Songklanagarind Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Problems and General Performance Conditions before Improvement Songklanagarind Hospital, Faculty of Medicine, was established on February 22, 1982. The super tertiary, 816 beds hospital with its royalty bestowed name “Sonklanagarind” is a research and academic center of medical and health sciences. The main mission is to manage critically-ill and complicated cases, and it also serves as a referral center in Southern Thailand. The number of patients is increasing with each year. In 2013, the hospital served 917,256 outpatients, 39,132 inpatients and 51,393 emergency cases. The Case Mix Index (CMI) of patients treated in Songklanagarind Hospital has the highest score in Thailand. In addition, accounted for in this number, are more than 100,000 patients from the unrested area of three Southern-border provinces. The hospital revenue comes from three major health funds: Health Security, Social Security and government welfare scheme. However, the reimbursement rate is considerably lower than the real cost of a medical school hospital such as this; therefore, the hospital must bear the ensuing financial burden. Indeed, as a state hospital under the Ministry of Education, the number of personnel has been limited by the state policy since 2000. This, in fact, contradicts the hospital’s expanding mission in responding to the universal healthcare coverage scheme launched by the government in 2002. At the present, among the 4,915 personnel members, 2,107 rely on the hospital self-generated revenue. As a medical center in the Southern Region of the country, which is prone to violent conflict, the hospital is confronted with the patients’ high expectation of being able to access efficient care and fast services. This poses a serious challenge to the hospital to meet all the public needs. Moreover, the hospital has become a practice centre for medical students, nursing students, pharmacists, medical science professionals as well as specialists in more than 40 disciplines. In order to set a good model for the personnel of these disciplines, a policy regarding providing services with high standards of quality and virtue at Songklanagarind Hospital must be created in order to ensure the institution’s continuing development.

B. Strategic Approach

 2. What was the solution?
Strategic planning is very important in an organization. Songklanagarind Hospital has developed its strategy since 2002. The updating of information regarding changes in technology, government policy, internal KPI, etc. in the strategic planning process (SPP) is carried out by the Strategic and Policy Department. The SPP and strategy are reviewed annually. In 2012, the newly-appointed Faculty Dean and his team (Figure 1), together with the Hospital Committee, Faculty Committee, partners and collaborators, reviewed the faculty’s visions, missions, core values and developed the present strategic plans as shown below: Guiding Principle: “Our soul is for the benefit of mankind” Core Values: 1.Focus on quality 2.Patient-centered service 3.Working as a team 4.Safety and risk awareness 5.High ethical standards Policy: 1.Focus on the quality of treatment, leading to a good learning model for training medical students, interns, residents and other medical personnel to conduct their profession with certain desired characteristics 2.Act in accordance with patients’ rights 3.Develop and assure treatment quality in all areas, which can be assessed by an external organization 4.Treatment, focusing on the patient and following evidence-based practices. Among treatment teams, there should be good communication; thus, allowing patients and their relatives access in the decision-making process and information regarding treatment plans and/or progress. 5. Complete and accurate medical records 6. Provide treatment to all, regardless of financial status 7. Fair reimbursement to stakeholders 8. Review of equipment to evaluate not only its efficiency but also sufficiency 9. Appropriate drug usage based on academic knowledge consideration and drug quality assurance 10. Cooperation with other local hospitals to increase treatment efficiency and improve performance potential 11. Checking and improving work quality based on suggestions, opinions and sensitivities of society. Also, all complaints should include a clear explanation 12. Being a good model of a health-service venue 13. Being a medical practice centre for medical students and fellows under the supervision of academic staff 14. Fund mobilization through appropriate mechanisms Key strategic objectives of Faculty of Medical and its relation to strategic challenges as shown below: 1.Integrated all 4 missions of Faculty by focusing on quality healthcare that will be the adopted standard for future physicians and healthcare personnel. 2.Embedded the Faculty’s guiding principle, “Our soul is for the benefit of mankind,” into daily operation . Hospital integrated spiritual healthcare into the patient care process, e.g., palliative care, healing environment, etc. 3. Quality ways for example - Ensure quality and safety of care using the Hospital Accreditation standard. - Enhance management quality using Thailand Quality Award framework . 4. Networking for the benefit of our patients: Hospital increased patient accessibility by collaborating with hospitals in Southern Thailand, resulting in an increase in referred patients, which led the highest CMI score among all hospitals in Thailand 5. Investment and cost reduction by : - Evidence-based management to improve patient outcome with appropriated costs - Used more medications from General Drug List with a quality guarantee by pharmacists - Self-developed Hospital Information System (HIS). The strategic objectives were cascaded down in order to become part of each unit’s active plan via a leadership system. All level of KPIs are monitored and reviewed for an alignment and improvement throughout the Faculty include hospital.

