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Improving Public Medical Service through Collabolative Networks
Maharaj Nakorn Chiang Mai Hospital
Thailand

The Problem

A small country in Southeast Asia, The Kingdom of Thailand, home to more than 72 million populations, is surrounded by 4 neighboring countries: Myanmar, Laos, Cambodia, and Malaysia. The country is divided into 4 natural regions: mountains of the North, rice fields of the Central Plains, semi-arid farm lands of the Northeast, and coastlines along the South China Sea and the Andaman Sea of the South. Around 80% of its inhabitants work in agricultural sector.
The Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai University, also known to the locals as “Suandok Hospital”, is a 1,400-bed university hospital. It was founded in 1958 to provide modern medical care for the people in northern region of Thailand and to serve as a medical education and research center. In addition to providing primary health care services, the hospital also serves as a referral center for hospitals in 17 provinces of Northern Thailand with over 10,471,276 people. A large segment of population lives in remote rural area. Superstitious beliefs, lack of financial means and of basic health education cause the people to delay seeking modern medical care and this oftentimes produces detrimental results.
The hospital serves more than 980,000 out-patients and 48,000 in-patients annually. About 30% of the patients are referred from hospitals in Chiang Mai and about 70%, from hospitals in other northern provinces. Without an efficient communication and referring system, patients waste valuable time and money finding a hospital that is available to admit them. Among the 48,000 in-patients, almost half are critically-ill and suffer from late-stage conditions including rheumatic heart disease with heart failure, chronic renal failure, tuberculosis, meningitis, cancer, and AIDS. Most of them require long-term palliative care.
For people in the remote rural area who are often poor, seeking timely medical care from Maharaj Nakorn Chiang Mai Hospital is a costly and challenging task. Even when they eventually arrive at the hospital, it often takes long time to receive medical care due to shortage of medical personnel and a large number of patients requiring treatment. In certain medical conditions such as acute myocardial infarction with ST elevation who should receive thrombolytic therapy within 6 hours after the attack and 30 minutes after arriving at the hospital (door-to-needle time < 30 minutes), the delay in treatment can be fatal and can cause serious complications.
In the past, Maharaj Nakorn Chiang Mai Hospital was the only hospital in the Northern region that is equipped to provide service such as thrombolytic therapy mentioned above. Patients in 17 Northern provinces who suffered from acute myocardial infarction with ST elevation patients would need to be referred to the hospital for the treatment. Thus, few patients received the appropriate standard management because of the delay in referral process or of complicated internal administrative procedures.

Solution and Key Benefits

 What is the initiative about? (the solution)
The solutions for the problem are to increase accessibility of patients to quality health care by streamlining hospital administrative processes and by forming heath care network with community hospitals. Reducing the amount of paper work and simplifying patient referring process are used to improve the hospital efficiency. Through heath care network, the hospital provides consultations and training courses for community, district, and provincial hospital to improve medical personnel’s skills and knowledge in managing complicated conditions by themselves before deciding to refer patients. The trainings help to reduce costs for patients seeking medical care from the Maharaj Nakorn Chiang Mai Hospital and to improve patients’ access to quality health care from their local hospitals.
Patients who require life-saving medical care or are critically ill or have complicated conditions are the most affected by the initiatives. After implementing the solution, the average service time in the out-patient department decreases from 140 minutes in 2005 to 78 minutes in 2008. Especially, the waiting time in the emergency department decreases from 4 minutes in 2002 to no waiting in 2008.
Under the new “Fast Track” program, the average door-to-needle time for patients with acute myocardial infarction with ST-elevation decreases from 70 minutes in 2005 to 40 minutes in 2007. The number is better than the national average of 85 minutes. Moreover, 40% of patients received therapy within 30 minutes in 2007 compared with 27% in 2005. This number is comparable to that of the United States.
Under the new health care network, pre-hospital death rate decreases from 0.70% to 0.34% in 2007 especially for patients with cardiac problems. Through knowledge transfer and academic support from the Maharaj Nakorn Chiang Mai Hospital, many community and provincial hospitals both in Chiang Mai and other provinces are able to develop their own Fast Track programs. At Nan provincial hospital, the program significantly reduces the mean door-to-needle time for thrombolytic therapy in patients with acute myocardial infarction with ST elevation. Thus, the number of patients needed to be referred to the Maharaj Nakorn Chiang Mai Hospital is reduced, unless the patients have complications.
After the initiatives, patient satisfaction survey conducted at emergency department of the Maharaj Nakorn Chiang Mai Hospital found that 96.5% of patients and relatives are satisfied with services. Surveys of hospitals in cardiac disease network found 100% of hospitals are satisfied with the collaboration.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
Under policy reformation by new hospital administration to improve quality of service at all levels, teams of specialists who took care of patients with complicated diseases acknowledged the problems and risks faced by the cardiac and trauma patients under previous hospital administrative procedures. Without change, the procedures would hinder the referring process from remote rural areas and may compound to the health problems and the spreading of diseases in those areas.
With this awareness and full support from the Faculty of Medicine’s administration, the hospital administrators and heads of related departments such as Cardiac Center, Trauma Center, and Information Technology met to find a way to improve the work system, to streamline administrative processes, and to design a computer support system for the patients. Community leaders, community hospitals, and private health care providers with their expertise, knowledge and skills were also involved in developing a network to provide medical care for patients. Thus, knowledge sharing among different sectors to improve the quality of primary care for the patients at initial sites before referral can ensure patient safety and prevent disability and mortality.

