer on Quality) Six issues of iQuality (a flyer on quality) were published since July 2012. It aimed at providing staff with relevant and focused information on quality improvement. The topic in each issue was specific and applicable to the daily practicing in all departments/ units, e.g. document control procedure, use of bags for waste, etc. To engage staff to pay attention on the flyer, an awarded quiz of multiple choice questions were included in every issue. There were totally 961 staff had participated the quiz with 737 staff got all correct answers. The message on the iQuality was successfully communicated to frontline colleagues. 95

Chapter 7 | Hospitals Sharing (ii) Quality & Safety Walkround Q&S has conducted walkround to different departments/units. The team composed senior doctors, Q&S manager, Patient Safety Officer, Quality Officer, Infection Control Nurse, OSH Coordinator and administrator. It conducted twice a month with 3 hours per session. During walkround, Q&S team focused on discussion with department staff on overall Q&S issue and quality programs, other members would conduct their expert round as well. Debriefing would be conducted right after each round to share each expert’s observations and the areas for improvement. 26 departments/Units were visited in 2012. Most departments strongly appreciated the walkround while it helped to identify the gaps in quality and safety aspects, followed by prompt improvement. All the participating departments recommended extending this to other departments/areas. The round was rated 8.3 out of 10 for its overall usefulness.96

Chapter 7 | Hospitals Sharing(iii) Quality Workshops Quality workshops were conducted to share with colleagues some of the best practice in different quality area in the cluster. Since January 2012, the quality workshop was held once in every month, about 1.5 hours during lunch time at PWH, and broadcast to other hospitals in NTE cluster. The subjects covered assessment, care evaluation, clinical handover, nutritional care, health care record and consumer participation, etc. As of June 2013, there were totally 20 workshops conducted with 4859 person-time attended the workshops. The majority of attendance expressed they were satisfied and very satisfied to the workshop. Various feedbacks were received that were of great reference for the improvement of future workshops. 97

Chapter 7 | Hospitals Sharing 7.7 Pamela Youde Nethersole Eastern Hospital 7.7.1 Recommendations and Improvements Criterion 1.1.3  Informed Consent The use of abbreviations of procedures in consent forms is common in the HA hospitals. In the Periodic Review survey in 2012, surveyors recommended that hospitals should identify best practice for documentation of the name and site of the operation/procedure and ensure that action is taken to reduce the risk of using abbreviations on consent forms. The process should include provision of evidence-based information to doctors. This HA-wide issue was brought up for discussion at corporate level. However, it was considered impractical to have a revolutionary change to the practice in view of the current service setting and caseload. As such, we took a progressive approach. Clinicians were reminded to write the full name of procedure on consent forms as far as possible and clinical departments were encouraged to consider using consent form with pre-printed procedure name or stamping full procedure name with ink chops to facilitate the process of obtaining informed consent. In the long run, we plan to carry out feasibility study on formulating an approved abbreviation list for some common procedures in the Cluster. Clinician obtaining informed consent Criterion 2.1.3  Near-miss Reporting Surveyors commented the robust quality and safety structure that exists at PYNEH supports a number of specific systems including incident management. We have implemented a number of strategies to enhance the reporting of near misses over the last two years and this is building a positive culture of reporting in this regard. The near miss reporting tool recently introduced in the medical ward to report medication incidents is commented as highly impressive.98