 3. How did the initiative solve the problem and improve people’s lives?
Hospital’s quality has undergone continuing development in the following areas: 1.Information Technology system The IT system has been continuity developed since 1982 and become a good model and study resource Centre for other medical Institutes nationwide, 2.Response to Needs and Requirements of clients 2.1 Hospital response to customer requirement by using manage channel such as satisfaction survey (twice/year).incident report from all work unit and customer complaint. 2.2 The number of patient increase each year using Lean concept and staff rotation to satisfied and facilitated all patients. 3.Network and collaboration with other hospitals in the region by using multiple communication channels. Satisfaction of general hospital by using 5 linkert scale increase from 3.13 in 2010 to 3.70 in 2013. 4.Support to increase efficiency and collaboration e.g., training, joint academic activities. 5.Management of Difficult and Complex Diseases The hospital has been successful in: 1) cancer treatment; 2) cardiovascular diseases; 3) minimally-invasive surgery of 4) physical and spiritual care for trauma patients due to violence in Southern Thailand. 5) The Extreme Preterm Birth Center – the first and only one in Southern Thailand, providing comprehensive care for newborns with a birth weight lower than 1000 grams.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Strategies used to achieve service development The quality development of Songklanagarind Hospital places an emphasis on continuous cooperation, which enhances permanency as well as meets excellent standards, while, at the same time, satisfying customers, staff, and stakeholders. Hospital Accreditation (HA) and Thailand Quality Award (TQA) criteria have been the main impetus throughout the past 15 years. In 2001, Songklanagarind Hospital was the first hospital in Thailand approved by the Healthcare Accreditation Institute (Public Organization) and has been continuously reaccredited till the present. In 2014, the hospital is a leading organization, implementing the higher criteria of Advanced Hospital Accreditation and Spiritual Hospital Accreditation (SHA) as we strive for higher objectives. At the same time, the TQA criteria are also used as a driving force toward a quality comparable to international levels. The major implementation concepts are as follows: 1. Creating a cooperative environment to drive our values, vision, policy, and strategic objectives. 2. Recruitment and development of all hospital staff considering individual responsibilities, potential, and strategies. The main human resource development concepts include developing workforce competency, raising happiness levels, and wisdom and career progression. 3. Appointed two main groups responsible for quality of work development: 1) Functional teams, implementing annual development projects run by all Heads of Unit that align with the hospital action plan, 2) Cross-Functional teams led by the Patient Care Team (PCT) and various committees like Infectious Control Committee, Operating Room Administration Committee, Emergency Room Committee, etc., which have a major role in creating an effective plan (Plan) that drives the actions (Do). This follows the performance outcome review (Check), and Action Plan; thus, leading to further improvement (Act). 4. Developing quality assessment indicators that provide accurate results, continuous assessment and comparability with other national and international hospitals. 5.Organized knowledge-sharing forum to share and publicize best practices and create an environment for innovation. 6. Arranged external assessments from national institutes such as Healthcare Accreditation Institute (Public Organization), Thailand Productivity Institute and Office of the Higher Education Commission (OHEC). Their key concepts include a self-assessment report, an internal survey and further feedback.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Stakeholders and Participants There are four levels of teams involved in implementation: 1. Organizational level The Hospital Administrative Team and the Executive Board set up the development structure and relay strategies and policies to the Head of each unit and other staff. 2. Process level Emergency Room Committee, Patient Care Team (Multidisciplinary Team), Infectious Control Committee, etc. work together as a cross-functional team to design the management process related to patient care. 3. Unit level Each unit sets indicators that conform to the hospital’s action plan. 4.Individual level (Head and other work force) Each level of staff employs the PDCA cycle in their practice. They plan and set supporting resources, management goal, (Plan), develop work processes (Do), evaluate their work using indicators (Check), and act as needed to ensure further improvement. Key Stakeholders involved in the implementation are: 1.Patients and their relatives take part in the care process. Patient and their relatives are encouraged to voluntarily join self-help groups during their stay in the hospital. 2.Private and local government organizations: For example, the hospital has collaborated with Kohong Municipality to develop a Public Health Center in Kohong Municipality and the Rotary Club and Songklanagarind Foundation have established the Yensira Building, a shelter home for poor patients and relatives. Government agencies such as Social Security Fund, Universal Healthcare Fund provide some care guidelines and financial support. 3.Medical students, trained physicians and other healthcare workers are involved in patient care and support their families.
