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Reform to Provide Humanized Chronic Disease Care
Nakhonchaisi Hospital
Thailand

The Problem

Located in a suburban area of Thailand, Nakhonchaisi Hospital is a small, 30 – bed hospital providing primary medical care services to the community of its vicinity. Nevertheless, a large segment of the 66,384 population, working in the agriculture or agriculture – related sectors, live in the distant areas from the hospital whereby a trip to the hospital is cumbersome, through the demanding transportation such as boat or a series of connecting bus.
According to the health status survey, it was found that amongst the population of 35 years of age or over, 1,295 or 3.61% suffer from diabetes and 827 or 2.31% suffer from hypertension whereas another 8,338 or 23.26% are at a high risk thereof.
Ninety percent of the diabetic or hypertensive patients are the poor and elderly who are in need of an assistance from their family members for every hospital visit. The visit trip usually begins around 4:00 or 5:00 a.m. in the morning and thereafter each patient has to spend 4 to 6 hours in the hospital due to the time – consuming processes with numeral procedures of the services. This has a profound impact on the diabetic patients with complications such as foot infections, amputated limbs, blindness, or swelling from kidney failure as well as the hypertensive patients with temporary or permanent paralysis. Thus, the waiting time will boost up pain and suffering of the patient as well as their family members.
Nakhonchaisi Hospital receives over 136,000 visits annually or about 500 visits per day. More than 70% of the patients, approximately 350 outpatients, visits the hospital in the morning and lay down the heavy burden to the 3 physicians daily reflecting in an extremely low doctor to patient ratio. As a result, it concedes a long waiting time for the patient and a relatively short care time provided by the physician; this ranges from 3 to 5 minutes per patient with chronic illnesses. The inadequate quality of care often results in the serious complications of the patients with chronic illnesses. Thereof, a handful of such patients receive the adequate medical care and attention. Some patients are fostered to leave without an adequate follow – up service. In 2006, the situation of 68% of the diabetic patients and 25% of the hypertensive patients were uncontrollable, resulting in critical complications. These patients are, therefore, at a high risk of death, disability, organ failure, impotence, and stroke. This eventually deteriorates the overall quality of life of the patient, family members, relatives, and the community.

Solution and Key Benefits

 What is the initiative about? (the solution)
The solution to the problems related to poor service time is to increase accessibility and to improve the health care provisions for chronic diseases through streamlining the administrative processes to facilitate the timely service. The patient processing shall be simplified to exclude the tasks be carried out by the patients or their family members. The follow – up scheduling system for hypertensive patients was improved by rearranging the follow – up to the afternoon session with the patients’ agreement on date and time. In order to facilitate the prompt and on – time session, a special service channel is established assuring the service time at 25 minutes, saving 3 – 5 hours for each visit, or 36 – 60 hours per year per patient, resulting in an estimated reduction in economic of scale 1,176,000 baht (US$ 35,209) per year.
Consequently, as the better doctor – patient ratio indicating, the physicians have more time with the patients. By an earnest implementation of a new concept namely “case management” to provide more compassionate and humanized care by the current staffs, the programme has been extended. Henceforth, the nursing staffs take the role of nurse – case manager providing a personal assistance to a particular patient and his/her family members in every visit. Each case managing nurse will also concerts the servicing with the multidisciplinary staffs, in planning the delivery of an appropriate care, encouraging change in daily health behavior and monitoring the outcome to ensure the better quality of life of the elderly patients.
Under the “multifunctional” core value whereby all of the staffs are ready, with intention and pleasure, to take any additional roles in the streamline procedure. Accordingly, the service is reduced to 4 procedures from the previous 7, thereby decreasing the conclusion of service process from 125 minutes in the rush hour to 25 minutes. Interestingly, patient satisfaction is increased from 75% to 83%.
Another important core value is “humanized care”, case management is another innovative method introduced to maintain a high quality care, which changes the medical perspective of the patient. Case management has helped hypertensive patients reach the controlled blood pressure from 75.19% to an astounding 90.23%, reducing the hypertensive crisis cases from 13.31% to 7.22%. The loss of follow-up cases is reduced from 3% to 1%. The number of successful case of diabetic patients in controlling blood glucose levels is increased from 32% to 53.81% with continuously tendency of improvement which eventually led to a reduced number of incidences of life-threatening and other disabling complications. For example, kidney disease is reduced from 20.16% to 15.67%, eye disease is decreased from 24.60% to 17.03%, and nerve damage of external limbs is decreased from 30.21% to 22.04%. In sum, this enhances the better quality of life of the elderly with chronic illnesses.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The patient care team and the administration of the hospital realized the threat of diseases and health status of the elderly patients with chronic illnesses would be affect, had the various existing problems such as the untimely medical care, the safety of diabetic and hypertensive patients, and an inconvenience of the elderly patients with chronic illnesses along with their family members, not properly addressed and corrected.
Thus, a joint meeting between the OPD unit and the other relevant units such as pharmacy, physicians, and the emergency medical unit, was arranged to reform the work processes aiming at the establishment of the more efficient, and compact processes, as well as founding an e-service, and empowering the nurse – case managers in providing a personalized, compassionate, and humanized care to patients with chronic diseases and in encouraging the altering of health practices of the patients and their family members as well as engaging into the afternoon follow – up session. This service reformation conceded the higher quality of care for elderly patients with chronic illnesses and their improved quality of life.

