| 4. In which ways is the initiative creative and innovative?
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The strategy of the project was part of the general strategy of the ministry of health in Bahrain and was implemented according to the clear missions and objectives defined in Bahrain’s economic vision 2030 as well as of Bahrain’s Health Agenda. At all times, our central goal was to ensure the availability of high quality service to all population.
The initiative was conducted according to 5 key phases.
(1) observation and planning
The project began by studying and evaluating the status and the quality of the service provided by our department. Salmaniya medical complex serves around one million of the Bahraini citizens with a total number of around 40,963 admissions per year. Although most of these admissions are under the care of the internal medicine, the department is responsible for a total of 221 inpatient beds only. As a result, one of the main challenges to our department was the large number of pending admission in the emergency department. In 2010, the average number of pending admissions was 40 admissions per day. Our proposed solution was managing patient’s discharge process via developing a system for early discharge of authorized patients.
We planned to start in the medical department as it is the largest departments in the hospital with a bed capacity of 250 beds in 13 wards in the hospital.
(2) Piloting
The project started in October 2012 with a pilot study by enrolling five auditors to monitor the discharge process in four out of 13 of the internal medical department wards. The auditors were highly selected medical residents in order to insure the continuity and sustainability of the process. The initial piloting period was closely monitored with daily updates and meeting to ensure that it is being conducted properly to achieve our goals with a great level of transparency. There was a twice daily rounds ion the wards at 9 am and another one at 12 noon to ensure that the pre discharge plan is ready one day earlier and them to ensure in the day of discharge that the process went smoothly and start collecting data. A checklist was created by the team and it was modified and edited 5 times based in the needs and the obstacles we faced. The initial results from the analysis were encouraging.
(3) Scaling
In March 2013, with an aim of empowering our project all the medical wards were included and by May 2013, all the divisions under the medical departments were enrolled including hematology, neurology and nephrology departments. We have started data collection manually and ended with electronic data sheets using Microsoft Excel program for data entering and analysis. We created innovative software for data entry in each ward and to be analyzed by one of the medical resident and then the results are sent to the ad of the departments and to the administration to be utilized for decision making and further planning.
(4) monitoring and refinement
In order to ensure the continuity and sustainability of our project, weekly meetings were conducted between the members of the project. During which new suggestions, obstacles, updates and data analysis and results were discussed with a great level of transparency in order to maintain sustainability of the project.
(5) reflection
In addition, regular meetings were organized with experts from the Bahrain Centre for Excellence, other departments in the complex, administration and representatives of stakeholders in the project including bed utilization, pharmacy, Information Technology (IT) and the laboratory department. In order to facilitate the early discharge process, the laboratory department participated by speeding up the process of issuing the laboratory results. Adding to that, a new section was established in the pharmacy for discharged patients to facilitate the discharge process.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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This innovative initiative was implemented in the medical department as it is the largest department in the hospital and thus contained more number of patients than the other departments. It basically covers a round 240 beds.
The main stakeholders:
1. the administration : helped in getting the team formulated and give all the support to the progress and daily needs for the successful outcomes
2. Medical department: with all the staff: chairperson, consultants, medical resident s: who were the cornerstone for formulating the team , running the daily round , entering the data analyzing the data and communicating with other stakeholders with transparency .
3. Nursing department: the nurses play critical role in formulating the team, helping ij daily rounds , communicating with the other stakeholders, following the patients , discussion of the management plan and discharge plan with the patient and the family members.
4. Patients : the most important stakeholders in the team were the patients as we were communicating with them on daily basis. That had changed the equation and increase the level of patients satisfaction. we have done a patient satisfaction survey which reflected the high rating for the project and the way it has been conducted.
5. Bed utilization: play an essential role in following with us the discharged plan and ensure that everything is ready for the patients at the time of discharge. They were following the beds availability and then infirm the emergency room staff to transfer the patients immediately to the room that are ready. Applying the concepts for hospitality.
