ISBN 978-4-909675-69-9

Table of Contents
Guideline for Citation											

02Foreword												

03Abbreviation												

04Session 1

05

1-1

Incident Reporting System..............................................................................
Challenges in Implementation of Incident Reporting System in Quy Hoa National Leprosy andDermatology Hospital									

07

1-2

Three Stages in Development of Incident Reporting System in Quang Nam Central Hospital		

12

1-3

Application of WHO Incident Classification in Incident Reporting System in Hung Vuong Hospital

16

5S......................................................................................................................

22

Session 2
2-1

Application of 5S in Land Use Planning in an Giang Hospital of Obstetrics,
Gynecology and Pediatrics									

24

2-2

Difficulties in Implementing S4, S5 in Ha Dong General Hospital

28

2-3

5S Maintenance in National Hospital of Obstetrics and Gynecology				

34

2-4

5S – A Commencement for Hospital Quality Improvement					

37

2-5

5S Practice in Vinh City General Hospital

39

Standardized Operating Procedures (SOPs)................................................

40

3-1

Development of SOPs in Hospital								

42

3-2

Experience in Developing Standard Operating Procedures for Management			

44

Session 3

Session 4

Information Communication Technology (ICT)................................................ 49

4-1

How Does Information Technology Support Hospital Quality Management?			

4-2

Applying IT in Managing and Monitoring the Implementation Progress of Hospital Quality
Standards in Thu Duc District Hospital

Session 5

51
59

Patient Safety Culture....................................................................................... 64

5-1

Survey on Patient Safety Culture in Bach Mai Hospital in 2017

66

5-2

Developing Learning Culture Through Analysing Medical Incidents

69

5-3

Some Activities Helpful for Strengthening Patient Safety Culture in Ha Dong General Hospital

70

Session 6

Role of QMD as a Communicator In and Out of Hospital............................... 71

6-1

The Role of Quality Management Department in Improving Waiting Time in OPD

73

6-2

The Relationship Between Department of Health and Hospitals in QM/PS

76

Forum Outline

80

Program81

Organization

84

List of Participants

871Guideline for Citation
How to cite this book:Nguyen HA and Murai S (Eds.). (2018). Practices in Hospital Quality Management and Patient
Safety in Vietnam: Challenges and Achievements (Vol.3). Tokyo, Japan: National Center for
Global Health and Medicine (NCGM).

How to cite an abstract/presentation in this book (Example):
Nguyen TT. (2018). Callenges in Implementation of Incident Reporting System in Quy Hoa
National Leprosy and Dermatology Hospital. In Nguyen HA and Murai S (Eds.), Practices in
Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements(Vol.3). Tokyo, Japan: National Center for Global Health and Medicine (NCGM).

2

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Foreword
Healthcare is application of medicine into society1. To tackle quality in healthcare, it isessential to discuss “What are requirements of quality in healthcare in a society?”. Then
there comes another question: “Can an international cooperation project led by an outsider
help generate such discussion in one country and its localities?" This has been the theme
challenged in the project of “Strengthening Management Capability for Quality and Safety in
Healthcare” by National Center for Global Health and Medicine, Japan for three years from2015 to 2017.
Similar to other international cooperation projects, the project conducted trainings on
quality and safety in healthcare in Japan. The Project invited a total of 26 heads or vice headsof quality management departments in 25 hospitals in Vietnam, one person from UNICEF andtwo people from Ministry of Health, Vietnam. However, we can imagine such trainings alone
will only encourage individual hospitals to strengthen their practices of quality and safety inhealthcare. Therefore, the project created an opportunity for those who actually work on
Hospital Quality Management and Patient Safety (HQM/PS) to share practical experiences
and to discuss application of practices of HQM/PS. That was “Vietnam Forum on Hospital
Quality Management and Patient Safety”. It was an opportunity for graduates and others whoare in charge of HQM/PS to learn about practical experiences in other hospitals and to seek
for better approaches that are applicable in Vietnamese context.
In Vietnam, efforts and progress of HQM/PS still differ in different hospitals. If hospitals
with slow progress knew practical experiences in hospitals with rapid progress, it would
provide hints for them to progress faster. If certain approaches need more discussion on how
to apply them into hospitals in Vietnam, participants from several hospitals could discuss it
based on their practical experiences. We believe such wave of sharing and discussion amongpeople who are in charge of HQM/PS would contribute to significant advance in HQM/PS in
Vietnam.
Finally, as development partners, do we really know what efforts on HQM/PS are going on
in hospitals in Vietnam? As members of the project team, two editors of this book had several
opportunities to observe hospitals in Vietnam, to meet people in charge of HQM/PS, andto conduct trainings and to support Vietnam Forum on HQM/PS. However, when we study
the forum’s discussion, we still learned more about how wide and how deep application ofpractices on HQM/PS were discussed among practitioners in Vietnam.
So the research project “Visualization of progress of efforts on quality and safety inhealthcare in developing countries (27 Shitei 2)” made an English book by compiling andediting abstracts and presentations in the Vietnam Forum on Hospital Quality Management
and Patient Safety. We hope this book will help development partners to know more about
ongoing efforts in hospitals in Vietnam. When we know efforts and difficulties in hospitals in
Vietnam, we believe we could discuss and offer better international cooperation in the field of
Hospital Quality Management and Patient Safety.
The research team of Visualization of progress of efforts on quality and safety in healthcare in developing countries

1

All Japan Hospital Association (AJHA) 2016 What hospitals ought to be - Report of the Committee on the Future of Hospitals
  2015-2016 http://www.ajha.or.jp/voice/arikata/2016/02.html, Access: 16 March, 20173

Abbreviation

4

CQI		

Continuous quality improvement

DOH		

Department of Health

GPD		

General planning department

HQS		

Hospital Quality Standards

IRS		

Incident reporting system

ISO		International Organization for Standardization

IT/ICT

Information technology/Information and communication technology

KPI		

Key performance indicator

KQI		

Key quality indicatorLAN		

Local area network

MOH		

Ministry of Health

NHOG		

National Hospital of Obstetrics and Gynecology

OPD		

Outpatient department

PDCA		

Plan – Do – Check – Act

PDSA		

Plan – Do – Study – ActPS		

Patient safety

QI		

Quality improvement

QM		

Quality management

QMD		

Quality management department

RCA		Root cause analysis

SOP		

Standard operating procedure

SOPP		

Standard operating procedure policyWHO 		

World Health Organization

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 1 | Incident Reporting System

Session 1

Session 1 Incident Reporting System
Summary of Discussion

Session 2

1.

How to implement incident reporting system?
1.

We need to set up necessary conditions to run Incident Reporting System (IRS) in a hospital. Such conditions
include (1) IRS staff in Quality Management Department (QMD), (2) a list of incidents for mandatory report, (3)Procedures for reporting, handling the reports, and responding to the reported incidents, (4) an incident reporting

Session 3

form needs to be prepared by paper basis and/or online basis and (5) an intranet, receiving mailbox and phoneline will induce staff to easily report incidents. We need to continuously improve IRS today to be more easy touse.
2.

QMD needs to take a role of monitoring and reminding hospital staff of reporting incidents. Then when theincidents were reported, QMD should work with relevant departments to handle the incidents and generate

3.

Session 4

solutions and prevention measures to prevent recurrence of the similar incidents for the future patients.
Trainings on how to run IRS need to be provided to Quality Management (QM) staff. Also IRS and Patient Safety
trainings would be necessary for key staff (head nurses, department leaders) and/or all staff. Trainings should be
repeated overtime.
4.

How to use incident reports to prevent recurrence of the similar incidents?
1.

Session 5

2.

A proper rewarding and punishment mechanism will motivate staff to report incidents.

QMD could summarize lessons learnt from the incidents and disseminate the lessons in the hospital by several
ways such as email, newsletter, website, standby screens etc.

2.

However, there are still limited experiences in evaluating the effectiveness of prevention measures for the similar
incidents.

Session 6

3.

Challenges and Overcomes1.

Lack of understanding of incidents
Currently hospital staff look having difficulty of understanding what incidents are. Understanding andinterpretation of incidents differ by staff. For example, near misses are not recognized as incidents.
Cultural barriers

Annex

2.

Staff are afraid of punishment and deduction of their bonus. Such afraid discourage staff to share incidents with
their colleagues.  They don’t want to report other people’s incidents either to avoid conflicts. They fear they may
get into trouble.
3.

Patient Safety Culture
Patient Safety Culture survey will help to identify specific cultural factors that inhibit fostering patient safety culture
in a hospital. Once we understood the current situation of patient safety culture, we could provide necessaryinterventions to strengthen patient safety culture such as soft skill trainings for department leaders to improve
communication and relationship between department leaders and their staff etc.

4.

Technical barriers
1)

Currently, a hospital has difficulty to find the root causes of the incident. An assignment of a staff who works
specifically on incident management would help. Investigation of incidents should be conducted right after
receiving the incident reports. Meeting should be held to analyze incidents as soon as possible, with people
who can understand well about the incidents and the situation. This meeting can be a part of hospital’s

5weekly meeting.
2)

Even though root causes may not be always identified, analysis of affecting factors could help understandthe incident and work as clues to consider solutions.

3)

Even after the hospital’s decision of the solution and the prevention measures, the hospital has dilemma
being not always sure whether the proposed solutions are effective in preventing the recurrence of similar
incidents.

5.

Weak support mechanisms
1)

Support from leaders is weak. Hospital leaders, department leaders and staff could give signatures for theircommitments on patient safety.

2)

There is no rewarding mechanism in a hospital so that a hospital needs to create a proper rewardingpunishment mechanism.

3)

Response to the incident is slow due to difficulties in analyzing incidents and proposing solutions. However,through experience, QMD staff learn how to analyze incidents (including Root Cause Analysis) and propose
solutions better and faster.

5.

Further discussion
1.

Does a large number of incident reports mean unsafe condition in a hospital?
1)

A large number of incident reports does not necessarily mean unsafe condition in a hospital. This is because
the number of incident reports includes near-misses. QMD wants hospital staff to report near-misses, which
did not affect patients but provide important suggestions to prevent the similar incidents that may affectother patients in the future.

2)

A small number of incident reports does not mean safe condition in a hospital. This is because hospital staff
cannot recognize all incidents in a hospital. If this is true, how can hospital staff have prevention measuresthat protect patients?

2.

How should a rewarding-punishment mechanism function? When to reward? When to punish?
1)

To be rewarded in Quang Nam Central Hospital, a department needs to report the incident, analyze theincident and handle the incidents. Only submission of the incident report is not rewarded.

2)

In Hung Vuong Hospital, rewarding is a temporary mechanism which was employed at the beginning. Bothquantity and quality of incident reports are taken into account. Rewarding is for a department that reported
many incidents which helped generating useful lessons for other departments and other staff. Later, even
without rewards, the number of reports is increasing.