(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 meet the needs of the elderly patients with chronic diseases for the better quality of life through an easy access to quality, expedited medical care service, the hospital administration had formulated a crystal clear policy aiming at the compacting of service processes, the increasing of the service channels, and an improvement of the quality of care for patients with chronic illnesses. Accordingly, paradigm shift of the hospital staffs and the core values embracing the staff’s loyalty to the hospital and colleagues are in need to found the quality services acceptable, desirable, and admirable to the customers. The leadership of the director of the hospital and administration setting a good example in teamwork, their dedication and creativity in applying knowledge management and information technology to the development of the work procedure in automation and quality of services are account for the materialization of the Case Management principles into implementation design.
The reform of the medical care and the improvement of its quality for patients with chronic illnesses comprise the following objectives:
1. Reduce the unnecessary service procedures and waiting time to eliminate the time loss.
2. Improve the quality of care for the patients with chronic diseases through the introduction of best practice.
3. Reduce death and disability resulting from complications of diabetes and hypertension.
Thereof the strategies applied to achieve the abovementioned objectives are as follows:
1. Initiate a paradigm shift of the staffs using organization development techniques to encourage their participation, to change the organizational culture, and to implant service mind.
2. Redesign a new service system using knowledge management and information technology in view of the introduction of e–services.
3. Craft a model of humanized medical care for elderly patients with chronic disease using a nurse–case manager.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
Nakhonchaisi Hospital started its hospital quality management system since 2002 and has been accredited by the Healthcare Accreditation Institute (Thailand) since 2008. In order to increase the efficiency and quality of medical care for the patients with chronic illnesses, especially diabetes and hypertension, the hospital administration laid a plan to improve its service along with the enhancing the knowledge and skills of its personnel. The initiative piloted from fine–tuning the staff’s attitude to lay down the common value embracing their loyalty to the hospital and colleagues according to the motto “love hospital, love colleague, make the hospital the second home”, building the Cross–Functional Team working, altering the service providing behavior to provide the high quality services acceptable, desirable, and admirable to the customers.
With dedication to develop the service system to meet the public needs, a giant leap forward reform of the service system was initiated with the following innovative administration:
1. In 2005, E–service exploiting knowledge management and information technology in place reduced the number of staffs operating daily from the 7 persons to 3 persons. Patient profile can be retrieved faster whereas patient registration can be completed by using smartcard, resulting in the number of initiatives such as reducing the use of time and resources as well as the medical record errors, introducing one stop service which eventually extended to cover all services.
2. Multi–functional Person concept via a paradigm shift started in 2006.
3. Workload management is done in 2007, with an emphasis on the use of efficiency and effectiveness principles in actual implementation to ensure that the workload is well distributed in 2006. Some of the elderly patients with chronic diseases have been moved to receive care in the afternoon via implementing the medical appointment system where those who “arrive on time receive care on time”. Thus, for the patient’s convenience appointments can be made at an available time and those who come by appointment go through a separate queue that has a guaranteed maximum service time of 25 minutes.
4.Two years later, case management is an initiative with innovation to raise the quality of care for patients with chronic disease to the best practice level. Innovative thinking is put to actual implementation to reform the patient care system for chronic illnesses. This approach is a modernized change to the perspective on each patient from treating the “disease” to treating a “human” with a compassionate feel in providing humanized care to each patient as their private case worker. This enables the hospital staff to better meet the individual care needs of each patient. Each patient is tracked on a monthly basis, resulting in better disease control in patients with diabetes and hypertension and in the prevention of critical life-threatening or disabling complications. The patients can live a normal life and have a high quality of life just like other people without any disease.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
At the onset in the development of the care system the primary obstacle was the lack of self confidence of the personnel. In other words, the employees generally did not feel they had the capacity to provide the quality level of care demanded by the new service design methodology. However, after the use of “organization development” principles under the “patient-centric” objectives, a stage for the exchange of ideas was set within the organization. The final outcome has been many praises, commendations from our hospital’s site visitors, and various national awards. All this has greatly encouraged our employees, making them proud of themselves and of the organization. In addition, the hospital administration has created an incentive system to encourage quality performance on the part of the employees by a system of benefits such as arranging housing, lunch, and snacks/drinks for 24 hours. This obstacle, therefore, was no longer considered a barrier.
Another important obstacle was the communication within the organization, especially the dissemination of news to communicate between the administration and the various levels of employees within the organization. The communication often led to an incorrect interpretation of the memo, causing problems among the various departments. The hospital tackled this problem by adding other communication channels to have multiple channels both formal and informal. In addition, many activities were organized to continuously foster strong ties among the employees at all levels within the organization.
Another obstacle was the lack of funds and budget. The hospital receives about 50% of its operating costs as a government grant budget. The hospital decided to address this problem by carefully regulating its expenses and by increasing revenues through providing proactive services such as community outreach programs on disease prevention, vaccinations, and onsite health checkup services for external organizations. This enabled the hospital to overcome its budgeting challenges.

