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The Holistic Humanized Care for Patients with Diabetes
Sena General Hospital
Thailand

The Problem

Pranakorn Sri Ayutthaya, the former capital city of the kingdom of Thailand is renounced as one of the world heritages since December 13,1991 The city is located in the central part of Thailand. Pranakorn Sri Ayutthaya has 16 amphoe (districts) and a total population of 764,811. Amphoe Sena, one of the major districts, comprises of 16 Tambon (a commune of about ten villages) with 66,100 population. The capita
income is based on agricultural (particular rice) products and handicrafts together with some textile, footwear and electronic industrial investment from both inland and overseas.

Sena Hospital was firstly established in 1979 as a 60-bed community hospital and slowly transforms into a 165-bed general hospital responsible for 16 primary care units (PCU) distributed in each Tambon as well as the secondary and tertiary cares(referral center) for the other 5 out of 15 community hospitals in Pranakorn Sri Ayutthaya province with the total coverage of 246,300 population. Sena Hospital serves more than 200,000 out-patients and 13,000 in-patients annually.

Type 2 Diabetes Mellitus (T2DM) is one of the top five health problems and top ranking on the causes of death at Sena Hospital. The global urbanization with epidemic spreading of metabolic syndrome (MS) and T2DM has made no exception for a rural community like Sena which has drawn our attention.The retrieval of medical information suggested that a large number of diabetic patients have currently acquired the inappropriate food selection and eating habit, less mobilization lifestyle in addition to the unawareness of the chronic diabetic complications as a consequence of poor control of blood sugar in diabetes. Thus, the lack of education in nutritional values, food supplements and substitutions, the essential of energy burning exercise as well as the patho-physiology of diabetes seem to be the main causes of this health problem.

Consequently, the persistently increased annually in the total number of patients, ranging 2513-2763 cases during 2007- 2009, and relatives attending the diabetic
clinic (about 160 to 200 patients per session )has brought the diabetic clinic in out patient department (OPD) of Sena Hospital into chaos. The toiletry utility was over clouded and unhygienic. With no intervention, the situation will certainly bring stress
on both health care customers (increased complaints from patients and relatives) and providers (medical staff/personnel) which definitely affecting both physical and mental efficiency of the health care providers and services.

Moreover, the numbers of diabetic pregnancy (23/857 = 2.68%, 27/793 = 3.40% and 28/690 = 4.06% in 2007, 2008 and 2009 respectively) attending the ANC (antenatal
clinic) and the childhood obesity (105/4211 = 2.5%, 141/4412 = 3.2% in 2007 and 2008, respectively) in the well child clinic (1-6 years) at Sena Hospital as well as in the community (371/6952 = 5.3% for children age > 3 years) are also rising, whilst the age of onset of T2DM is progressively declined.Certainly,a prospective intervention such as pre-diabetic watch-out program is also required to tackle the problem.

Solution and Key Benefits

 What is the initiative about? (the solution)
The initiative is based on holistic humanized care with patient centeredness.

• Leaning the streamline processes.
- Using the strategy of one stop service
enhanced by the information technology.
- To minimize the waiting time, Test Strips for
blood sugar are used in patients who don’t need
other blood tests.

Altogether, one-third of the average waiting time in diabetic clinic was curtailed from 324 minutes in 2008 to 216 minutes in 2009.

• Improvement in controlling of blood sugar.
- Patients and relatives are engaged in diabetic
education and self help program of 3E (Eating,
Exercise, Emotion) empowerment while waiting
for physician.

The increment of patients with HbA1c ≤ 7.0 (from 31.7% to 36.9% and 49.6% in 2007, 2008 and 2009, respectively) is the key benefit.

• Lean and clean hygienic environment
- To alleviate congestion at OPD, an outdoor
relaxation and recreation area with natural
foot massage on coconut shells was created in
front of OPD.
- Toiletry utility was redesigned to provide a
fresh and clean environment and has been
awarded “The Best Public Toilet of the Year”
since 2006.