3)

In principle, the incidents should be reported so if a department did not report the incidents in reality,
the relevant department was punished. Voluntary reports are encouraged so if the reports were actuallyreported, the relevant department was rewarded.

3.

6

Individual errors v.s. systematic errors. What to do with human errors?
1)

A popular view is that when an incident occurred, it was due to both individual errors and systematic errors.

2)

Generally speaking, QMD should only care about systematic errors because they help improvement.

3)

Systematic errors usually stand behind individual errors.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 1 | Incident Reporting System

Session 1

Session 1-1

Session 2

Challenges in Implementation of Incident Reporting
System in Quy Hoa National Leprosy andDermatology Hospital
Nguyen The Toan
General Planning Department, Quy Hoa National Leprosy and Dermatology Hospital

Session 3

Quy Hoa National Leprosy and Dermatology Hospitalsystem), so they can report anytime and anywhere,
attach photos of the incident and stay anonymous if
necessary. The software saves reports and extracts

the hospital has gained some intitial results. However,some reporting files. It is a work in progress.

there are still many difficulties in implementation.

1.

Basis for implementation- Circular number 19/2013/TT-BYT dated July 12, 2013

3.

Results
Since implementation, QM Unit has received somevoluntary incident reports as follows:
LAN

Email

of MOH promulgating Hospital Quality Standards (HQS).

2.

Incident reporting system
2.1.

Reporting in document form

A report form was developed and sent to every
department, then departments fill in information andsend reports to QM Unit. (The reporting form is below.)

Number ofreports

12

2

5

12

27

Related to
medicalincident

3

-

2

2

7

•

Reporting via network- The incident reporting software was introduced at theend of August 2017 but we have received many incident
reports, most of which were non-medical though.

in LAN; departments send reports using the4.

Email: the mailbox baocaosuco.bvqh@gmail.com
was created to send information to departments;
departments report via email.

•equipment, very few were related to patients’ health.

LAN: a folder for incident reporting was createdavailable form.

•- Most of the reports were about incidents related toSoftware installed in mobile phone: members of
QM network had the reporting software installedin their mobile phones (Android operating

Annex

2.2.

Software Total

Session 6

Document

quality management (QM) of medical services in hospitals.

Session 5of the Ministry of Health (MOH) guiding implementation of- Decision number 4858/QD-BYT dated December 03, 2013

Session 4

has been implementing medical incident reporting system(IRS) since August 2016. After one year of implementation,1

Difficulties and challenges- Hospital staff do not understand well about incidents
and medical incidents1. Chiefs of departments assume
that head nurses or members of the incident reporting
network are responsible for reporting.
- Staff cover one another’s mistakes, are afraid of being
involved as an individual and as a department, afraid of
being affected financially.  

1 Incidents is defined as "an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient in the system*. "The definition does not mention
causes of an incident. However, in Vietnam, historically incidents that seemed to be caused by medical practices were called "medical incidents", which has been handled byGeneral Planning Department in a hospital. Incidents that seemed to be caused by other than medical practices have been handled by newly established Quality Management
Department (QMD) since 2013. To distinguish these two types of incidents, the term "medical incidents" is used in Vietnam.
*: Jennifer Cooper et al. Classification of patient-safety incidents in primary care. Bulletin of the World Health Organization. Vol.96, Number 7: 2018, 441-512.

7

- Safety culture in the hospital: habits, incidents are notconsidered incidents.

trainings into hospital scientific activities or meetings.
- Develop safety culture, in which staff voluntarily report- Some near-miss cases were detected and solved timely

incidents and one’s incident is considered a lesson for

but not reported as incidents.

others.

- QM Unit’s staff are working part-timely for QM, so- Develop patient safety (PS) newsletters and share them

reports have not been evaluated timely, root causewith hospital staff and patients. Therefore, encourage

analysis (RCA) has not been conducted, and solutions

more departments to actively report via the hospital IRS.

have not been proposed.

- Commitment of hospital leaders in rewarding.

- Rewarding and encouragement mechanisms are notavailable yet.

5.

- All hospital staff must unite, believe and support eachother in reporting and handling incidents.

Solutions- Strengthen trainings for all hospital staff; integrate

1. Basis for implementation
MINISTRY OF HEALTH
QUY HOA NATIONAL LEPROSY AND DERMATOLOGY HOSPITALPRESENTATION	  CHALLENGES IN IMPLEMENTATION OF
MEDICAL INCIDENT REPORTING SYSTEMIN QUY HOA NATIONAL LEPROSY AND
DERMATOLOGY HOSPITALFROM AUGUST 2016 TO AUGUST 2017v Circular number 19/2013/TT-BYT dated July 12, 2013 of
the Minister of Health guiding implementation of quality
management of medical services in hospitalsv Decision number 4858/QD-BYT dated December 03,
2013 of the Minister of Health promulgating Hospital
Quality Standards

Presenter: Dr. Nguyen The Toan, MD, PhD

Vung Tau, September 2017

Contents

8

1

Basis for implementation

2

Hospital incident reporting system

3

Results4

Difficulties and challenges

5

Solutions

2. Implementation of incident reporting system
Incident reporting system in
Quy Hoa National Leprosy and Dermatology Hospital

In document

INCIDENT REPORTING FORM
LAN
Folder for incident reportingVia network

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

EMAIL
baocaosuco.bvqh@gmail.com	
  	
  SOFTWARE
Installed on mobile phone	  Session 1 | Incident Reporting System

4. Difficulties and challenges

Incident reporting form
Influenced person
Full name:
Position:

Healthcare worker

Title:

Patient

Department:

Patient familyOthers:………………..
Time of incident

Venue of incident(Please indicate specific bed, ward,
department)

Date, time of report:
Date, time when incident occurred:
Briefly describe the incident

WAYS TO RECEIVE FEEDBACK

2. Via document: ……..............................
2. Send email General Planning Department Note: Please specify a phone number/email
or to baocaosuco.bvqh@gmail.com).
address/address to receive feedback
document.

Session 3

For Quality Management Department staff

Session 2

WAYS TO REPORT

1.Send/call directly to Quality Management
Department (Tel: 0905186525)
1. Via phone: …………………………

v Hospital staff do not understand well about incidents and medical
incidents. Chiefs of departments assume that head nurses ormembers of the incident reporting network are responsible forreporting.
v Staff cover one another’s mistakes, are afraid of being involved as anindividual and as a department, afraid of being affected financially.
v Safety culture in the hospital: habits, incidents are not considered
incidents.
v Some near-miss cases were detected and solved timely but notreported as incidents.
v QM Unit’s staff are working part-timely for QM, so reports have notbeen evaluated timely, root cause analysis has not been conducted,
and solutions have not been proposed.
v Rewarding and encouragement mechanisms are not available yet.
v Hospital staff are not unified.

Session 1

ReporterThis item can be skipped
Full name:

5. Solutions

1. Near missCharacteristics of the incident

2. Variance
3. Sentinel event

Harmful level to patients

0

1

2

3a

3b

4

5

The fields relating to incidence
6. Information technology

2. Technical errors and medical incidents

7. Medical equipment and materials

3. Safety in drug use

8. Security, fire safety

4. Infection control

9. Accident, fall

5. Medical record

10. Others:……………………………….

Root cause analysis
Solutions (improvement actions)

Session 4

1. Examination and treatment proceduresv Strengthen trainings for all hospital staff; integrate trainings
into hospital scientific activities or meetings.
v Develop safety culture, in which staff voluntarily reportincidents and one’s incident is considered a lesson for others.
v Develop patient safety newsletters and share them withhospital staff and patients. Therefore, encourage more
departments to actively report via the hospital IRS.
v Commitment of hospital leaders in rewarding and punishment
related to reporting incidents.
v All hospital staff must unite, believe and support each other inreporting and handling incidents.

Monitoring implementation of improvement actions and evaluating (their effectiveness)
  Session 5

Procedure for recognizing, processing and reporting serious medical incidents
Detect incident

Reached patient

Did not reach patient

Onsite emergency
response
Report to chief of dept.

Report to chief of department

Emergency response,
report to the Directing
Board, GPD, QMD for
directions

CHIEF OFDEPARTMENT

Handle, adjust
Report to the Directing Board,
GPD, QMDVerify the incident
Give new direction
Conduct root cause analysis
Organize review meetings
Record in “Classification andevaluation of technical incidents”
notebook

GPD, QMD

Session 6

Heath care
workers

Classify
incident

Verify, record
Conduct root cause analysis
Organize review meetings

Keepmeeting
minutes

Annex

Approve andimplement solutions
Chair review meetings

DIRECTING
BOARD

3. Implementation results
Table: Statistics of voluntary reports
Documen
t

LAN

Email

Software

Total

Number

12

2

5

12

27

Related to
medical incident

3

-

2

2

7

Comments:v Most of the reports were about incidents related to equipment,very few were related to patients’ health.
v The incident reporting software was introduced at the end of
August 2017 but we have received many incident reports, mostof which were non-medical though.

9Annex 1.

No:	  MINISTRY  OF  HEALTH  QUY  HOA  NATIONAL  LEPROSY  AND  DERMATOLOGY  HOSPITAL      BM.05.KHTH  Effective date:	
  Review no.:	
  INCIDENT  REPORTING  FORM  	  Incident	
   is	
   an	
   occurring	   event	
   outside	
   normal	
   activities	
   of	   a	   healthcare	
   institution	   or	
   outside	
  normal	   patient	
   care	
   activities	
   for	
   a	
   specific	
   patient.	
   Errors	
   and	   incidents	
   are	   unavoidable	
   in	
   the	   hospital’s	
  environment.	
   In	   order	
   to	
   improve	
   quality	
   and	   to	
   minimize	
   incidents,	
   the	   Directing	   Board	
   encourages	
   all	  hospital	
  staff	
  to	
  report	
  incidents	
  according	
  to	
  following	
  form:	
  	
  	
  

Part  1:  CONTENTS  OF  THE  INCIDENT  REPORT  Reporter	  Full name: 	  This item can be skipped.	
  Full name:	
  Title:	  Department:	
  WAYS TO REPORT  1. Send/call directly to Quality
Management Department (Tel:0905186525)	
  □ Healthcare worker	  □ Patient 	
  □ Patient family	
  □ Other: department	  Venue of incident	
  (Please indicate specific bed, ward, department)	
  Position:	
  Time of incident	  Date, time of report:	  	
  Date, time when incident occurred:	  	
  Briefly describe incident  
	
  
	
  

Affected person	
  WAYS TO RECEIVE FEEDBACK   1. Via phone: .........................................................

2. Send email to General Planning 	
  2. Via document: document	  Department or to:
Remark: Please specify a telephone number/email
baocaosuco.bvqh@gmail.com).	
  address/address to receive feedback document 	  10Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 1 | Incident Reporting System

Session 1

Annex 2.