(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.
Through the determination of hospital’s administration to comply with the requirements of patients in remote rural area, it was dictated in the hospital policy that all patients are able to access medical care regardless of their medical conditions, ethnicity, social or financial status. A value system for the hospital personnel was created to promote personnel engagement and to foster a service mind for patients. The hospital director and administrative team lead by example to foster team work and innovation. Information technology is used throughout the hospital to improve internal work system and communication with collaborative hospitals.
The medical care network initiatives were established with the following objectives.
1. Raise current internal standard of care for patients to the level of best practice.
2. Improve access to medical care for underprivileged population in remote rural areas. (Improve referring system from remote community hospitals).
3. Promote medical care network among collaborative hospitals.
4. Increase community hospital’s competency to manage complicated cases; thus, reducing the death-before-admission rate.

The strategies used to achieve the above objectives are as follows.
1. Promote personnel engagement by establishing core values, recognizing/ rewarding system, and pride among the personnel.
2. Transform public health care network to include hospitals from different governmental agencies throughout Northern Thailand.
3. Establish and maintain direct and an effective two-way communication line among the collaborating hospitals using information technology.
4. Streamlining the referring process to accommodate patients from collaborative hospitals.
5. Empower community hospitals’ staffs to provide medical services with quality comparable to those provided by the Maharaj Nakorn Chiang Mai Hospital.
6. Build a tightly integrated network among 117 hospitals in northern Thailand in order to provide appropriate medical care and replicate this novel network system to other regions of the country.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
In response to the policy of Office of the Public Sector Development Commission, the hospital implemented the quality improvement system in 1999 and has been accredited by the Institute of Hospital Quality Improvement and Accreditation since 2002. In order to build personal engagement and common goal in seeking high standard of care, it was necessary to promote understanding and build common core values: “Suandok People”. The core values are then communicated to all the personnel using every available channel.
The patient administration system was streamlined by taking the advantages of information technology. Patient screening and registration processes were reduced to a single step called “One-Stop Service”. Many processes such as patient appointment and referral could be done over the internet. Digital medical record also helped to reduce the amount of necessary paperwork and personnel’s workload.
Streamlining the referring process to accommodate patients from collaborative hospitals was accomplished by setting up a Referral Center. The Center coordinated different activities involved in providing appropriate medical care. These activities included doctor consultation, preliminary medical care including pre-referral treatment, and pre-arrival arrangements in order to provide immediate care. The hospital also provided Emergency Medical Service (EMS) to transfer patients from the site of incidence to the hospital.
In order to develop an effective medical service system, we have organized hands-on medical trainings including advanced trauma life support (ATLS), acute coronary syndrome (ACS), acute stroke, and palliative care for physicians, nurses, and health professionals at their working sites since 2007. Community hospitals were allowed access to the hospital’s library.
Started in 2005, the Northern ACS Network was extended to cover most of Northern provinces by 2008. The medical team enabled regional hospitals to admit cardiac patients from their own network and had their own fast track. As a result, small networks proliferated and played a role in effectively reducing death and disability rate.
Northern ACS Network also educated and empowered the patients’ family, community leaders and care takers to take care of patients at home after being discharged from the hospital and to encourage patients to exercise. Medications such as streptokinase (SK) and medical equipment are also provided for the collaborative hospitals. Problems and obstacles faced during the operation were discussed and rectified at monthly meetings.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Although improving medical services increases patients’ safety and satisfaction including health personnel’s work satisfaction, 3 major obstacles exist.
Physicians, medical personnel, and medical equipment shortage are major problems faced by hospital administration. Although the salary rate is not high, the administration has provided other means to maintain personnel’s satisfaction and engagement. The measures include providing opportunity for the personnel to bring their expertise and ideas into improving health care delivery, and encouraging two-way communication throughout the organization.
Limited funding from the government is subsidized by fund-raising activities at various charity events. This additional supply of funding allows the hospital to acquire necessary medical equipment.
Unfamiliarity of community hospitals’ staffs with the management of patients with complicate conditions is rectified by training, education, and medical provisions from the Maharaj Nakorn Chiang Mai Hospital.