6. Social service: they had a great role in communicating with the family members and the patients in order to ensure that they have answered their quarries and they understand the discharge plan
7. Paramedics and Ambulance services: where we need their help in transferring patients who needed a transfer to their homes to the nursing home.
8. Primary care service: where we improved our commucnation with them in order to follow the discharge plan and for the patients to follow with their primary care physicians and do not loose their follow up.
9. The nursing home: where they played an essential, role in communicating with the team about the available beds and early transfer of the patients to their facility.
10. IT department by developing the electronic form thus making the project easier to transfer to other wards and departments and so it can be used in all the departments in the hospital
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| 6. How was the strategy implemented and what resources were mobilized?
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The implementation of this project was part of a wider organizational plan and aiming for changing the existing culture in the institution. What makes our initiative a unique project and made stand out among the others, is that it was done at no extra cost and on other hand we were saving money through the better utilization of the existing number of beds.
We had to mobilize the following resources;
1. Human resources: The human power used in the project was already available in the hospital. This includes doctors, Nurses, paramedics, clerks, social workers and IT technicians. The innovative part of this project is that we made the same people around us taking care of the problem by empowering them. We were conducting regular meetings and improved our communications through the organization in order to get more people interested and willing to participate in the project.
Through the implementation of the pilot part of the project we were concentrating in selecting the team members and disseminating the idea of team work and proper collaboration.
2. Technical: The infra-structure needed for the project -such as computers, intranet (network) and printers- was already existing in the hospital and available in each ward.
The members we selected in the team they have a lot of skills , one of them were their computer skills which helped a lot if creating the different forms : the checklist for the pre-planned discharge. The online from and the patient satisfaction forms.
3. Financial: The project didn’t require any kind of funding as all required human power and the infrastructure was already available. All it needed is some extra work and organization between those who were involved in the initiation of the project and later on with those who joined the project to help solve the identified problems. Never the less, the project has reduced the costs of the hospital by reducing the length of stay of the patient and speeding up the discharge process were a lot of beds were utilized in better way. Through early discharge and decreasing the length of stay.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The main outputs of this project were as follow:
1. Decreasing the length of stay of the patients: by putting a proper pre discharge plan and more transparent communication among the stakeholders, we were able to decrease the length of stay in most of the common medical diagnosis.
2. Increase patient satisfaction: as the patients are out main customers and in order to provide equality of services for all the residents and citizen in the kingdom of Bahrain , we were able to increase the level of patients satisfaction. We had a lot of great comment and quotes from the patients as the major difference in the situation now.
3. Saving a lot of money : be implementing this project we were able to decrease the waiting time of the patients in the emergency room ,facilitate the early discharge , so we were able to use the beds for other patients without increasing the number of beds.
4. Database: we were bale through this project to create a database for admissions and discharges in the organization which can be used by the higher authority for decision making. Although the project was built on collecting data about discharges, the aim was to use this data to speed up the discharge process without affecting the quality of the service provided. In relatively short time, the data collected amazingly highlighted several points that caused significant delay in the discharge process. With further follow-up and after several meetings with colleagues form other departments we were able to reduce the time or eliminate some points of the discharge process. This was reflected directly on the data collected showing noticeable reduction in discharge time. This effect quickly propagated to other sections of the hospital specially the emergency department were there was decline in pending admissions. This results in less crowding of patients in ER, which meant healthier atmosphere along with better care form health providers.
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| 8. What were the most successful outputs and why was the initiative effective?
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The project itself was built for monitoring. This provided an advantage to us as any step taken to resolve the problem was directly measured. Throughout the project adjustment to the electronic form was made to make it suitable to measure whatever additional data needed, thus increasing its power for monitoring.
The database was an innovation as it provided a background to not only monitor the targeted information regarding discharges but also gave us the opportunity to look at other things like the flow of patients in each ward and the distribution of patients among the different specialties or consultants. In addition, the revolution the database made was its ability to measure the length of stay of patients by diseases. By this we had a clearer view of which disease are taking more beds over longer periods. We also compared the results with the international data trying to improve the length of stay in the hospital.