• Early detection of diabetic complications are also
provided at the OPD.
- Fundoscopic examination was increased from 364
to 1,342, while detection of proliferative
diabetic retinopathy was declined from 2.2% to
1.42% in 2008 and 2009,respectively.
- Cardiac consultation was made available once
every two-month by a volunteer cardiologist
from the private hospital.
- BUN, Cr and urine albumin were determined
appropriately.
- Diabetic foot care and education are provided
by nurse specialists. Patients with high and
very high risk groups were closely followed-up.
- Smoking cessation are strongly encouraged. One
fourth (41/166 = 24.7%) of diabetic smokers
were able to cease and the rest could cut down
the number.
- Screening for alcohol drinking and mental
anxiety including oral health care and
prevention were also performed.

The above initiatives were reflected by the increment of customer satisfaction levels from 88.0% to 89.7% and 91.3% in January, April and July 2009,respectively.

• Early identification and prevention of newly
developed diabetes in all PCUs.
- The primary prevention screening program for
T2DM was implemented in the population over 40
years old in 2007 and over 35 years in 2008
and 2009. There were 28%(5775/19866)and 30.52%
(6771/22186) of the population fell into high
risk groups with 0.80% and 0.83% developed
diabetes in 2007 and 2008,respectively. After
intervention the number of high risk group
(4593/23996=19.14%) and new cases of diabetes
(0.54%) have declined in 2009.
- Diabetic and nutritional education was
introduced in the community. The appropriate
choice of food selection and understanding on
diabetes was increased from 66.53 to 91.67% in
the intervention group.

• Long-term prevention of diabetes. The intervention
was taken further in child-care centers and schools.
- All schools were reorganized up to the
standard quality approval of Health Promoting
School under the Department of Health support
since 2007. Neither sweet and candy nor sugary
soft drink are allowed to sale in schools.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
Under the reformation policy by the hospital director and administrative committee to improve the quality with customer focus at all level of services to fulfill the patient need. Such implementation requires the co-operation and coordination of patient care teams (PCTs) both intra- and inter-organizations. Obviously, the use of information technology (IT) is necessary to speed-up the streamline processes, to minimize human error and workload including the number of paper documentary at Sena Hospital.

The improvement of quality in health care services is also encouraging on the voluntary basis by both National Health Security and Social Security Offices (NHSO and SSO). The add-up budget per capita will be allocated to the institution that has met the standard quality of approval in health care services.

The diabetic prevention and control program has been implemented by the Health Promotion Hospital (HPH) Committee at Sena Hospital, not only for patients and relatives but also for all health care providers and people in the community. Some of these intervention activities were partially or fully supported by the NHSO. Health care providers at PCUs who work closely with the village health volunteers (VHVs) will receive an educational training at Sena Hospital in conjunction with a direct (on the job) training at PCUs by the physician from Sena Hospital who take turn to visit each PCU at least once in every two months.

Working towards the approval quality of health care services, with the emphasis on health promotion, disease (diabetic) prevention and control is not only benefit to all health care customers (patients and relatives), health care purchasers (NHSO, SSO), but also benefit to the health care providers who will spend less amount of budget on cure (as a result from prevention) as well as for the sustainable human resources development to maintain their integrity, work efficiency and healthy lifestyle.

(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.
The main objective of the initiative is to deliver a holistic humanized care for diabetes to the satisfaction of patient need. Such initiative also fulfills the second objective on the health promotion and prevention to reduce the number of patients with T2DM as well as the quality of health care services.