 6. How was the strategy implemented and what resources were mobilized?
Besides the human-resource management mentioned earlier, the Financial-Resource Management is carried out as follows: Songklanagarind Hospital is a state agency that raises and manages its own income, but it is also granted funding from the central government budget. At the present, all expenditures of the Faculty of Medicine account for more than 4,500 million Baht a year, while 2,932.53 million Baht come from the faculty’s revenue. The faculty revenue is allocated according to the faculty’s strategic policies, which are under the regulations and supervision of the university. The allocation of the budget for service development can be categorized into the 3 main groups: 1.Staff development budget consists of 3 types: 1.1 Executive-level development budget covering the development of the institution’s vision, its leadership for change, and competence in the development of the quality of work. 1.2 Career development budget for medical instructors, physicians, and nurses covering short-term and long-term training both in Thailand and overseas. It focuses on individual competencies, based on job description, towards professional excellence and the treatment of severe and complex diseases. 1.3 Staff development strategy covering staff related to Information Technology, English language instruction, and usage of work development tools. All staff involved in the above aspects are granted funding to attend training courses as per their personal interest, which is dispensed in the frame of an individual yearly budget. The HRD sets the overall development plan and evaluates outcomes. 2. Management of financial rewards for development projects: 2.1 Annual performance assessment awards for departments that achieve outstanding KPIs (with a 40%-70% ratio of the overall outcome of each department) 2.2 Management of annual promotion quota categorized into 3 levels of performance-based achievement – average, above average and below average. This result also impacts the management of advancement quota for individual staff members and heads of unit. 2.3 Management of rewards for office heads, who successfully complete the annual development project approved by the Service Quality Development Committee. About 200 heads of office each year are awarded up to 6,000 Baht monthly depending on the individual project. A yearly report on its performance progress is required. 3. Investment in modern medical devices and technologies to enhance the overall level of our institution’s treatment capability. The actual plan is set up by the hospital administration team in collaboration with the relevant hospital departments, and is considered and approved by the faculty Steering Committee. The submitted plans (performance plan, staff-development plan and medical-device-investment plan) must not overlap and/or duplicate current devices, must reflect the existing institutional readiness. Environment was renovated as appropriate to support patient care and healing.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Success outputs and examples are shown below: 1. Performance based on the guiding principal philosophy, “Our soul is for the benefit of mankind” - Best patient safety in Thailand, e.g., Ventilator-Associated Pneumonia (VAP) rate in ICU. - Highest Case Mix Index (CMI) in the country - Creation of innovations such as A-Knife (a Scalpel for Percutaneous Trigger Finger Release), and Latex Polymer Head Pad (for intra operative pressure sore prevention) 2.Organizational culture resulting in continuous enhancement of work quality and being a best-practice institution in many aspects of patient care. - First medical school in the country to have its quality certified by HA –the 4th time in April, 2014 - Receiving the Thailand Quality Class (TQC) Award in 2007 and LEAN Award in 2010 - Starting to use of visual control for medication safety in 2005 (Figure II), which is applied worldwide and nationwide by pharmaceutical companies. 3. Self-developed Hospital Information Technology system connecting every hospital service unit. - A user-friendly and economical system and being a role model for other institutions nationwide. - Considered as the best paperless healthcare IT systems in Thailand. - Capable of monitoring daily hospital operations such as physician prescriptions and laboratory results. 4. Strong cooperation networks for the benefit of both patients and relatives. - Establishment of networks such as the Rotary Club, Local Administrative Organizations, and foundations helping the poor as well as those affected by the unrest situation in the South. - All network hospitals in Songkhla Province have been quality certified through the Southern Hospital Accreditation Collaboration Center. - Enhancing service accessibility for all patients through the established referral system. 5. Dedicated workforce with a high professional capability in spite of working in a situation of unrest - Numerous innovations and awards related to patient care. - An Emo-meter reading indicating that 74% of employees are engaged with the organization, which is higher than the national average of 50% (surveyed by National Institute of Development Administration (NIDA), 2013).