FOR QUALITY MANAGEMENT DEPARTMENT STAFF
1. Near miss
2. Variance
3. Sentinel event

Level of harm to patient

0

1

2

3a

3b

4

5

Session 2

Characteristics of the incident

The field related to the incident
2. Professional errors, medical incidents

7. Medical equipment and materials

3. Safety in drug use

8. Security, fire safety

4. Infection control

9. Accident, fall

5. Medical record

10. Other: ……………………………….
Root cause analysis

Session 5

Solution (improvement actions)

Session 4

6. Information technology

Session 3

1. Examination and treatment procedures

Session 6

Monitoring implementation of improvement actions and evaluating (theireffectiveness)
Annex
11

Session 1-2
Three Stages in Development of Incident Reporting
System in Quang Nam Central HospitalTran Quang Dat
Quality Management Department, Quang Nam Central General Hospital1.

The initial implementation stage
In 2013, MOH issued HQS. In order to meet the needs of

hospital development, in December 2013, Quang Nam Central
General Hospital established Quality Management Unit.
In October 2014, Quality Management Department(QMD) was established. QMD organized the first training
course on QM for members of the hospital’s QM network,
introducing the concepts of hospital quality and patient

A major cause of ineffectiveness in the initial
implementation stage was that many staff lack knowledge
on QM and PS, especially understanding of medical
incident was inappropriate. Many people did not carewhile leaders of departments did not support. Moreover,
QMD staff’s knowledge was limited and the IRS wascomplicated, not convenient for reporting.

2.

safety (PS) to network members, helping them recognize
near misses and hidden risks to generate preventive
measures and countermeasures to handle consequencesmore safely and more economically. In addition, it isexpected to gradually shift from a hiding and punishment
culture to a culture of transparent mistakes, learning fromerrors, and seeking systematic errors rather than seeking
individual mistakes.
In November 2014, the hospital implemented an IRS:
developing procedures for reporting, receiving reports andhandling incidents; developing a reporting form, creatinga separate email for staff to send reports easily; andassigning staff in-charge...
However, during this period, the implementation of IRS
was not effective, with very few reports (Figure 1) :The improvement stage
In May 2015 and November 2015, QMD staff

attended training courses on QM/PS in Japan, whichwere organized by JICA and NCGM1.
After the trainings, the staff have implemented a seriesof improvement activities, such as establishing a medical
safety group and making progress charts of reported
medical incidents, developing regulations on medical
safety, revising the procedures for reporting medical
incidents and receiving reports, organizing trainings on
RCA in monthly meetings of QM network, organizing 03
training courses on PS with trainers from Hue Central
Hospital. During trainings, staff actively participated in
IRS. However, after that, the number of incident reports
decreased as shown in the following figure:

	
  

	
  

Figure 1 : The number of incident reports in initial
implementation stage
1

12

Figure 2 : The number of incident reports during thestrengthened training period

JICA Recruited trainees for the training in May 2015; NCGM recruited trainees for the training in November 2015. NCGM conducted both trainings.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 1 | Incident Reporting System

To attract and encourage people to actively reportmeetings and created a policy for rewarding departments
which reported many incidents in a quarter, creatingcompetition in the hospital. However, we met a difficulty
in rewarding because some departments thought that

RCA meetings:••

hospital would still reward departments which report if
they also submit RCA results and preventive measures.
If QMD staff detect incidents from technical meetings,
incidents are detected by QMD but not reported, thecompetitive score of relevant departments or individuals
would be deducted. In line with such activities, theDirecting Board also pay more attention to medical
incidents, “shifting from a hiding and punishment culture
and seeking systematic errors rather than seeking
individual mistakes”

The tools used in the meeting include: a board,colored cards, pens in order to facilitate members
to give their comments and solutions.

In conclusion, in order to make IRS work well, it
requires not only the role of QMD but also the participationof all hospital members, from the Directing Board, chiefsof departments, and hospital staff. In addition, it needs thecommunity’s awareness and sympathy towards medical
incidents in healthcare facilities.

Session 4

to a culture of transparent mistakes, learning from errors,•

Build consensus and generate solutions.

Session 3

we ask relevant departments or individuals to report. If•

Session 2

Therefore, in 2017, we made some changes: theEveryone is equal and able to give comments tofind out the causes of the problem.  

rewarded departments were those who had most medical
incidents.

No individuals are blamed or criticized in themeeting.

Session 1

incidents, we continuously reminded them in QM network

Shifting traditional review meetings and mortality audits to

Session 5	  Strengthening RCA and seeking systematic errors
•
•

Annex

3. Current stage: Strengthening RCA,
generating appropriate and timely corrective
and preventive measures

Session 6

Figure 3 : The number of incident reports during thestrengthened communication – rewarding period

Organize network activities once every month.
Develop regulation on prioritized incidents thatneed instant response and incidents that require
meetings among relevant stakeholders. Regarding
incidents of levels 0 and 1 (the patient was notaffected), the department conducts RCA andgenerates solutions before reporting to QMD.

•

Once roots causes are found, there need tobe corrective measures to be applied on alarge scale to avoid repetition of the mistakes.
Implementation of solutions must be monitored.

13

Difficulties and challengesv Staff lacked knowledge.
v Lack of support from department’s leaders.
v Hospital leaders were not active enoughv Knowledge of QMD staff was still limited.
v The system was not good enough.

CONTENTS

Initial implementation stage

Difficulties and challenges

Learning from experience andimprovement

Current stage

I. Initial implementation stagev Started implementing IRS in November 2014.
v Activities

II. Learning from experience andimprovementv QMD staff participated in QM training coursesv 3 trainings on PS were organized for staffv Regulation on PS was developed; IRS was
improved.
v Reports were received, systematic causes
were analyzed and preventive measures were
proposed.
v Trainings on RCA were provided for network
members once a month.

II. Learning from experience andimprovement
The number of incident reports§ Training on QM/PS for network members§ Developing procedure for receiving reports andhandling incidents§ Developing a reporting form§ Assigning in-charge staff

The number of incident reports in the improvement stage

I. Initial implementation stage
The number of incident reports

The number incident reports in the initial implementation stage

14

Continued improvementv Continued to remind staff through the network,
head nurse meetings, and hospital meetings.
v Rewarded and encouraged staff, createdcompetitiveness.
v Remind individuals and departments about theirunreported incidents.
v The Directing Board’s attention to medical
incidents, “shifting from a hiding and punishment
culture to a culture of transparent mistakes,
learning from errors, and seeking systematic
errors rather than seeking individual mistakes”.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 1 | Incident Reporting System

Continued improvement

Session 1
Session 2

The number of incident report in the continued improvement stage

Session 3

III. Current stage

Session 4v Strengthening RCA and seeking systematic
errorsv Generating appropriate and timely corrective
and preventive measures

Session 5

CONCLUSION
Director

Leaders of
departments

Incident
reporting

QMD

Session 6

Success

Staff

Annex

Society15

Session 1-3
Application of WHO Incident Classification in
Incident Reporting System in Hung Vuong Hospital
Phan Thi Hang
Vice Director, Hung Vuong Hospital

1. Implementation of incident reporting
system
According to requirements of MOH and our practicalneed to manage technical incidents to correct thoserelated to patient care and treatment, Hung Vuong

incidents, including 1,345 mandatory reports (64.2%) and
751 voluntary reports (35.8%), were reported in different
ways: 1,619 were reported in paper form (77.2%), 472
were reported verbally (22.5%) and 5 were reported online(0.2%).

Hospital studied documents and developed an incident
reporting procedure as well as voluntary and mandatory

Incident reports from August 2016 to August 2017

reporting forms in July 2014. To familiarize all staff with
reporting, the mandatory incident reporting form lists all
incidents that must be reported so that staff can reporteasily.
After starting mandatory incident reporting, voluntary
incident reporting was also required but there were very
few reports in the first two years (less than 8 reports
per month). QMD then conducted trainings on incident
reporting for all healthcare workers in the hospital;

Figure 1: Monthly reports by typestrengthened analysis and giving feedback to departments
about analysis results; developed recommendations forlearning from errors every week. Quality indicators on
handling incidents were monitored and recorded strictly.
Since July 2016, Hung Vuong Hospital has been studying
and piloting incident classification by World HealthOrganization (WHO). Changes in reporting forms andtrainings has helped familiarize staff with the new forms.
The hospital’s PS Committee conducts RCA without
criticizing or blaming the staff involving in the incident,
instead focusing on finding systematic errors andproposing corrective measures. The hospital director
regularly reminds staff to promote safety culture. The

Figure 1: Monthly reports by typehospital usually conducts trainings on communication
skills and incident handling skills in various formats for all
key staff members.  
Results: From August 2016 to August 2017, 2,096

16

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 1 | Incident Reporting System

Incident frequency

Proposing corrective and preventive solutions.

•

Generating solutions for preventing incident
repetition in hospital meetings.

•

Monitoring implementation of solutions and time

Session 1•

spans for handling incidents.
•

Adding “systematic errors leading to incidents” inSession 2

the regular PS checklist.

Figure 3: Incident frequency by type(WHO classification)

Session 3

Incidents’ impacts were monthly analyzed andreported to key staff members. 74.2% of the incidents
increased resources used for patient care. 10.4%
increased patients’ complaints. Time spans for handlinghelps reporters find reporting incidents useful and become
more active in reporting.

PRESENTATIONQUALITY MANAGEMENT PROGRAMSIN HUNG VUONG HOSPITAL

Session 4

incidents were regularly monitored and improved, which

Dr. Phan Thi Hang, MD, MSc

Session 5

Average time span for handling an incident (days)

CONTENTS2	  Figure 4: Average time span for handling an incident

Prevention of incident repetition4	
  • Introduc1on	
  of	
  IRS	  in	
  Hung	  Vuong	
  Hospital	  • Results	
  of	
  applying	
  WHO	
  classiﬁca1on	
  in	
  IRS	
  opera1on	
  • Lessons	
  learnt	
  

Annex

2.

3	
  

• Hospital	
  introduc1on	
  Session 61	
  Analyzing influencing factors and causes of incidents
and proposing effective solutions are to handle incidents
and prevent incident repetition.
Analyzing causes, influencing factors and consequences
caused by incidents is helpful for clearly identifying
prioritized improvement opportunities and for measuring
incidents. After root causes are found by RCA, specificsolutions are generated with timeline for implementation
and assignment of in-charge person for monitoring andreporting.
Activities to prevent incident repetition include:•

Analyzing influencing factors.  

•

RCA.