The strategies employed to achieve the above objectives are as follows.
1.Working together as a team towards the same goals.
- The hospital director and the administrative
committee together with all levels of the
health care team were met to discuss and
solving the problems. Specific tasks were
delivered to the relevant groups and
individuals after the exchanging and sharing
their ideas with the emphasis on both
lateral and vertical communication.
2.Installation of the effective IT program.In 2007,
the local area network (LAN) of the IT system
was upgraded to meet the “one-stop service” at
the OPD.
3.Empower diabetic patients with “3E” to facilitate
the changing of lifestyle and eating habit.
E1 - Eating appropriately in quality and
quantity.
E2 - Exercise regularly and appropriately.
E3 - Emotion relaxation.
In addition, an example of appropriate meal for
breakfast are also available free of charge at
diabetic clinic under the voluntary donation
basis.
4.Creation of the clean and lean environment.
- To reduce the number of patients in the
waiting area, a recreation site in front of
OPD was created for those who on the later
queue of the waiting list.
- The fresh and clean toiletry utility was re-
designed with constantly attended by the
house-keepers.
5.Establishment of the two-way referral system with
the PCUs to downsize the number of diabetic
patients attending the clinic at Sena Hospital.
- Approximately 10% of patients from Sena
district who have a better control of blood
sugar (FBS <130 mg%) were referred to follow-
up at the PCUs using mobilization of
physician.
- Conversely,patients with poor control of
blood sugar(FBS>300 mg%)will be re-educated
and counseled individually with closely
follow-up by phone or home visit made by
health care workers.Such intervention could
bring down 56.6% (30/53) and 43.4% (23/53)
of patients with high FBS (>300 mg%) to the
level <180 and <300 mg%, respectively.
6.Training and education were also supported for
sustainable human resource development.
- Long-term medical professional training i.e.
certificate of proficiency in Internal
Medicine, Nephrology, and Ophthalmology etc.
- Specific short-course training for nurses
and paramedical personnel such as diabetic
foot care, nutrition, knowledge management,
IT program, etc.
- All medical staff and health care personnel
were compulsory to attend a one-day course
on “Excellent Service Behavior” organized by
the hospital administrative committee.
7.Prospective intervention to reduce the number of
patients with diabetes.
- Implementation of health promotion program
for the prevention of diabetes
- Metabolic syndrome (MS) and waist
circumference (WC) watch out program for
health care workers and community
- No candy and sugary soft drink in child-care
centers and schools.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
Sena Hospital has been slowly but constantly engaged in the process of quality improvement in health care services for over 15 years. Perhaps, the enthusiastic encouragement came from the small award for the
“ standard sanitation approval of the catering department” recognized by Department of Health, MoPH
in 1994.
- 1995, “The Best Hospital Development and
Reformed” awarded by MoPH .
- 1997, “Honorable certificate for the
maintenance of standard sanitation in catering”
for 4 consecutive years awarded by Department
of Health .
- 1998, “The Excellent Hospital in Waste
Management” from MoPH .
- 1999, “Mother and Child Health Award” from the
Department of Health, MoPH . and the WHO
- 1999, Certificate on “Hospital Quality
Improvement and Accreditation” from The
Institute of Hospital Quality Improvement
and Accreditation (HA Thailand)
- 2003, The first winner award on “Aerobic
Competition” under the health promotion program
from the Department of Medical Service, MoPH .
- 2003, “The Best Mental Health Services” and
“The Best Therapy and Rehabilitation for
Addicts” from the Department of Mental Health,
MoPH .
- 2003, “Clean Food Good Taste” Awarded by the
Department of Health, MoPH.
- 2004, Approval Certificate for Health
Promotion Hospital from HA Thailand.
- 2005, “Oral Health Promotion in Mother and
Child”, the first runner-up on regional
competition from the Department of Mental
Health, MoPH .
- 2006, “The Best Public Toilet of the Year” for
two more consecutive years at the sub-
regional competition level,from the Department
of Health, MoPH.
- 2006, “Excellent Health Promotion Club and
Networking” from the Department of Health,
MoPH.
- 2007, The First Winning Award on “The Best
Activity Intervention for Oral Health
Promotion in Primary School” and another year
on “The Best Public Toilet Award” from the
Department of Health, MoPH .
- 2008, The recognition of “Healthy Workplace”
up to the gold standard of approval for 5
consecutive years (2004-2008) from the
Department of Health, MoPH .
- 2008, The finalist award of “Outstanding
Public Service” for the OPD of Sena hospital,
From the Office of the Public Sector
Development Commission (OPDC)
- 2008, Gold Award on “Mother-to-Child Love” The
Breastfeeding Promotion under the Patronage of
HRH Princess Srirasm, Royal Consort to HRH
Crown Prince Maha Vajiralongkorn from the
Department of Health, MoPH.
- 2009, Certificate of Hospital Care Quality
Award (HCQA) from the Department of Health
Service, MoPH .
- 2009, Winner of “Outstanding Public Service
Award” on “The Holistic Humanized Care for
Patients with Diabetes” from OPDC .