By regular meetings with other departments involved in the project continuous feedback about the project was provided insuring the main objectives of the project were met. Furthermore, the patient questioner was another tool used to monitor the satisfaction of patient thought out the project, thus insuring the quality of the service provided was improving or at least not affected.
So the projects was created on the following cornerstones which ensured continuous monitoring, auditing and evaluation:
1. Selecting of highly motivated members for the team
2. Regular meeting with all stakeholders weekly
3. Regular meeting with the monitoring team daily
4. Creating a software which is easily accessible and we pull report on a weekly basis
5. The monitoring team do twice daily round to ensure that the forms are filled and the data are entered and the patients had left on time satisfied.
6. Regular feedback are provided for stakeholders and the administration
7. Regular reports are generated and shred among the stakeholders to give feedback and improve the process
8. Because of the above rigorous follow up and monitoring our forms and checklists were modified 5 times to reach the best way.
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| 9. What were the main obstacles encountered and how were they overcome?
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What were the main obstacles encountered and how were they overcome?
Obstacle name: Lack of patient satisfaction and trust in the current health system
Challenge: we were faced with a high level of dissatisfaction and no trust from the patients
Solution: To ensure the satisfaction of the patients and provide health services at high levels with equality and transparency. We provided a questionnaire to evaluate the performance of the doctors and nurses, the flexibility of admission and discharge process, the hospital services, the commitment to professional ethics and adequate explanation of the patient’s condition as well as the available treatment options were addressed.
The result of the questionnaire and the impact on the patient’s satisfaction were discussed with the doctors, and several meetings were held to address the problem and solve it.
We had monitored the doctors and nurses very closely through our auditing team to solve the problems and to ensure the efficiency of the early discharge plans and following the patient’s laboratory results and the consultations as well as solving the social issues which may cause delay to the discharged patients. 80% of the patients have evaluated the discharge process as excellent out of 77 patients which were the initial sample for the patient satisfaction survey.
Outcome: This results in improvement of the health services provided to the patient that lead to his satisfaction through getting the appropriate health service in the appropriate time, getting the laboratory results as soon as needed and having the discharges early, which allow to decrease the pending admissions and give better emergency service. The average of the number of pending admissions has markedly decreased from 40 in January 2013 to only 4 by June 2013.
Obstacle 2:
Obstacle name: lack of database with the required details for each department to enable them for forecasting and intelligence.
Challenge: we were faced with the lack of a database or any kind of registry to start the project and to monitor its progress.
Solution: We innovate a database with all the required details for each department because of the lack of the data in the period prior to the initiative about the number of pending admissions in the emergency, the waiting time for each patient and the delayed discharges in the wards for different reasons and the patient satisfaction about the health care service provided.
We start to make a database through collecting the data and information starting from emergency and medical department and then to the other departments to address the size of the problem and find the solutions.
We started with a small team and few wards initially then expand to the other wards.
We increased the number of the team and auditors to cover most of the medical wards in addition to the weekly meetings with the team members and members of other departments to ensure the accessibility of the database to the other departments and we created the on line discharge electronic form on the intranet to facilitate the data entry, collection and analysis.
Outcome: This has built a solid database about the number and time of pending admissions and the causes beyond the delay of discharge from wards.
So we reduced the patient waiting time in emergency from 20 hours to 4 hours which has reduced the cost from 4400 BD to 880 BD per day, speed the patient transfer to wards and getting the discharged patients out on time , the number of discharged patients before 4 pm has improved from 4% to 85%.
Obstacle 3:
Obstacle name: inability of the team to handle the administrative work.
Challenge: we were faced as physicians that we are not trained to be administrators or to run quality projects especially among the most junior physicians who do not have the experience.
Solution: To face the problem of the lack of experience in the administrative work, we arranged several meetings to the members of the initiative to improve their administrative skills, so the team was trained academically through several meetings with administrative expertise.
Outcome: It creates a competition among the initiative members and improves their work quality from the data collection to the analysis and application, and helps them to collaborate in many other projects that enhanced the health care and the patient satisfaction.
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