HOSPITAL INTRODUCTION

17

INTRODUCTION OF HUNG VUONG HOSPITAL• 1st level central hospital
specialized in obstetrics andgynecology• 900 beds, including 100
newborn beds
• 35,000-40,000 newborns per
year• 20,000-25,000 operation
cases per year
• 20 technical departments, 10functional departments• Manpower: more than 1,200

Procedure	
  for	  receiving,	
  handling,	
  and	
  providing	
  feedback	
  for	
  voluntary	
  incident	
  reports	
  ANNOUNCEMENT OF QUALITY GOALS OF THE HOSPITAL AND DEPARTMENTS
1. Đồng hành cùng bạn - vượt cạn an toàN	
  2. Sáng y đức - vững chuyên môn - vuông tròn hạnh phúc	
  3.	
  Kết quả chuẩn vàng - an toàn điều trị
4. Gieo mầm hy vọng - gặt trọn yêu thương
5. Cấp cứu chuyên nghiệp - bắt kịp sự sống6. Phục vụ tận tâm - nâng tầm thương hiệu7. Đổi mới tới tầm cao
8. Ươm mầm hôm nay, vững chắc tương lai	  9.	
  Niềm tin trọn vẹn, hạnh phúc nhân đôi	  10.	
  Tiếp xúc vui vẻ, bệnh khỏe mỗi ngày	
  11.	
  Môi trường thân thiện, tiện như ở nhà	
  Rates  of  opera+on  cases  complying  to  standards  for  1st  level  emergency  response  +me
102%	
  
100%	
  
98%	
  
96%	
  
94%	
  
92%	
  
90%	
  
88%	
  
86%	
  

100.00%	
  

100%	
  
97.70%	
   97.73%	
  97.50%	
   97.72%	
  92.11%	  91.30%	  T1/2017	
   T2/2017	
   T3/2017	
   T4/2017	
   T5/2017	
   T6/2017	
   T7/2017	
   T8/2017	
  
Tỷ	
  lệ	
  Số	
  ca	
  thực	  hiện	  phẫu	  thuật	  đúng	  thời	  gian	  Cấp	  Cứu	  Khẩn	  cấp	  loại	
  I	
  	
  

Slogan of departments and 120 hospital quality indicators

Quantity and quality of incident
reports
Numbers	
  of	
  incident	
  reports	
  in	
  2	
  years	
  
1200	
  
1043	
  
957	
  

1000	
  
800	
  

581	
  

551	
  

600	
  
400	
  

INTRODUCTION OF IRS IN
HUNG VUONG HOSPITAL

200	
  
30	
  

86	
  

0	
  

nguyện	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  M
Bắt	
  
buộc	
   	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Tổng	
  
cộng	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  Tự	
  
Voluntary	  andatory	
  
	
  	
  	
  	
  Total	  Năm	  2014	
  Incident reporting form

2015	
  

Barriers preventing staff from reporting incidents (n=468)

Aware	  of	
  incident	
  repor1ng	
  (n=340)	
  Could	  not	
  ﬁnd	
  repor1ng	
  form	  at	
  the	
  department	
  
	
  
	
  
Thought	
  that	  “reported	  incidents	
  would	
  not	  be	
  handled”	
  
	
  
The	
  repor1ng	
  form	  is	
  too	
  long,	  no	
  1me	
  for	
  ﬁlling	
  the	
  form	  	
  Detected	  incidents	
  but	  no	
  1me	  to	
  report	
  
	
  
	
  
Do	
  not	
  know	
  when	
  incidents	
  should	
  be	
  reported	  	
  Reported	  but	
  did	  not	  receive	  feedback	
  
	
  
	
  
Afraid	  (of	  being	
  punished,	
  hated	  by	
  colleagues,	  department	
  leaders…)	
  A  total  of  386  people  a-ended  2  training  courses.  216  par9cipants  on  June  8  and  170  on  September  21.  

18

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 1 | Incident Reporting System

Incident	
  repor1ng	
  Date,  +me  receiving  the  report
Fill  in  MSP,  MSC

Rates	  of	
  posi1ve	
  responses	  Cởi mở thông tin trong khoa

51.5	
  

Nhân lực

51.8	
  Hành xử không buộc tội khi có sai sót

52.1	
  

Procedure for receiving andhandling incident reports

Send  error/incident  review  form  to  relevant  departmentsNote	
  the	
  1me	
  and	  the	  receiving	
  department	
  in	
  the	
  report	
  	
  	
  

Bàn giao và chuyển bệnhEnter	
  informa1on	
  into	  the	  management	
  sosware	
  	
  

66.0	
  

Nhận thức của nhân viên y tế

76.2	
  

Tần suất báo cáo sự cố

76.7	
  

Làm việc nhóm giữa các khoa

Inves+gate  the  incident:	
  contact	
  the	
  relevant	
  department	
  or	
  reporter	
  (voluntary	
  reports),	
  ﬁnd	  the	
  medical	
  record	
  (voluntary/mandatory	
  reports)	
  	
  	
  

82.8	
  

Thông tin, phản hồi về sai sót

85.0	
  

Hỗ trợ của lãnh đạo bệnh việnSession 1

RESULTS OF PATIENT SAFETY
CULTURE STUDY

88.7	
  
90.4	
  
92.4	
  

Làm việc nhóm trong khoa

94.7	
  
0.0	
  

10.0	
  

20.0	
  

30.0	
  

50.0	
  

60.0	
  

70.0	
  

80.0	
  

90.0	
  

100.0	
  Write  RCA  mee+ng  minutes  (aKer  the  mee+ng)

Disseminate	
  lessons	
  learnt	
  from	  mistakes	
  (in  paper,  email  and  hospital  mee+ngs)	
  every	
  Monday	  Enter	  more	  informa1on	
  about	  causes	  and	  preven1ve	
  solu1ons	
  into	
  the	
  database	  Dissemina+on  of  lessons  learnt  (hospital  mee+ngs,  standby  screen,  QM  bulle+n  board)    TRAINING ON INCIDENT REPORTING
1	
  severe	
  adverse	
  event	
  30	
  mild	  adverse	
  events	  Session 3

HEINRICH principle

40.0	
  

Organize  weekly  mee+ngs  for  incident  analysis  (Thu/Fri)

Session 2

Vai trò của lãnh đạo khoaChủ động triển khai - Cải tiến liên tục300	
  poten1al	
  risks	  Root  cause  analysis

Safety is not a matter of luck but of
minimization of potential risks.

Session 4

13	
  
13	
  

Session 5
Session 6

TRAININGS ON LEADERSHIP
THINKING AND COMMUNICATIONRESULTS OF INCIDENT REPORTING
WITH WHO’S CLASSIFICATION

Annex

Training	
  on	
  communica1on	
  with	  internal	
  clients	  	
  Campaign	
  for	
  communica1on	
  improvement	  	
  Increasing	
  brand	  pride	
  and	
  staﬀ	
  connectedness	  Crea1ng	
  close	  rela1onship	
  between	
  leaders	
  and	
  staﬀ	  	
  19

Incidents	
  by	
  impact	  level	  Improvement of quantity andquality of incident reports

1800	
  
1600	
  
250	
  

1400	
  
1200	
  
1000	
  
800	
  

1,300	
  

600	
  
400	
  

Yearly	  incident	
  reports	
  

200	
  

29	
  

0	
  

0	
  
Tình	
  huống	
  được	  báo	
  cáo	
  

2500	
  

People	  impacted	
  by	
  incidents	
  

NVYT	
  
khác,	  26	  NVYT,	  163	
  Khác,	
  23	
  

2000	
  

323	
  
149	
  
27	
  
17	
  
Sự	
  cố	
  xảy	  ra	
  chưa	  ảnh	   Sự	  cố	  xảy	  ra	  đã	  ảnh	  hưởng	
  Sự	
  cố	
  xảy	  ra	  đã	  ảnh	  hưởng	  hưởng	  bệnh	  nhân	  lên	  bệnh	  nhân	  nhưng	
  chưa	   lên	  bệnh	  nhân	  có	
  gây	  hại	  	
  gây	  hại	
  

709

Bắt	
  buộc	  Tự	  nguyện	  Frequency	
  of	
  inﬂuencing	
  factors	
  

1500	
  

900	
  

700	
  

[CATEGORY	
  NAME],	
  [VALUE]	
  

1,337

30

500	
  

618	
  

600	
  
500	
  

1001

957

780	
  

800	
  

397
86

1000	
  

400	
  

342	
  

339	
  

300	
  

545

200	
  

0	
  

2014	
  

2015	
  

2016	
  

Sự	
  
cố	
  bắt	
  breports	
  
uộc	
  
Mandatory	
  

100	
  

2017	
  

Numbers of incident reports

4	
  

1	
  

0	
  

Môi	
  trường	  làm	
  Các	  yếu	  tố	
  khác	   Yếu	  tố	  mặt	  tổ	
   Yếu	  tố	
  ngoại	  lai	
  
việc	
  
chức	
  

Sự	
  
cố	
  tự	
  n
guyện	
  Voluntary	
  reports	
  

NVYT	
  

Bệnh	
  nhân	  Classification of affecting incidents
Incidents	
  by	
  impact	  level	
  
1800	
  

Numbers	
  of	
  incident	
  reports	
  from	  08/2016	
  to	
  08/2017	
  
250	
  

1600	
  
219	
  
196	
  
173	
  

165	
  
150	
  

149	
  

50	
  

34	
  

72	
  

69	
  
62	
  

39	
  

41	
  

44	
  

Sep-­‐16	
  Oct-­‐16	
  Nov-­‐16	
  

156	
  
119	
  

116	
  

1000	
  
118	
  

104	
  
88	
  

72	
  

1200	
  

173	
  

150	
  

140	
  

116	
  

113	
  

90	
  

100	
  

139	
  

129	
  
131	
  

129	
  

115	
  

800	
  

91	
  

80	
  

78	
  
59	
  

52	
  

57	
  

54	
  

Aug-­‐16	
  

36	
  

Dec-­‐16	
  

400	
  

Jan-­‐17	  Bắt	
  buộc	  Feb-­‐17	  Tự	
  nguyện	  Mandatory	
  1,300	
  

600	
  

52	
  

200	
  
0	
  

250	
  

1400	
  

200	
  

Voluntary	  Mar-­‐17	
  Apr-­‐17	
  May-­‐17	
  Jun-­‐17	
  Jul-­‐17	
  Aug-­‐17	
  

0	
  

Tổng	
  cộng	
  

323	
  

29	
  

149	
  

0	
  

Tình	
  huống	
  được	  báo	
  cáo	
  

17	
  

27	
  

Sự	
  cố	
  xảy	  ra	
  chưa	  ảnh	  hưởng	
  bệnh	
  
nhân	
  

Sự	
  cố	
  xảy	  ra	  đã	  ảnh	  hưởng	
  lên	  bệnh	  nhân	
  nhưng	
  chưa	  gây	  hại	
  Total	  Bắt	  buộc	
  