 8. What were the most successful outputs and why was the initiative effective?
The major concepts applied in monitoring are: 1.All levels of workforce are encouraged to use the data related to patient needs and/or complaints in order to improve our service quality. 2.The hospital makes quality outcome the basis for its institutional management. 3.The hospital also participates in the benchmarking system hosted by the Thailand Hospital Indicator Project(THIP)in order to evaluate its quality and learn from other best-practice organizations. Quality frameworks such as TQA and HA guide our improvement plan. The hospital’s service tracking and assessment system as well as the hospital-wide information technology system help the hospital collect, analyze and evaluated daily service data led to hospital improvements as per the following level. 1.Executive Board reviews hospital KPIs, action plans progress reports every month. 2.Hospital Morning Briefing monitors and improve action plan every week. 3.Quality Team agenda include quality development report, Incidence report, Risk management, Complaint management results which reviews every month. 4.Work systems was reviewed and improved the performance by various committees e.g. or committee. 5.Patient Care Teams take action for patient care improvement. 6.Songklanagarind Foundation provide budget for the poor people and for support Yensira building.

 9. What were the main obstacles encountered and how were they overcome?
Problems, obstacles and management A) Imbalance between number of patients and accessibility to healthcare Solutions: 1. Increased system efficiency by reducing the patient length of stay, which allowed for a better patient admission management and flexible hospital bed management. In addition, after-hours services were offered. 2.Enhanced healthcare efficiency of hospitals nearby through trainings, teleconsultations as well as providing clinical data and treatment plans to all patients discharged from our hospital. B) High resignation rate and work overload Solutions: 1. Implemented the Lean administrative concept to reduce the“7 wastes” 2. Increased the use of information technology and other supporting outsourced services. 3. Improved workforce benefits to help decrease the number of nurse and other health professional resignations. C) Deficiency in the capital budget Solution 1. Using utilization management to enhance productivity in all work units 2.The expenditure control and loss reduction was made possible by procurement development, material quality analysis, price comparison, stock management, reasonable medication use, systemic drug control, and the use of approved locally-made drugs replacing imported ones. These measures have resulted in Songklanagarind Hospital’s medication criteria becoming a national model. 3. Strategic investment via a collective leadership system 4. National and international financial resource management through government budgeting, private company collaboration, and donations As historically excellent contributors to the Songklanagarind Hospital Foundation, they have resulted in the continuous increase of our fund-raising efforts (From 80,000,000 Bath in 2007 to 180,000,000 bath in 2013)

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Benefits 1. Efficiency-safety Despite the fact that the number of critically ill patients is increasing, causing the mean of severity of disease in the hospital to be the highest CMI nationwide, we can decrease patient length of stay as shown below: 1.1 Length of Hospital Stay decrease from 7.87 in 2008 to 6.61 days in 2013. 1.2 The hospital puts a priority on safety and reducing complications. 1.2.1 Infection Rates of Ventilator Associated Pneumonia in ICU is the best practice Nationwide in 2013 [Thai Hospital Indicators Project (THIP)] 1.2.2 Medication Error Rates are within international standard 1.2.3 Readmission Rates within 7 days is decrease from 0.88% to 0.51% from 2010 to 2013 respectively. 2. Service Accessibility More patients from the 14 southern provinces can reach Songklanagarind Hospital. 2.1 Outpatients / Inpatients / Referred Patients increase each year. hospital serves … out patient in 2013 3.Patient Satisfaction and Complaint management 3.1 Patient satisfaction is increasing 3.2 Complaints management result: Hospital is able to resolve the complaint immediately in 63%. 4.Financial Assistance for Poor Patients and Relatives 4.1 The amount of overall financial aid reach 37.4 million bath in 2013. 4.2 Yensira Building: a shelter for poor patients and their relatives. With infinite kindness for poor people living in the southern region, in 1986 His Majesty King BhumibolAdulyadej donated his personal funds to assist in the establishment of a shelter for poor patients and their relatives from acrossthe14 provinces. This shelter for the poor helps a lot of patients with cancer and other chronic diseases live comfortably while receiving long-term treatment. It is located in a temple just the opposite of the hospital and can accommodate up to 450 people per day. In 2012, it was awarded a national commendation. 4.2.1 Number of Visitors and Expenditures increase to 132,675 and 2,536,975 bath in 2013. 4.2.2 Funeral Assistance Welfare On average 15-30 families per year have received funeral assistance welfare from Songklanagarind Hospital since 2008. 5. Staff/ Service Staff / Hospital 5.1 Engagement/dedication/satisfaction (Emo-meter) The hospital places an emphasis on staff happiness and satisfaction. Thus, many facilities have been provided to promote a better quality of life, such as safe and convenient residences, fitness centers, suitable landscapes and environment, and health-care benefits covering staff members and their families. The results showed might engagement in 74% of workforces. 5.2 Employee’ career Progression is increase every years 5.3 Turnover Rates of nurse reduce for 9% in 2011 to 6.88% in 2013 6.Awards: Hospital Accreditation (HA) (2001), Claim Award (2004-2008), HA 1ST Re- Accreditation (2005), Thailand Quality Class / 5S Silver Award/ HA 2nd Re-Accreditation (2007), KAIZEN Award(2009), KAIZEN Award/ Lean Award (2010), MechaiViravaidya Award/ KAIZEN Award (2012), Surveillance Hospital Accreditation (2013), HA 3rd Re-Accreditation/ PMQA (2014)

