One Region, One Big hospital (OROBH)
Maharaj Nakorn Chiang Mai Hospital

The Problem

Healthcare service of Chiang Mai University Hospital (CMUH) faced major problems as follows:

1. Patient:
Patients had to travel a long distance from other districts of Chiang Mai or even other provinces to CMUH, but the hospital did not have sufficient capacity to take care of all patients on the same day. Moreover, the patients’ arrival did not coincide with the schedule of required specialty clinic. Some patients came to the hospital when their conditions were very severe. Frequently, patients who came to CMUH were also uninsured, had no financial means, and lack of health education.

2. Community hospital:
he risk of complications and mortality. Access to medical care at appropriate time has always been the problem for patients from remote areas of the country. Thus, the ability of local hospitals to effectively manage these conditions is an essential part of overall quality medical care. The CMUH recognized the limitations and has initiated a program to empower these community hospitals and developed a more efficient referral system.

According to the research done by CMUH, there were 171,818 referred patients to the CMUH in 2008 that increased to 216,882 patients in 2012. These patients were usually referred to the CMUH too late for best possible healthcare outcome and sometimes death ensued. This was because Community hospitals lacked appropriate skills to manage complicated cases. Another problem was the unorganized and unsystematic patient care and inefficient referral system.

These factors together limited patients’ access to services provided by large and comprehensive hospital center. Moreover, the healthcare policy of first admitting patients at community hospitals in the vicinity of patients’ residence contributed to the problem of collaboration among the hospitals causing undue hardship for the patients.

Solution and Key Benefits

 What is the initiative about? (the solution)
One Region, One Big Hospital (OROBH)
Due to lack of healthcare personnel and high-competency medical staff, various systems were developed at the level of community and provincial hospitals to facilitate access to medical services provided at the CMUH for patients living in remote areas.
In 2007, CMUH formed a collaborative network between CMUH and community hospitals. The development of network was accomplished in the northern part of Thailand through collaborative effort of hospitals in both private and public sectors. As a result, the coronary heart disease network was the first to be established.
In 2010, CMUH expanded more collaborative networks to include stroke network, breast cancer network and palliative care network in order to provide high quality medical services for patients in the northern part of Thailand.
To assist community hospitals in managing emergency cases, a 24-hour hotline service and a Fast Track system were also implemented. Through this network, training courses to increase personnel’s knowledge and skills including pre-referral patient management guidelines were organized. However, patient mortality rate during referral was still high because the duration of hospital admission for these patients was long and patient’s information transfer including patient management were not of the same standard throughout.
In 2011, a significant initiative namely the “One Region, One Big Hospital” or “OROBH” was developed under the hospital’s medical director vision to create a seamless integrative working system from remote hospitals in rural areas to the CMUH, creating a unified virtual hospital through the integrative network. Medical consultations between hospitals would seem like a consultation between hospital's internal departments that would reduce working processes, time and any obstacles due to traveling distance for the patients.
CMUH has developed an E-discharge Summary program for transferring medical information back to the originating community hospitals in order to provide continuous patient care in accordance with CMUH’s guidelines. The success of the program led to a development of Logistic Medical Information or “LMI” to send medical information back to the community hospitals in order to notify the hospital of patient’s treatment, medication, diagnosis, management plan and other information necessary for patient care. The information was sent every day at midnight to community hospital’s mailbox via secured email messages to protect patient’s privacy.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
Working in the medical school for more than thirty years, the hospital director has seen the patients in the remote areas struggling with long-distance travel to obtain medical services from CMUH. Consequently, a proactive policy was initiated to change the mindset of hospital personnel and staffs. A segmented thinking model was replaced by an integrated thinking model where hospitals were working as partners to promote collaborative mindset that everyone was working in the same hospital.
A new service channel was formed by collaborative efforts of programmers from provincial hospitals, community hospitals and Health Promoting Hospital (HPH) including private hospitals to design a computer application that was suitable and responsive to health professional’s needs within the context of each hospital.
CMUH as the leader arranged a meeting among doctors and health care personnel from community hospitals to solve the problems and to form a team between the CMUH and community hospitals. Working plans, system development and resource preparation are enthusiastic implemented. Community hospitals’ director and IT team were invited to attend meetings to communicate and learn how to use the on-line referred program, to transfer medical information and to protect confidential information according to the patients’ right.
Data obtained from meetings between hospitals regarding patient referral through the on-line referred system demonstrated a successful collaboration from hospitals in the network as evident by the growing number of patients referred through the system.

Active participation from other organizations contributed to the success of the project. These organizations included provincial hospitals, community hospitals, private hospitals, Department of Health, Emergency Medical Service and National Health Security Office (NHSO).
Patients were the central focus of the initiative with intent to facilitate access for patients from any area in the northern part of Thailand to medical services of the same standard as that of medical school at their nearby hospitals.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.