Sự	
  cố	
  xảy	  ra	  đã	  ảnh	  hưởng	
  lên	  bệnh	
  
nhân	
  có	
  gây	  hại	  	  Tự	  nguyện	  Factors influencing incidents

Incident	
  reports	
  by	
  type	
  
1800	
  

1,619	
  Frequency	
  of	
  inﬂuencing	
  factors	
  

1600	
  
1400	
  
1200	
  
1000	
  

Yếu	
  tố	
  liên	
  quan	  đến	  bệnh	
  lý	
  

967	
  
652	
  

800	
  
600	
  
400	
  

100%	
  

94	
  

200	
  
0	
  

Ways	
  of	
  repor1ng	
  by	
  reporter’s	
  posi1on	
  

472	
  

378	
  

Bắt	
  buộc	  Báo	
  cáo	  giấy	
  

80%	
  

Tổng	
  cộng	  Báo	
  cáo	  miệng	
  

70%	
  

Báo	
  cáo	
  Online	
  

30%	
  
20%	
  

29	
  

538	
  

Sự	
  thống	
  nhất	  trong	
  hoạt	  động	  đội/nhóm	  [CELLRANGE],	
  [VALUE]	
  

Bác	
  sĩ	
  

Hộ	
  sinh,	  điều	  dưỡng,	
  KTV	  Báo	  cáo	  giấy	  Báo	
  cáo	  miệng	
  Nhân	
  viên	
  khác	  Báo	
  cáo	
  online	
  

33	
  

Bắt	
  buộc	
  

Yếu	
  tố	
  môi	  trường	  [CELLRANGE],	
  [VALUE]	
  Sự	
  thống	
  nhất	  trong	
  quyết	  định	  (Văn	
  hóa	  tổ	  chức	  [CELLRANGE],	
  [VALUE]	
  Không	  đặc	  trưng	
  cho	
  các	  phân	  loại	  nhóm	  chính	
  từ	
  1	
  đến	  5	  [CELLRANGE],	
  [VALUE]	
  Quy	
  định	  hiện	  hành	  của	  môi	  trường	  làm	  việc	  Nhân	
  viên	
  khác	  [CELLRANGE],	
  [VALUE]	
  
0	
  

Tự	
  nguyện	  Classification of incident reports

200	
  

Tỷ	
  lệ	
  %	
  
0.14	
  

1,119	  Nhiễm	
  khuẩn	  bệnh	  viện	
  

100	
  

233	
  

Dụng	
  cụ,	  trang	
  thiết	  bị	
  y	
  khoa	
  

113	
  

Cơ	
  sở	
  hạ	
  tầng	
  

82	
  

Hành	
  vi	
  

67	
  

Thuốc/	  Dịch	  truyền	
  

600	
  

5.78	
  

10.42	
  74.19	
  

33	
  

Tai	
  nạn	  đối	  với	  bệnh	  nhân	
  

500	
  

6.6	
  

129	
  

Quản	
  lý	
  lâm	
  sàng	
  	
  

400	
  

2.06	
  

0.81	
  

279	
  

Tài	
  liệu	
  	
  

300	
  

Damages for hospitalFrequency	
  of	
  incidents	  Quy	
  trình,	  thủ	
  thuật	
  lâm	
  sàng	
  	
  

21	
  

Quản	
  lý	
  tổ	
  chức,	  quản	  lý	
  nguồn	  lực	
  

5	
  

Oxy/	
  khí/	  hơi	  nước	
  

5	
  

Dinh	
  dưỡng	
  

4	
  

Vi	
  phạm	  vấn	  đề	
  pháp	
  lý	
  

Tổn	
  hại	
  danh	
  1ếng	  Truyền	  thông	
  

Máu	
  và	
  các	  sản	  phẩm	  của	
  máu	
  

2	
  

Hư	
  tổn	
  tài	  sản	
  

Khác	
  

Than	
  phiền	  của	  bệnh	  nhân	
  

Khác	
  	
  

1	
  
0	
  

20

[CELLRANGE],	
  [VALUE]	
  [CELLRANGE],	
  [VALUE]	
  Quy	
  trình/chính	
  sách	
  

520	
  

Hộ	
  sinh,	  điều	  dưỡng,	
  KTV	
  [CELLRANGE],	
  [VALUE]	
  [CELLRANGE],	
  [VALUE]	
  

Dịch	
  vụ,	  hệ	  thống,	
  chính	
  sách	
  

811	
  

Bác	
  sĩ	
  

[CELLRANGE],	
  [VALUE]	
  

Yếu	
  tố	
  sai	  lệch	  (là	  những	
  sai	  lệch	  về	  nhận	  thức	  mà	
  nhân	  viên	  y	  tế	  cho	  là	  đã	  hiểu	  rõ	  hoặc	  được	  đánh	  giá	
  cao	  nhưng	
  các	  ý	  kiến	  thường	  không	
  được	  chú	  trọng.	
  
Yếu	
  tố	
  về	
  nhận	  thức	  (vd	  	
  như	  hiểu	  biết/cách	  giải	  quyết	  vấn	  đề:	
  không	
  biết	  cách	  tổng	  hợp	
  
hoặc	
  xử	
  lý	
  những	
  thông	
  1n	
  có	
  sẵn),	
  	
  

0%	
  

440	
  

0	
  

[CELLRANGE],	
  [VALUE]	
  [CELLRANGE],	
  [VALUE]	
  

10%	
  
165	
  

200	
  

[CELLRANGE],	
  [VALUE]	
  Sản	
  phẩm,	  Yếu	  tố	  mang	  ¶nh	  kỹ	
  thuật	  và	
  yếu	
  tố	
  cơ	
  sở	
  vật	  chất.	
  Những	
  thái	  độ	  đang	  được	  chú	  ý	  như	
  hay	  quên,	
  xao	  nhãng,	
  phân	
  tâm,	  mệt	  mỏi,	
  quá	
  tự	
  
1n…	
  

Yếu	
  tố	
  về	
  nhận	  thức	
  

929	
  

40%	
  

600	
  
400	
  

2	
  

2	
  

[CELLRANGE],	
  [VALUE]	
  

Yếu	
  tố	
  về	
  hành	  vi	
  (vd	  như	  bất	  cẩn,	
  có	
  nguy	  cơ	
  cao,	
  hành	  vi	
  phạm	  lỗi)	
  

50%	
  

1200	
  

800	
  

3	
  
28	
  

438	
  

[CELLRANGE],	
  [VALUE]	
  Quá	
  trình	
  thực	  hiện	
  

60%	
  

Incident	
  reports	
  by	
  reporter’s	
  posi1on	
  and	
  report	
  
type	
  
1000	
  

0	
  

90%	
  

Tự	
  nguyện	  [CELLRANGE],	
  [VALUE]	
  

Yếu	
  tố	
  về	
  phương	  pháp	  điều	  trị	  (vd	  như	
  sai	  lệch	  những	  kỹ	  năng	  chuyên	  môn),	
  sai	  luật	  (áp	  dụng	
  sai	  những	
  quy	  chế,	
  quy	  định)	  Tăng	
  nguồn	  lực	  chăm	  sóc	
  cho	
  BN	
  
200	
  

400	
  

600	
  

800	
  

1000	
  

1200	
  

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

700	
  

800	
  

Session 1 | Incident Reporting System

Average	
  1me	
  span	
  for	
  handling	
  an	
  incident	
  (days)	
  
20	
  
18	
  

17	
  

16	
  

Session 1

Time span for handling an incident

14	
  
12	
  
10	
  
8	
  

10	
  

9	
  
6	
  

6	
  
4	
  

3	
  

4	
  

4	
  

3	
  

3	
  

3	
  

2	
  

2	
  

2	
  

2	
  

2	
  

Session 20	
  – Provide trainings– Create patient safety culture– Create reliability for reporters– Organize regular RCAs, give directions to actively handle incidents– Timely disseminate lessons learnt in various ways
– Remind staff to handle remaining incidents

Session 4• Mandatory IRS was developed first, sense about the role ofreporting.
• Specific and clear regulations; remind staff when incidents
subject to mandatory reporting are not reported• Study the reasons why staff hesitate to report• Intervene and improve in various ways:

Session 3

Lessons learnt

Session 5
Session 6
Annex

THANK YOU VERY MUCH FOR YOUR ATTENTION!

21

Session 2 5S
Summary of Discussion
1.

How to implement 5S?
1.

Experiences shows that 5S can be started in different ways; (1) pilot implementation of 5S to selected
departments at first then expand it to a hospital-wide, (2) a hospital-wide implementation from the beginning and(3) asking all departments/units to practice 5S to some extends such as up to the third S etc.

2.

Implementation of 5S should go slow but steady and patiently such as starting with injection trolleys in one
department etc.

3.

Standardized conditions should be clear on checklist or photos in advance before monitoring the progress of
5S activities. When monitor the progress of 5S, taking photos is important as evidences for the improvement
opportunities through 5S activities as well as knowing the results of the 5S implementation.

2.

How to sustain 5S?
1.

We need to keep practices of S1, S2, S31 to create a habit in a hospital/department/individual.

2.

Breakdown of tasks for everyone to have tasks of 5S activity. 5S will be sustained when everyone participated in
5S activity.

3.

5S component should be added into existing work in a hospital.

4.

Standard conditions to achieve by 5S activity should be regularly revised and upgraded for continuous
improvement.

3.

Challenges and Overcomes:
1.

S1 (Sort)
Removing or disposing unnecessary things requires (1) a storage but finding a storage is not easy, (2) consensus
among stakeholders about proper procedures, (3) understanding and support of hospital leader and relevant
departments (e.g., administration department, equipment and material department, finance department)
because sometimes there is no consensus on what is unnecessary and need to be removed. More discussion
and collaboration with others are needed. A hospital could establish a committee for disposing things (Hoi dongthanh ly) if necessary, like in Da Nang Hospital for Women and Children.

2.

Low motivation of 5S among hospital staff
People do not see benefits of 5S. People do not want extra work which might be brought by 5S activities.

3.

Motivation comes from a good pilot implementation in the hospital. When people can see the real
benefits, they will be more willing to adopt 5S.
1)

QMD needs to work directly with each pilot department to identify what need to be done in 5S activities. The
pilot department is the one to decide what things are necessary or unnecessary for their work, what order isconvenient for their work, etc.

2)

QMD’s role is assisting hospital staff to think clearer and more about what need to be done in 5S activities.
Providing an outsider’s view or advice is another approach which may work.

1 The sequence of 5S (Sort, Set, Shine, Standardize and Sustain) focuses on effective work place organization and standardized work procedures*. In short manner, Sort isdescribed as S1, Set is S2, Shine is S3, Standardize is S4 and Sustain is S5.
*: Hasegawa S and Karandagoda W. Change Management for Hospitals. 2013. JICA, Tokyo, Japan.

22

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 2 | 5S

4.

Financial incentive to motivate staff
In An Giang Hospital, a practice of 5S is counted as a consideration of bonus for each department. If a
department does not do 5S activity, they will earn less bonus than they could.
2)

In Da Nang Hospital for Women and Children, the QMD convinced the hospital director to let each

Session 1

1)

department collect and sell their own recycle waste and they can keep the money made. That becomes
an extra income for the department, so the staff are very eager to do this. QMD and Nursing Department
5.