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Sustainability management and magnifying its outcome to other offices The hospital has performed the following: •Valuing and building organization culture 1. “Our soul is for the benefit of mankind” serves as our guiding principle when making any decision concerning matters of social impact and potential conflicts of interest, such as the consideration of expanding or reducing services, priority management of accessibility, placing more emphasis on disease severity than patients’ socioeconomic status, treatment costs, management, and monitoring that the quality of service responds appropriately to customer needs. 2. In order to generate the sustainability of our guiding principle, staff and medical students undergo orientation training. Furthermore, various mechanisms, including job descriptions, KPIs, and development plans in all of the hospital’s units, have been implemented. Staff is required to complete performance assessments, and comparative analysis is conducted. Performance outcomes directly impact compensation and budgets for annual development. Outstanding personnel are encouraged to present development seminars in order to inspire their colleagues. • Magnifying achievements for other offices using the following channels: 1.Alumni: Songklanagarind Hospital trains over 180 physicians and 80 specialists each year. Graduates have been trained to never forget our guiding principle while focusing on service quality, unity, and teamwork. Our graduates work nationwide, driving the concept of quality care to others. The hospital also places a priority on supporting all of our alumni, especially in the cooperation of the treatment of complex diseases. As a result, various communication channels have been opened, such as E-library, counseling visits, and moral support. Short and long-term training courses have been developed in order to address any problems that may arise. 2.Health care institute nationwide 2.1. HACC was established to support the development of all neighboring hospitals in order for these hospitals to become accredited. By sending surveyors to visit and guide all of the targeted hospitals, the number of accredited hospitals is higher than the national average, although they are rural and face a great number of difficulties. 2.2 Our quality experts are always volunteering to be guest lecturers, advisors, surveyors or assessors for various organizations, medical schools, and many of the nation’s leading hospitals. In addition, the hospital provides opportunities for many observers each year to visit and share technologies with other hospitals and various organizations –especially in the areas of information technology, drug management, safety management, infectious disease management, staff development, performance development, palliative care, centers of excellence, and the management of trauma patients; recently Harvard Medical School has expressed interest in collaborating in a trauma fellowship training program.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
What are the lessons learnt from service development? Essential factors for being successful: 1.Dedication of the team leader, with an emphasis on quality of work. 2.Our guiding principle, values, and strategic policy provide excellent guidance in valuing and harmonizing us to work for the benefit of mankind. 3.Support from the University Council and university executives that allow more empowerment and flexibility in terms of issuing regulations related to the management of the medical faculty. 4.There is an effective performance assessment system in place, which emphasizes quality of work. 5.The staff of the Faculty of Medicine is dedicated and has a strong intention to work for the benefit of mankind. 6.The Faculty of Medicine uses an international organizational quality framework, including Hospital Accreditation (HA) and the Thailand Quality Award (TQA). We also employ various quality tools, evaluation mechanisms, and follow-up feedback for continued improvement. 7.The faculty has effective information technology, developed by staff, without any annual fee requirement. 8.The faculty cooperates with other organizations. Learning outcomes 1. The organization has to proactively continue to develop. 2. Everybody has to work as a team with mutual visions and strategies while integrating work vertically and horizontally. 3. Even though quality development requires a large amount of money, lack of quality costs more, and could discourage employees. 4. There are many quality tools, thus, we must effectively select the tools which are suitable for the workplace and compatible with personnel, within an organizational context. Suggestions 1. Keep on doing all the good we can, following the guiding principle, “Our soul is for the benefit of mankind”. 2. Choose a suitable framework and key quality indicators and develop the database. 3. Improve the team and ongoing work system. 4. Enhance collaborations with other organizations in order to benefit patients and society in the support of good behavior.

Contact Information

Institution Name:   Songklanagarind Hospital
Institution Type:   Government Agency  
Contact Person:   Mr.SUTHAM PINJAROEN
Title:   Faculty Dean  
Telephone/ Fax:   + (66) 74 451158/ +(66) 74 212900
Institution's / Project's Website:  
Address:   Faculty of Medicine, 15 KANJANAWANICH ROAD
Postal Code:   90112
City:   Hatyai
State/Province:   Songkhla

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