1. Customer Focus

One Region, One Big Hospital; OROBH. CMUH has a policy for the community hospitals to consult and refer cases to CMUH when necessary similar to consultations between the departments within the same hospital. This creates an integrated working environment between hospitals where partisan is absent, making it a truly seamless system. This provides patients at community hospitals the same standard of care as that of the CMUH but with easier access to services. Additionally, through this network, knowledge sharing and learning can be accomplished to increase community hospitals' competencies to manage and provide an increased standard of care for all patients.
The LEAN and Seamless Healthcare were key factors to a successful healthcare system that was seamlessly interconnected at every level of hospitals including primary, secondary and tertiary hospital by the introduction of this new mindset and culture. The implementation of LEAN and seamless concept to healthcare greatly facilitated patients' access to medical services and streamlined patient referral process from other hospitals.

2. IT Implementation
CMUH successfully implemented IT for management to improve convenience and timeliness and to reduce physician's workload. The hospital also encouraged the use of IT system in transferring medical information to the hospital that had referred severe and difficult cases through an online system for treatment. When these patients were discharged from CMUH, patient treatment summary and records would be sent after midnight to an electronic mailbox of the originating community hospital through an automated system. The record sent to the community hospital contained information relating to diagnosis and treatment plan that would ensure continuity of treatment using similar practice guidelines and standards for patients at their local community hospitals. Additionally, the patients were not required to travel a long distance to CMUH for similar medical services. Implementation of this Logistic Medical Information (LMI) system also supported the Continuous Medical Education (CME) for health professionals at community hospitals.
3. Participation
CMUH arranged meetings for stakeholders from hospitals to attend in order to determine their requirements and needs and to communicate medical records transfer process, confidential patient information protection, and CMUH's objectives and guideline to ensure alignment of work processes.
A request was made to hospitals in the network to use online referral system that would reduce work steps and provided convenience to patients. The cooperation resulted in a higher rate of referred cases online. The online referral system allowed patients living in remote areas to receive faster medical services at CMUH. Additionally, online appointment could be done by physicians and nurses of community hospitals in to expedite the access to medical treatment at the CMUH on the appointment date.
In addition to participation from hospitals in the network, cooperations at policy level were also done with other agencies such as Provincial Health Office, private sectors and the National Health Security Office to determine practice guidelines for strengthening the network and raising the standard of medical services in Thailand.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
Hospitals’ administrative teams and stakeholders regularly met to solve problems together and to create working plans. Plans were implemented to communicate with organization’s personnel, to write applications for online referral, online registration and e-discharge summary, to create mailbox for each hospitals, to test the system before implementation. Results from performance assessments were used to improve the systems.
Initially, this project was implemented only in Chiang Mai province. Then was expanded to include other hospitals in the upper part of Northern Thailand including private hospitals.

Implementation steps
Multiple channels were arranged to promote patients’ access to integrated medical services as follows.
Registration online program is an innovation to create an online medical appointment registration. Using new technology, this program provided a new channel for patients to receive medical services more conveniently without having to line up at the hospital for registration. The internet registration was implemented for patients both at CMUH and other hospitals.
Referred Online Program was established for hospitals to receive and transfer medical records where the CMUH will provide the server to relay the information. The use of a new technology as backbone of the service system on the connection of information, management and the use of information among hospitasls was an integrating problem-solving.
Development of referred online program has shortened the process required for referring patients among the hospitals. The collaboration among hospitals replaced the traditional practice where patients had to bring the referral note to the CMUH. Failure of patients to come on appointed date for appropriate specialty service schedule may result in rescheduling and delaying of treatment. With this referred online program, patients receive convenience and timely medical services, and prompt hospital admission.
Logistic Medical Information The IT system was used to send medical information. When patients with severe conditions referred through online system were discharged, the system late sent the summary treatment information to the mailbox of community hospitals. The information provided doctors at community hospitals about the diagnosis and treatment guidelines in order to continue treatment with the same standard as that at the CMUH. The patients did not have to travel a long distance to receive medical services at the CMUH. Moreover, LMI also supported the (Continuous Medical Education; CME).
Tele-monitor uses satellite transmission to track patient’s condition in ambulances. The National Health Security Office funded the project to solve the problem of shock or death during transportation. Tele-monitor records patient’s information during ambulance transportation including blood pressure, heart rate, respiratory rate and blood oxygen levels which are then sent via satellite to CMUH. The information allowed physicians at emergency department to closely monitor patient’s conditions and to provide advice on initial treatment to the nurse in the ambulance during the transportation. Moreover, the location and the time of arrival could be determined so that the emergency team could start necessary preparation including operating room before patients’ arrival at the CMUH.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
At the initial stage, very little coorporation was received because community hospitals lacked understanding of the proposed concepts. All works were done under the analytical mindset, not the integrated mindset. Each community hospital alone tried to manage the patients at its best capacity despite a lot of patient workloads. Also, computer systems among hospitals were not connected, causing limited online referral to the CMUH.
CMUH arranged meetings to acknowledge the problems of each community hospitals and allocated funding to produce an application to be used among hospitals. The aim was to bring convenience and quality medical services to patients in a timely manner

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized

To communicate among the hospitals, information technology and program for information transferring was implemented. Other resources including computers were also used in the hospital.