A hospital could create 5S events like the 5S festival in Ha Dong Hospital to attract hospital staff andinduce more attention to 5S.

6.

Misunderstanding of 5S
1)

Vietnamese translation of 5S does not convey the full meaning of each “S”, especially S4 (‘san soc’ literally
make practitioners feel that 5S is all about keeping things clean and tidy for a good image. So trainings areimportant, not only about theories but also about the meaning of each “S”, especially detailed interpretationof 5S into specific contexts (i.e. what to do exactly in each “S”).

2)

We need to use translations of 5S that are closer to meanings of what to do in 5S instead of the popularhoa’ (standardize) for S4 and ‘duy tri’ (maintain, sustain) for S5 shows what to do in S4 and S5.

Nobody does 5S activity even after making a 5S plan

Session 4translations. Translation of 5S does not necessarily stick the idea to start with an “S”. For example, ‘chuan

1)

Session 3means ‘taking care’) and S5 (‘san sang’ literally means ‘ready’). Also S3 (‘sach se’ means ‘clean’) may

7.

Session 2

instructed the department to implement and monitor the implementation.

Breakdown of works maybe not detailed enough. It should assign specific tasks for specific persons. 5S
work can be integrated into individual job descriptions.
Everyone should participate in 5S or most people will expect 5S activity is only a job of a small group ofpeople who were specifically assigned 5S activity. It is better that hospital leaders do a part of 5S works to
be a model for their staff.

4.

Session 5

2)

Further discussion:
Why should we implement 5S?
1)

The highest goals of 5S activity is (1) convenience for work and (2) safety for patients through reducing
confusions and mistakes. 5S activity is not just keeping things clean and tidy.

2)

Session 6

1.

Among different Quality Management tools, 5S is the feasible, simplest and easiest tool. It is a good start for
Quality Management work.
5S is a foundation of stepping up to the higher-level of hospital quality management such as LEAN

4)

Implementation of 5S is counted as an indicator of the Hospital Quality Criteria by MOH.

Annex

2.

3)

Where should we start for 5S activity in a hospital?
1)

QMD itself is a good place to start 5S activity

2)

In National Hospital of Obstetrics and Gynecology, the director’s office was one of the first targets of 5S
activity in the hospital3)

National Heart Institute, Bach Mai Hospital and some other hospitals started with departments/units thatwere more open and showed willingness to adopt 5S

4)

For those who decided to start hospital-wide implementation of 5S activity from the beginning, eachdepartment can choose starting from small things in their departments

23

Session 2-1
Application of 5S in Land Use Planning in an Giang
Hospital of Obstetrics, Gynecology and Pediatrics
Tran Quang Hien1, Le Van Duc2
1 Director, An Giang Hospital of Obstetrics, Gynecology and Pediatrics
2 Quality Management Unit, An Giang Hospital of Obstetrics, Gynecology and Pediatrics

An Giang Hospital of Obstetrics, Gynecology and
Pediatrics is a 2nd level provincial hospital with 300 beds,
which was separated from the old, degraded provincial
general hospital. It is financially autonomous regarding its

major specialties: obstetrics and pediatrics.
•

Shine: build a Green – Clean – Beautiful hospital•Standardize: develop ISO-based SOPs for all
healthcare activities.

regular expenditures.
Early after establishment in April 2017, the hospital•

Sustain: meet people’s needs for healthcare.

decided to apply 5S “Sort - Set in order - Shine -Implementation of 5S sounds simple but is notStandardize - Sustain” in land use planning to meeteasy. An Giang Hospital of Obstetrics, Gynecology andpeople’s needs for healthcare, aiming to build a “green clean - beautiful” hospital as it is today.
•

S o r t : b u i l d i n g s n e c e s s a r y f o r c re a t i n g acontinuous chain for both obstetric and pediatricexamination.

•

Pediatrics has implemented 5S well owing to leaders’high determination and hospital staff’s full participation.
5S implementation must be sustained with continuous
quality improvement (CQI). 5S has changed the hospital’s
awareness and actions. This will be a basis for thehospital’s sustainable development.

Set departments in order: according to two

Outline of An Giang Hospital of
Obstetrics, Gynecology and Pediatrics

APPLICATION OF 5S IN LAND USE PLANNING
IN AN GIANG HOSPITAL OF OBSTETRICS,GYNECOLOGY AND PEDIATRICS
Dr. Tran Quang Hien, MD, PhD
Dr. Le Van Duc, MD, 2nd Degree Specialist
An Giang Hospital of Obstetrics,
Gynecology and Pediatrics

24• Provincial, 2nd level with 300 beds
• Financial autonomy regarding regularexpenditures• Started operation on April 10, 2016
• 12,000 turns of outpatient per month (45% withhealth insurance)• Bed occupancy rate: 110%
• Operation: 25 cases/day• Normal delivery: 25 cases/ day

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 2 | 5S

ORIGIN AND DEVELOPMENTTHE HOSPITAL IN THE BEGINNING

Session 1

In 1903, Delivery House was established thanks tocontribution of land from 2 individuals.
In 1965, Long Xuyen Hospital was constructedcompletely

Session 2

THE HOSPITAL IN THE BEGINNING

Session 3

ACTUAL STATE AFTERESTABLISHMENT

Session 4
Session 5

HOSPITAL GATETHE HOSPITAL IN THE BEGINNING

Session 6
Annex

OLD OUTPATIENT DEPARTMENT

THE HOSPITAL IN THE BEGINNING

25

THE HOSPITAL IN THE BEGINNING

HOSPITAL DEVELOPMENT POLICY
In the beginning, An Giang Hospital of Obstetrics,
Gynecology and Pediatrics decided its operation
principles:- Motto:“Safe – Friendly – Hospital for People ”- The hospital must be a place to receive and apply
new technologies in healthcare activities, while alsotransferring them to other hospitals in the province.
- Use 5S “Set – Sort in order – Shine – Standardize Sustain” to immediately improve the hospital’s
outlook.

5S IMPLEMENTATION IN THE HOSPITAL

After 01 year of operation• Sort: buildings necessary for creating acontinuous chain for both obstetric and pediatricexamination.
• Set departments in order: according to two
major specialties: obstetrics and pediatrics.
• Shine: build a Green – Clean – Beautiful
hospital• Standardize: develop ISO-based SOPs for all
healthcare activities.
• Sustain: meet people’s needs for healthcare.

Sort and Set the total area in order

OPD has been renovatedHospital land use re-planning

26

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

OPD

Session 2 | 5S

Park improvement
Session 1
Session 2
Session 3

Playing yard for children

Session 4
Session 5

Inpatient blocks

New hospital gate
Session 6
Annex

CONCLUSIONS• Implementation of 5S sounds simple but is
not easy.
• It requires leaders’ high determination andhospital staff’s full participation to implement
5S well.
• 5S implementation must be sustained with
CQI like PDCA.
• 5S has changed the hospital’s awarenessand actions. This will be a basis for thehospital’s sustainable development.

27

Session 2-2
Difficulties in Implementing S4, S5
in Ha Dong General Hospital
Nguyen Thi Huong Lien, Nguyen Thu Hang
Quality Management Department, Ha Dong General Hospital

A purpose of implementing 5S is to create good

– Blood Transfusion, Pharmacy, Outpatient, Nephrology,

work habits for everyone. It is a good habit that would

Odonto-Stomatology have remarkably changed,

help reduce mistakes caused by lack of concentration,

which motivates healthcare workers in these and otherpeople work faster and reduce time looking for necessary

departments to implement 5S. However, S4 and S5 could

things. Consequently, a comfortable and logical working
environment would be created, reducing medical incidents
and ensuring PS.
In Ha Dong General Hospital, 5S has been
implemented. Via implementing 5S, healthcare workers
are more aware and there has been some change in theirthinking. However, it is still a big challenge to make 5S
become a habit and to maintain S4, S5.
Before implementing 5S, our hospital had started
the “Hygienic Hospital” campaign (May 2015). From
December 2015 to May 2016, 5S was piloted in threelaboratories: Biochemistry Department, Microbiology
Department and Hematology – Blood Transfusion
Department. Since June 2016, 5S has been implemented
in every department. We conducted 5S trainings for all
nurses and QM network members and organized “5Shealthcare workers actively implemented 5S while mostthink that 5S wastes much of their time.

3.

Advantages- The hospital leaders have realized the necessity of 5S
implementation.
- 5S Steering Committee was established with
implementation plans developed for departments in eachperiod.

4.

Difficulties- Healthcare workers: habits and hesitation tochange are obstacles to improvement activities and 5S
implementation. Many healthcare workers think that 5S
wastes time, requires budget for implementation, andis work of department leaders and head nurses but notDay” to encourage competitiveness in 5S implementation

theirs.

among departments.

- Leaders of departments: know well the benefits of 5S

1.

but have not really taken actions nor encouraged their

Objective
To develop a habit of implementing 5S regularly indepartments, especially in clinical ones (some areas suchas meeting rooms, administrative rooms, injection trolleys,
corridor…)

2.

Results- Most of healthcare workers in clinical and para-clinicaldepartments know what 5S is, the necessity and benefitsof 5S implementation.
- Departments of Biochemistry, Microbiology, Hematology

28

only be maintained in a short time because only few

staff to implement 5S, thinking that 5S is work of QMD.  
- Hospital: The facility is narrow and degraded. Broken
equipment has not been fixed, replaced or collected, so
it requires a lot of space for storage. The budget for 5S
activities is still limited.
- QMD: has conducted 5S trainings and made a planfor 5S implementation but the plan is not detailed to thedepartment level and 5S implementation in departments
has not been monitored. The department has notproposed a regulation for rewarding and punishment soPractices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 2 | 5S

departments are not motivated to implement 5S.
S5: overcrowding, lack of patient’s collaboration in making
patient wards tidy and in putting trash in appropriate
places are some barriers for healthcare workers in 5S

groups and tailor training contents to suit each group.
After the training, there should be a test to evaluate thetraining’s quality.
- Establish a 5S taskforce, the members of which regularly

implementation.

Proposed solutions- QMD gives advice to 5S Steering Committee to makea specific and detailed 5S plan to the department level;
monitors closely using the 5S checklist; develops a
regulation for rewarding and punishment to timely praise
departments which implement 5S well.

DIFFICULTIES IN IMPLEMENTING S4,S5- Add 5S content in departments’ patient meetings
to educate patients so that they participate in 5S
implementation.
- The Directing Board strongly directs departments toimplement 5S and allocates a budget for 5S activities.

Session 4

HANOI DEPARTMENT OF HEALTHHA DONG GENERAL HOSPITAL

monitor S4, S5 implementation.