Working continuously together as a team towards the quality in achieving the above winning awards does provide us a strong background for the key development and implementation of the initiative that has been fully described in section 2 and 4a.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Two main obstacles were encountered while implementing the initiative,the limited number of medical personnel ,particularly internists (we have only two internists), other specialists and nurses, and the poor co-operation from patients and relatives.However, the both obstacles seem to be overcome with the promising prospects.
- Currently physicians from different wards and
medical specialties are voluntary joining the
medical services in diabetic clinic at Sena
Hospital.
- The lack of medical experts was temporally
relieved by an ophthalmologist from Pranakorn
Sri Ayutthaya Hospital and cardiac
consultation can be made directly to the
volunteer cardiologist from the private
hospital once in every two months at Sena
Hospital.
- Recruitment of young medical graduates with a
scholarship offer for further professional
training for long-term human resource
development (4 residents of internal medicine
are in training at a moment).
- Heartfelt volunteers (non-medical) from the
community provide their helping hands on the
measurement of physical information (PR, BP,
BW, Ht, WC)
- Village health volunteers work closely with
health care providers at the PCUs in the
health promotion and screening programs.
- One major obstacle in achieving any medical
intervention and therapy is poor compliance of
some patients in changing lifestyle and eating
habit and some did not turn up on the
appointment. However, we do not give-up and
utilize our advantage of being a hospital in
the rural community having a good connection
with the health care providers at PCUs.
Patients with poor control of blood sugar
(FBS >300 mg%)will be reeducated and counseled
individually with closely follow-up by phone
or home visit by health care workers. Patients
who did not turn-up on the appointment at
diabetic clinic will receive a remind phone
call from us with a new appointment date. Our
health care worker will spend a visit to
his/her house if he/she did not turn-up on the
new appointment in order to make sure that
everything was O.K. for the patient. With
these ways of approach in combination with an
example of an appropriate meal for breakfast
available free of charge at diabetic clinic
under the voluntary donation basis, the number
of patients with poor control of blood sugar
and failing to visit diabetic clinic are
declined.

(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
The major financial support (greater than 50%) for the implementation of the initiative was derived from the government annual budget program which support the payment of basic salary and infrastructure facility for providing the health care services.In addition,
the financial support also came from several administrative bodies as follows:
- The National Health Security Office (NHSO)
- The Social Security Office (SSO)
- Thai Health Promotion Foundation (THPF)
- Local administrative bodies at provincial,
municipal and district levels
Finally, several interventions and activities were also supported directly by the hospital income from providing the medical services.

The successful implementation of the initiative required mobilization of human resource from different sectors that has already mentioned in the section 4c.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The initiative is continuously pursued and developed under the constant support of the hospital administrative committee, not only to maintain the function but also to expand and recruit other health care providers such as diabetic foot care specialists into the team. The two-way referral system for good blood sugar control patient follow-up to downsize the number of out patients at diabetic clinic was created, and “on the job training” was provided among members of the PCU network.

For the long-term human resource development, members of the diabetic team both medical and non-medical were supported for both specific and advanced training to enhance the quality of diabetic services.

During the process of diabetic health care system development, various aspects of the system were presenting and sharing to the other health care providers from time to time including at the provincial level where the submission of the work to OPDC was encouraged.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The key elements that brought the success to the initiative were as follows:
- The strong determination of the hospital
director and administrative committee to
pursue and support constantly the activities
working towards the improvement of quality and
the initiative.
- The culture of caring and sharing society in
the rural community among health care
providers and willing to work together as a
team in delivery the health care services to
the patients and relatives is also the key
element of success.
- The positive view and attitude of medical
staff/personnel and health care providers at
PCUs on quality improvement enhanced by the
positive encouragement from different Bodies
and Organizations who confer the Awards.

- The constant financial support from the
central government and at different levels of
local administrative bodies including hospital
income and public donation. More or less they
were all contributed to the success of the
initiative.

Many lessons have learned from pursuing towards the quality and initiative, but the most crucial factors are “working together in harmony (respect each others) as a team” combine with “installation of good system and technology” and most importantly “the loving and caring society with positive view and attitude” will bring the success to all initiatives.

Contact Information

Institution Name:   Sena General Hospital
Institution Type:   Government Agency  
Contact Person:   Dr. Saisunee Poomwitchuwate
Title:   Director  
Telephone/ Fax:   +(66)3521 7118
Institution's / Project's Website:   +(66)3520 1739
E-mail:   phh1402@health2.moph.go.th  
Address:   51 Moo 1 Tambon Chaojed , Amphoe Sena
Postal Code:   13110
City:   Pranakorn Sri Ayutthaya
State/Province:   Pranakorn Sri Ayutthaya
Country:   Thailand

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