Key benefits
The initiative benefitted 3 groups: patients, community hospitals, and CMUH.
(i) Patients: The OROBH reduced the hardship and the travel expense for patients living in remote areas to the hospital for medical services. The overall cost for patients was reduced due to receiving services from hospitals in the local area. Moreover, OROBH also streamlined the referral process. The Key Performance Indicator (KPI) related to time indicated an improvement in readiness of the team of doctors and nurses to provide medical services to patients arriving at the CMUH. Depending on the severity of the conditions, in case of emergency, physicians were able to provide treatments to a patient in less than one minute. The service cycle time of the CMUH reduced significantly from 2.5 hours to 1.7 hours.
The KPI on medical treatments according to the referral standard developed by the CMUH indicated that the mortality rate in critical cases, which requires immediate treatment, was decreased, especially for conditions that were the leading cause of death such as acute myocardial infarction and stroke.
Because of the coorporation between hospitals, the mortality rate of acute myocardial infarction was lower when compared with other medical schools. The mortality rate of stroke at the CMUH was also lower than that of other medical schools.
The results of the evaluation regarding patients’ satisfaction with the services and patients’ engagement showed as increasing trend. The KPI that shows the patients’ satisfaction at CMUH was always above 80 percent.
Ultimately, the initiative contributed to raising the country’s healthcare standards by ensuring that patients received quality medical treatment with similar standard to that of CMUH at their local community hospitals.

(ii) Community hospital: The collaboration between community hospitals and the CMUH increased community hospitals’ competency and confidence to advice, diagnose, care and refer patients when necessary, thus creating an opportunity for all patients to receive high-standard healthcare. Eventually, morbidity and mortality would be reduced.
The medical information and guidelines provided to the community hospitals from the CMUH enable doctors in the rural areas to provide continuity care to patients and also learn the diagnosis and treatments methods, which is a CME.

(iii) CMUH: CMUH was able to reduce patients congestion and workloads leading to a better care for appropriate number of patients.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
CMUH developed the establishment of medical collaboration network between hospitals in the northern region of Thailand. The collaboration from hospitals lead to the development into One Region, One Big Hospital or OROBH. Plans were implemented to set up work systems for communication and consultation leading to a systematic referral system and an increase in the number of patients through referred online program.
OROBH can be implemented in other regions of Thailand to increase standard of care of hospitals in Thailand to the same level. The National Health Security Office extended and developed this initiative to other regions all over Thailand to close the gap on medical services between hospitals,thereby creating a true seamless system. With the support from all related parties, the OROBH was beyond “successful”. The initiative was expanded and implemented to other parts of the country leading to improvement of medical care quality and efficiency in Thailand. By receiving standardized medical services, the quality of life for Thai patients can be improved. This concept of OROBH can also be applied to other countries with similar National Health security system.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The concept of OROBH is a distinctive initiative of collaboration between hospitals that truly benefits patients. This actually destroys the wall among affiliated hospitals, thus creating a barrier free medical service. The OROBH creates connection between hospitals from different affiliations, reduces the process and timing and absolutely solves the problem of delay and obstacles existed in the past. The initiative empowers hospitals to provide continual care for complicated and difficult cases. The concept of OROBH elevates the efficiency and quality of community hospitals, decentralizes the medical services and allows patients access to quality healthcare at hospitals closed to their homes.
Main factors for success include the determination and commitment of administrator to patients' benefits, the participation of all stakeholders, and open communication among the hospitals thereby creating a boundary free healthcare. Patients in the upper north of Thailand can now have access to medical care of similar standards. Minimizing patients' traveling CMUH has reduced reduce diagnosis and treatment delay, and morbidity and mortality rate, creating a win-win situation. The ultimate outcome is the equity of access for patients to high-quality medical care.

Lesson learned

The empowerment of hospitals in the network to elevate healthcare standard is the key success factor of developing quality and efficiency of healthcare system in Thailand beyond patient's need, expectation and dream.

Contact Information

Institution Name:   Maharaj Nakorn Chiang Mai Hospital
Institution Type:   Government Agency  
Contact Person:   Watana Navacharoen
Title:   Associated Professor  
Telephone/ Fax:   +6653945122,Fax +6653-217144
Institution's / Project's Website:
Address:   Faculty of Medicine, Chiang Mai University
Postal Code:   50200
City:   Chiang Mai
State/Province:   Chiang Mai
Country:   Thailand

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