Session 3- Strengthen training activities: conduct 5S trainings for all

go to clinical departments to help them implement 5S and

Session 2

5.

technicians and cleaners…). Divide training targets into

Session 1- Patients: play an important role in implementation of S4,

healthcare workers in the hospital (doctors, pharmacists,

IN HA DONG GENERAL HOSPITAL

Session 5

Nguyen Thi Huong Lien, Nguyen Thu Hang
Quality Management Department

Session 6
Annex
29

30

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 2 | 5S

Session 1

Session 2

Session 3

Session 4

Session 5

Session 6

Annex

31

32

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 2 | 5S

Session 1

Session 2

Session 3

Session 4

Session 5

Session 6

Annex

33

Session 2-3
5S Maintenance in National Hospital of Obstetrics
and Gynecology
Vu Van Du
Quality Management Department, National Hospital of Obstetrics and Gynecology

1. 5S implementation in National Hospital of
Obstetrics and Gynecology••

According to the 83 criteria set (criterion A3.2)

culture, develop the project “Hospital Brand

approval of a 5S project in National Hospital

Identification”

3.

Difficulties – Recommendations

determination and enthusiasm of healthcare

Difficulties

workers in departments, by August 2017 (after 13•

months), 40/43 departments had implemented atleast one 5S content.
5S was piloted in all departments/centers/units•

laboratories, administrative rooms, etc.
5S implementation has not only brought visible
and practical benefits to both patients andhealthcare workers but also helped enhance

are under construction), which causes difficulties
for coherent implementation of 5S.
••

management of personnel, medical equipment

Recommendations

and materials.

•

For healthcare workers: a clean, tidy, logical andcourses and organize 5S day...
•

training on 5S and keeping common areas clean...

1

34

Continuously maintain and develop 3S (Sort – Set
in order - Shine) in departments/centers/units.

•

Professionalize monitoring activities for S4(Standardize) and S5 (Sustain): connect with IRS,

How to maintain 5S
Maintain: create habits for sorting, setting in order,

Enhance awareness of healthcare workers on
5S, especially 5S maintenance: conduct training

For patients: shortened time, accuracy, safety,

wasting and better disciplinedness.

•

The 5S monitoring system is not professional (lackof computerization)

friendly working environment, avoidance of time-2.

It takes much time to summarize information andpropose solutions to improve 5S implementation.

limited errors…
•

Limited budget → incomplete infrastructure (somebuildings are new, some are old and some otherof the hospital, including clinical, para-clinical andtrolleys, drug cabinets, document cabinets,

Limited self-discipline of healthcare workers; 3S
not being maintained continuously.

functional departments in every area: injection•

Improve, enhance 5S quality: nurture a 5S

and the hospital’s Directing Board’s support andhas been promoted in the whole hospital. With•

Monitor: collect statistical data, evaluate 5S
implementation in departments in the hospital.

1of Obstetrics and Gynecology (July 2016), 5S••

install a software for 5S auto-monitoring…
•

A clear reward and punishment mechanism for

Hospital Quality Standards (HQS) issued by the Ministry of Health, which incdlues 83 criteria. Therefore, HQS was often referred to as the 83 criteria set.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 2 | 5S

departments which implement 5S well and not•

Session 1

well.
Continuously improve and develop 5S
implementation.
•

Develop a typical 5S culture of NHOG (integrate
5S contents in the project for hospital brand•Session 2

development).
It requires supports from the Directing Board,such as a budget for maintaining and developing
5S implementation.

Session 3
Session 4
Session 5

5S IMPLEMENTATION IN NHOG••

5S was piloted in every areaof hospital: injection trolleys,
drug cabinets, document
cabinets, laboratories,
administrative rooms...

DR. VU VAN DU, MD, PHD: QUALITY MANAGEMENT DEPARTMENTCONTENTS
1. 5S
IMPLEMENTATION IN
NHOG

2. HOW TO
MAINTAIN 5S?
3.
ADVANTAGE
SDIFFICULTIE
S

Annex

5S MAINTENANCE IN NATIONAL HOSPITALOF OBSTETRICS AND GYNECOLOGY (NHOG)

Session 6•

According to the 83 criteria set (criterion
A3.2) + the hospital’s Directing Board’s
support and approval of a 5S project in
NHOG(July 2016), 5S has been promoted in
the whole hospital. With determination andenthusiasm of healthcare workers indepartments, by August 2017 (after 13
months), 40/43 departments had implemented
at least one 5S content.
5S is implemented in all departments/centers/
units of the hospital, including:
Clinical depts
Para-clinical depts
Functional depts

5S IMPLEMENTATION IN NHOG
5S implementation has not only brought
visible and practical benefits to bothpatients and healthcare workers but
also helped enhance management of
personnel, medical equipment andmaterials.
• For patients:
shortened time, accuracy
PS, limited errors…
• For healthcare workers:
A clean, tidy, logical andfriendly working environment.
• T
Avoidance of time-wasting.
• c
Better disciplinedness

35

HOW TO MAINTAIN 5S
Develop Project “Hospital Brand Identification”

HOW TO MAINTAIN5S
before

after

after

beforebeforeafter

before

after

after

beforeHOW TO MAINTAIN 5S

Conduct
5S
trainings

Create habits
for sorting,setting inorder

DIFFICULTIES IN MAINTAINING 5S
Difficulties in maintaining 5S: easy to implement the first 3S (Sort – Set inorder - Shine) yet difficult and challenging to maintain S4 (Standardize),
S5(Sustain)
Limited budget →incomplete infrastructure(some buildings are new,some are old and some otherare under construction)

Limitedself-disciplineof some staff

It takes much time tosummarize
information andpropose improvement
solutions

The monitoring system
for S4 (Standardize) andS5 (Sustain) is
incomplete andunprofessional (lack ofcomputerization)

Keeping common
areas clean

SOME EXPERIENCE - PROPOSALSHOW TO
MAINTAIN 5S
Dept.

•

5S checklist from Jan to Jun
2017

Areas

Jan

Feb

Mar

Apr

May

Jun

Obtained result

Average
score

Obtai
ned

Partially
obtained

Not
obtained

(√)

(Ο)

•
•

(X)

Treatment
Services

drug cabinet, injection trolley,
document cabinet, medical record,
personal cabinet

√

√

√

Ο

Ο

√

4

2

0

5

Delivery room

drug cabinet, injection trolley,
document cabinet, medical record,
personal cabinet

X

√

Ο

√

√

X

3

1

2

3.5

Anesthesia Resuscitation

drug cabinet, injection trolley,
document cabinet

√

X

Ο

√

√

√

4

1

1

4.5

Pathological
Obstetrics

drug cabinet, injection trolley,
document cabinet, medical record,
personal cabinet

√

√

√

√

Ο

Ο

4

2

0

5

NormalObstetrics

Drug cabinet, injection trolley,
document cabinet, medical record,
personal cabinet

√

√

√

X

Ο

√

4

1

1

4.5

SepticObstetrics

drug cabinet, injection trolley,
document cabinet, medical record,
personal cabinet

√

X

Ο

√

√

√

4

1

1

4.5

Endogynecology

drug cabinet, injection trolley,
document cabinet, medical record,
personal cabinet

√

√

√

√

Ο

√

5

1

0

5.5

Surgery –gynecology

drug cabinet, injection trolley,
document cabinet, medical record

√

X

Ο

√

√

√

4

1

1

4.5

Oncologygynecology

drug cabinet, injection trolley,
document cabinet, medical record,
personal cabinet

√

√

√

√

X

X

4

0

2

4

Hematology

personal cabinet, document cabinet,
personal cabinet

√

√

√

√

X

Ο

4

1

1

4.5

Office of Trade
Union

Document cabinet, office desk

√

Ο Ο

√

Ο

√

3

3

0

3.5

•
•
•

•

Enhance awareness of healthcare workers on 5S,
especially 5S maintenance: conduct training courses
and organize 5S day...
Continuously maintain and develop 3S (Sort – Set
in order - Shine) in departments/centers/units.
Professionalize monitoring activities for S4(Standardize) and S5 (Sustain): connect with IRS,
install a software for 5S auto-monitoring…
A clear reward and punishment mechanism for
departments which implement 5S well and not well.
Continuously improve and develop 5S
implementation.
Develop a typical 5S culture of NHOG (integrate
5S contents in the project for hospital branddevelopment).
It requires supports from the Directing Board, suchas a budget for developing and maintaining 5S
implementation.

HOW TO MAINTAIN 5S
Develop
5S
cultureindepartments

36

A reward/punishment mechanism forstaff for maintaining 5S well and not
well.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 2 | 5S

5S – A Commencement for Hospital Quality
Improvement
Medical Center, School of Medicine and Pharmacy, Da Nang University(Former Vice Director of Quang Nam Central General Hospital)

is the best way to reduce cost” - a saying by Genichi
gradually becoming financially independent, towards
totally independent in 2021, to consider cautiously tochoose the most suitable way for his/her hospital to
become a recognized hospital. From quality improvement(QI) experience in Quang Nam Central General Hospital,
implemented in hospitals which are determined toenhance their service quality.
Talking about 5S, I still remember a lecture given
by Professor Handa Yujiro, a famous Japanese qualityof the lecture, he led us to 5S as a fundamental activity
in QM (Figure 1). Besides, an image of NCGM hospital(Japan) being organized in a logical, tidy, orderly andcollaboration between Nursing Department and QMD:
From Starting, selecting pilot departments; Adjusting andsetting higher objectives and developing interventional
solutions; to Expanding and improve effectiveness.
So far, this activity has brought many visible results toevery department. After that, from S4, S5 activities, staff
gradually get to know the concept of standardization (S4:Standardize), continuously maintain and improve results(S5: Sustain). 200 improvement projects related to 5S ofdifferent scales in the first 6 months of 2017 are evidence
for the sustainability of this activity in our hospital.
Success of 5S depends much on the role of chiefs ofSession 6

expert, in a training course on QM in Japan. At the end

3 cycles of PDSA (Plan-Do-Study-Act) for implementing
S1, S2, S3 (Sort, Set in order, Shine) under active

Session 5

I think 5S is an important first step that needs to be

Quang Nam Central General Hospital has experienced

Session 4

Taguchi reminds each hospital leader, in this period offamiliar with QM through visible daily 5S activities.

Session 3“Cost is more important than quality but quality

Session 2

Le Viet Nho

Session 1

Session 2-4

departments and head nurses. At the departments where
key staff understand, support and directly work with theirstaff, with support from QMD, 5S implementation is very
who did not actively implement 5S at the beginning

Annexeasy and quickly brings effectiveness. Some departments
have remarkably changed after their chiefs changed
their attitude. For example, in Anesthesia - Resuscitation
Department, at the beginning, the department chief said
that he supported 5S but actually did not care how it was
actually implemented or what kind of difficulties they met.
Figure 1: Professor Handa Yujiro’s lecture

Meanwhile, the head nurse did not share with him thedifficulties they met in 5S implementation. After detecting
the problem, QMD organized a training on 5S for all

clean manner to every corner motivated me to study

staff in the department, in which they invited staff fromand implement this activity because I realize that QM is a

Pediatric Department, who had actively implemented 5S,vague and abstract concept; therefore, in order to maketo share experience. After that, the chief of Anesthesia -hospital staff get to know, understand and gradually apply
abstract QM theories, they should gradually become

Resuscitation Department actively involved and 5S in thedepartment has clearly changed.