(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
Resources used to improve the medical service network include
- Interdisciplinary medical team including coordinators such as nurse managers and nurse coordinators
- Budget for medical equipment especially for used in emergency department, ambulance, and information technology equipment. The budget came from government through various agencies such as the National Health Security Office, Social Security Office, Thai Health Promotion Foundation and from donation through the Suandok Hospital Foundation.
- Donation from private sector and non-profit organizations such as the Rotary Foundation
- Computer programmers who understand the needs of medical service providers

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The Maharaj Nakorn Chiang Mai is dedicated to maintain functioning medical care networks by providing annual budget for quality improvement, medical training, and medical resources for each network. Performing customer satisfaction and loyalty survey, and monitoring Performance Indicators defined by individual network are also important functions to sustain medical care network.
Individual network plays an important role in maintaining its own function through continuous self improvement by knowledge sharing among different networks to determine and maintain Best Practice. Each network also acts as a learning center and a referral site for smaller sub-network.
External agencies such as the National Health Security and the Thai Health Promotion Foundation also provides an additional source of fund for acquiring sophisticated medical equipment and expanding medical care network to cover other diseases. The fund is allocated according to the performance of each hospital; thus, helps to facilitate continuous quality improvement, and to maintain effective networks.
It has been a policy of the Maharaj Nakorn Chiang Mai Hospital to promote knowledge sharing among different health care providers. For this reason, the hospital has organized annual Regional Forum on Hospital Accreditation and Health Promotion since 2000 to provide a platform for sharing best practices. To promote quality medical care, the hospital provides training courses and publishes pre-hospital medical care guidelines on advanced trauma life support and ambulatory trauma care for other hospitals in Northern region. Being recognized for its role in hospital quality improvement, the hospital is considered a role model and often visited by other hospitals from Thailand and abroad.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
After implementing the initiative, collaborative networks have expanded to cover many areas of health care services including acute coronary syndrome (ACS), trauma, acute stroke, palliative care, breast cancer and other cancers. Community hospitals’ potential to provide quality patient care has improved to the level comparable to those provided by the Maharah Nakorn Chiang Mai Hospital. Successful collaborative networks have also produced not only patients’ satisfaction but medical personnel’s satisfaction and pride in their work as well.
The Maharaj Nakorn Chiang Mai’s dedication to quality improvement has won the organization many awards such as:
• “Best Hospital” 1st Prize from the Social Security Office of Thailand 2007, 2008
• Winner of “Claim Award” from the National Health Security Office of Thailand in 2007 and 2008
• Winner of “Outstanding Public Service Award” from Office of the Public Sector Development Commission in 2008
• “Quality Cycle Control for Innovation” from the Department of Industrial Promotion in 2005, 2006, 2007, and 2008
• Humanized Health Care Awards from the Institute of Hospital Quality Improvement and Accreditation of Thailand in 2008
• Role model in Tertiary care of Trauma Center from The Trauma Association of Thailand in 2008
• BUPA Clinical Excellence Award for Participatory and Integrate Medical Rehabilitation Service for Sustainable Improvement of Quality of Life of Persons with Disability in 2004, 2005
• Outstanding Emergency Medical Service Award from Chiang Mai Provincial Public Health Office in 2008
• Recognition from The Royal College of Surgeons of Thailand for significant contribution to Advanced Trauma Life Support training course in 2008
In addition to winning awards from external organizations, the hospital is also accredited by the following organizations:
• The Institute of Hospital Quality Improvement and Accreditation of Thailand for quality improvement from 2002 to present
• ISO 15189 Laboratory system from 2006 to present
• Thailand Nursing and Midwifery Council in 2008

Lessons learned
1. Working as a collaborative network helps deliver quality service to underprivileged patients and improve public health in general.
2. Working towards a common goal to deliver an ever improving quality of service promotes teamwork and medical staff’s commitment and engagement for future endeavors.
3. Hospital network provides means to ascertain patient’s real needs and to organize the provided services effectively.
4. Hospital network helps the medical service providers to understand patients’ real needs and serves as a basis for client-centered approach to medical care.
5. Successful collaborative network can serve as a model for providing medical services in other medical fields such as stroke and palliative end-of-life care.
6. Successful collaborative network can be replicated in other regions of Thailand.

Contact Information

Institution Name:   Maharaj Nakorn Chiang Mai Hospital
Institution Type:   Government Agency  
Contact Person:   Dr.Watana Navacharoen
Title:   Hospital Director  
Telephone/ Fax:   +6653946155
Institution's / Project's Website:   +6653945154
E-mail:   wnavacha@mail.med.cmu.ac.th  
Address:   110 Intawaroros, Suthep
Postal Code:   50200
City:   Chiang Mai
State/Province:   Chiang Mai
Country:   Thailand

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