(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 resources used to improve the quality service include:
- Human resources. The physicians, nurse-case managers, pharmacists, and other health care specialists first formed an alliance to improve the service mindset and to encourage a paradigm shift towards the multifunctional personnel for the benefit of the organization.
- Information Technology Equipment. This includes computers, local area network, and queuing machines from the hospital’s budget.
- Computer Software (open-source software) to support the needs of medical service providers from the hospital’s budget.
- A new building and some medical equipment were donated for this cause by the private sector and non-profit organizations such as the Rotary Foundation and Nakhonchaisi Hospital Foundation.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The newly reprocessing designed service system remains in permanent operation and, further, has been extended to all target groups of all hospital services including in–patient department (IPD) for instance, the complete one stop service for maternity ward. Cultural change is also commenced through the revamping of internal administration aiming at the empowerment of self – monitoring and report practice. In addition, to seeking hurdles and enabling rapid response to operative’s needs, staff’s open accessibility to executives is channeled through the regular visits to all departments of top administration exclusively the director of the hospital.
External enhancement also plays an important role in the hospital services’ improvement. In order to ensure the sustainability of public services’ improvement, auditing and supporting agencies such as The Office of Public Sector Development Commission (Thailand) organizes an annual contest on the public service innovation and quality. Furthermore, the Healthcare Accreditation Institute (Thailand) and the National Health Security Office (Thailand) has been following up the progress of quality and standards of the hospital on a systematic and regular basis. These accreditation bodies have commended Nakhonchaisi Hospital to be a good model for the providing of quality and efficiency services, and the system remains in operation thereof.
The other 719 community hospitals in Thailand whereby the similar problems on congestion, service time, and quality for elderly patients with chronic diseases are in common may review and adapt the Nakhonchaisi model to suit their needs with relative ease and low budget, given that the system is founded on the simple technology and resources available in the community hospitals throughout Thailand.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
Since its inception, the medical care for elderly patients with chronic illnesses is established to be a provider–customer balanced service administration conceding a conclusive outcome in raising customer’s satisfaction through the reducing of waiting time for the patients and family members, the enhancing of the timely humanized care delivery of the health professionals. Accordingly, the quality of life of the patients with reduced complications, and the saving of expenditure of the patients, their family members, Nakornchaisi Hospital, and Thailand are acquired.
Through a continuous reform of the service system and its quality, Nakhonchaisi Hospital has received several prestigious awards and recognition as followed: appraisal
- Excellence Award for Service Innovation, the Office of Public Sector Development (Thailand), 2009.
- Certification of Honor for the establishment of service for Influenza A H1N1, the quality assessment committee of the National Health Security Office (Thailand) and the World Health Organization (WHO), 2009.
- Good Work Risk Assessment of Employees, the Ministry of Health (Thailand), 2009.
- Certification of Hospital Quality Standard Assessment, the Healthcare Accreditation Institute (Thailand). 2008.
- Representative for an innovative program on “Providing Outpatient Maternity Ward Facility Service”, the Hospital Accreditation Forum, 2008.
- Claim Award First Runner up, the National Health Security Office (Thailand), 2008.
- Representative for an innovative program on “An Automation System for OPD Services”, the Hospital Accreditation Forum, 2007.
- Winner of Award “Excellence in Medical Equipment Maintenance System”, the Ministry of Health (Thailand), 2007.
- Internship site service for medical, nursing, and pharmacy students of university in Thailand such as Mahidol University, Christian University, Huachiew University, Boromarajonani College of Nursing, and Silpakorn University.
- A Study center in E-services for patients and in innovative use of information technology of Thailand.

Lessons learned
1. Paradigm shift of both provider and customer can be achieved in assistance of a reform of services through the application of Lean Management principles on service administration and quality improvement for elderly patients with chronic illnesses through humanized care.
2. Through an integrated care of multidisciplinary aiming at the holistic treatment of body, mental, sentimental and social aspects as well as the altering of health behavior of the patients the genuine solution to the problems and the improved quality of life of the patients is achieved.
3. The hospital is ready to serve as a model for other community hospitals in the improvement of medical service and health care for patients with chronic illnesses.
4. The Humanized Chronic Disease Care system can be extended to 2 pilot health center of the Nakhonchaisi Hospital’s network.

Contact Information

Institution Name:   Nakhonchaisi Hospital
Institution Type:   Government Agency  
Contact Person:   Chanvit Suphpaprasith
Title:   Hospital director  
Telephone/ Fax:   +66 34 331174
Institution's / Project's Website:   +66 34 331030
E-mail:   chansith@hotmail.com  
Address:   5 moo.3 T.nakhonchaisi
Postal Code:   73120
City:   A.Nakhonchaisi
State/Province:   Nakhonpathom
Country:   Thailand

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