37

In order to make 5S become a culture rather thanjust a trend, it requires that hospital leaders keep paying
attention and strengthening this activity for at least
several years with more PDSA cycles. Only when noone remembers what 5S is specifically but the hospital isalways tidy, clean and especially more convenient andsafer, then we can say that we are successful in 5S.

38Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 2 | 5S

5S Practice in Vinh City General Hospital

Session 2

Pham Van Son
Vice Director, Vinh City General Hospital

hospital. Designed with 280 beds and 350 healthcare

departments. After two months, evaluate

workers, the hospital actually has 450 beds and 415

comprehensively all departments to decidestaff members. Average number of outpatients per day

bonuses and rewards.

is about 1,000 and about 1,600 as highest. 5S has been

Some experience for success1.

To implement 5S in the hospital, firstly, it is

Leaders must be a role model in 5S implementation.

2.

It requires trainings for everybody so that 5S isunderstood and practiced.

the benefits of 5S to gain maximal support for
implementation.
2.

3.

establishing a clear rewarding mechanism,

Make 5S plans following a PDCA cycle: pay

evaluation.

attention to involvement of leaders of departments
and socio-political organizations (trade union,and competitiveness.
3.

Conduct trainings on 5S practice and experience4.

In departments: assign individuals to be responsibleof each area or division so that they remind eachother to implement and maintain 5S.

Session 6

youth union, etc.) to develop promotion policy

Participation of organizations: signing commitments,

Session 5

necessary to make the hospital leaders see

1.

Session 4

to generate lessons learnt for the remaining

Session 3

Vinh City General Hospital is a 2nd level district

implemented since July 2017.

Session 1

Session 2-5

for key staff such as chiefs and vice chiefs ofdepartments, head nurses.
Request departments to conduct trainings on
5S practice for their staff with QMD’s support.
In fact, QMD had to go to each department to

Annex

4.

conduct 5S training for their staff. Sometimes,
we think about e-learning because 5S requires
participation of all members to be effective.  
5.

Establish a 5S taskforce to conduct surveys,
develop a 5S checklist and consult departments.
Select 3 clinical departments to pilot 5S.

6.

Departments sign commitments with the hospital
director under witness of political organizations.
Announce reward after the first evaluation. Staff
sign commitments with chiefs of departments.

7.

After one month, evaluate the pilot departments

39

Session 3 Standardized Operational
Procedures (SOPs)
Summary of Discussion
1.

How to describe clinical and safety components in SOPs?
1.

QMD develops a simple general form for SOP and trains other health staff about writing an SOP: the content
must include a process diagram and description, the procedure should be simple so that a new staff canunderstand their task by reading it, each SOP has one checklist for managers to check implementation.
•

In Saint Paul Hospital, the content must include incidents and adverse events that can happen in each stepand how to handle them when they occur.

•
2.

In Thu Duc Hospital, the content must include affecting factors to the process.

The practitioners draft an SOP, then QMD and maybe others help complete the SOP;•

In Thu Duc Hospital, the head of department appoints some doctors to make the draft, each doctor is
responsible for some specific SOPs in their department. The hospital established a team to help complete
the SOP. This team includes representatives from internal medicine, surgery, general planning department,
QMD and some relevant departments. The team has a meeting with the relevant doctors and department
head to contribute ideas for the SOP. QMD is the one who finalizes the SOP before sending to the director
for approval. One difficulty is that clinicians are not much interested in contributing to SOP development.
Normally, they only check SOPs when something bad happens.

3.

In Thu Duc Hospital, SOPs are made specifically for each targeted audience (e.g., doctors, patients). For
example, for the process of taking specimen, there are one SOP for health staff and another SOP for patients.

2.

How and when SOPs are updated?
1.

SOPs are usually reviewed once every year and revised if necessary. Then SOPs can be updated when an
incident showed requirements of changes in the current SOPs. Also SOPs can be checked when patients ortheir families complained against the relevant services defined by the current SOPs.

3.

How to achieve and maintain compliance to SOPs?
1.

Vertical monitoring: the department head/vice head and the head nurse of each department monitors
compliance to SOPs in their department;

2.

Cross-cutting monitoring: QMD checks compliance to SOPs in all departments or participating in a team whodoes this job.
•

In Saint Paul Hospital, QMD goes to department unannounced and interviews its staff about their awarenessand knowledge of their SOPs.

•

In Thu Duc Hospital, QM staff join the hospital’s monitoring team. This team, dividing into small groups, goescheck the compliance in departments twice a day (once in the morning, once in the afternoon). This teamprioritizes monitoring procedures that hospital staff are less likely to comply to, or those related to issues the
hospital is paying attention to or issues reported by many patients.

3.

Thu Duc Hospital relies a lot on the IT system to make their staff, especially doctors, to comply to SOPs. For
example, if the doctor has not finished one step in the SOP, the system does not allow them to do the next work.

4.

In Tu Du Hospital, they have monitoring priorities for their almost 1,000 SOPs, and can only monitor 20% of theirpriorities selected for each year.

5.

40

An unanswered question is: how to make hospital leaders comply to SOPs? What QMD does if their hospital

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 3 | Standardized Operational Procedures (SOPs)

leaders do not comply to SOPs?

Further discussion:
1.

What is the purpose of developing SOPs?
SOPs help people do the work in the same way to create similar outputs, as required by their leaders

2)

SOPs are a tool to help hospital managers to monitor and evaluate their staff’s work performance

3)

SOPs are part of process control. It is a tool to ensure patient safety.

4)

SOPs can help identify individual responsibilities when adverse events happened. In Japan, SOPs help
protecting health staff if their work was complied to SOPs.

2.

Session 2

1)

Session 1

4.

Clinical pathway (a.k.a. care pathway, care map)
In Vietnamese, we have only one word for procedure, which is “quy trinh”. Usually we say “quy trinh” forshort. MOH uses “quy trinh chuyen mon” (literally translated as “professional procedure”) referring to “clinicalpathway”.1 In 2016, the Minister of Health issued a Decision (4068/QD-BYT, 29/07/2016) guiding hospital
to develop “quy trinh chuyen mon” with 26 “quy trinh chuyen mon” for 26 common diseases as examples.

Session 3

1)

However, “quy trinh chuyen mon” in Vietnam seemed to be quite different with “clinical pathway” used in
the world. Cho Ray Hospital, one leading hospital in the South of Vietnam, is learning and experimenting
2)

Currently, the MOH’s Hospital Quality Criteria does not count clinical pathways in its scoring. The section
C5.3. mentions development of medical procedure (“quy trinh ky thuat”, literally translated as “technicalSession 4

developing their own clinical pathways to meet the world standards.

procedure”) and the section C5.4. mentions development of clinical guidelines (“huong dan dieu tri”). These
are basis for clinical pathways in the far future.

Session 5
Session 6
Annex

1 http://kcb.vn/wp-content/uploads/2016/08/H%C6%B0%E1%BB%9Bng-d%E1%BA%ABn-bi%C3%AAn-so%E1%BA%A1n-Quy-tr%C3%ACnh-chuy%C3%AAnm%C3%B4n.pdf

41

Session 3-1
Development of SOPs in Hospital
Uong Thanh Tung
Chief of Quality Management Department Saint Paul General Hospital

Necessity

1

DEVELOPMENT OF

4q Improper implementation or skipping some steps oftechnical procedures.
q Providing services: healthcare processes are complicated,discontinuous, involving many uncollaborative focal points
and individuals (systematic errors)

SOPs IN HOSPITALà Possible consequences:
Medical incidents that harm
patients

Dr. UONG THANH TUNG, MD, MSc
CHIEF OF QUALITY MANAGEMENT DEPARTMENTSAINT PAUL GENERAL HOSPITAL

Definition

2

What is Standard Operating Procedure (SOP)?
SOPs in hospital?

Necessity

5u

Reduce working stepsu

Optimize information processing process: enter data, extract data, check,procedures, protocolsu

Automate smartlyu

Monitoring systemu

Minimize adverse effects: continuous training, updating knowledge, etc.

Latent errors
Risks
Active errors
Properly following safety principles in each step of the procedure
will help prevent adverse events.
(James Reason, BMJ 2000;320:768-770)

Necessity

3

Technical procedures issued
by the Ministry of HealthA clear procedure helps practitioners and managers:42u

imagine quicker ways to do their jobs.

u

Save time.

u

Increase accuracy in work.

u

Check and review completed work easily.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 36

Session 3 | Standardized Operational Procedures (SOPs)

Medical incident statistics in the hospital
7

An example

11

Session 1

Quantity
No.

Type of incident

Year 2016

1
2
3
4
5
6
7
8
9
10
11
12

Wrong patientWrong/lack of medical indications
Due to drugs/blood/chemicals
Wrong surgery
Nosocomial infection
Environment (electric shock, burnt…)
Fall
Lack/damage of equipment
Crime
Non-compliance to procedures
Occupational exposure
Risks in surgeries and procedures

13
14

Others
Non-reported incident

08

Total

42

01
11
01
01
03
02

Some important contents in 12
developing a procedure

Convenience in work: to-do steps are listed in a certain orderwith specific required papers.

u

Quality control-

Describe quality control methods, including
calibration of machines and devices.

-

In case there are specific procedures forcalibration, it is not necessary to describe thiscontent in details. Only write the name(s) andcode(s) of relevant procedure(s).

uSafetyEasy to monitor: the order of the working steps in a procedure
helps one person know whether the previous steps have been
performed sufficiently and correctly or not.

u

Increased work effectiveness: procedures create
professionalism and shorten training time.

Identify safety issues that practitioners need to pay
attention to when implementing the procedure (ifany).

Session 4u

Session 3

8

Benefitsu

Session 2

13
02

Session 5

Instruction for writing a procedure

9

Contentsu

Progress and reporting results- Specify obtained results- Specify how to solve problems when incidents happen.
- For technical procedures, add the following information:

Session 6

1. The rounded rectangle presents the starting and ending pointsof a procedure

Some important contents in 13
developing a procedure+ Calculation formulas, units (if any)
+ Explanation of results for abnormal cases

2. The rectangle represents instructions or activities+ Specify the limits of the analytic system, biological reference
intervals and alert values (if any)uMonitoring after performing the technique

Monitor possible adverse events and complications.

Instruction for writing procedure(2)Contents

10

Annex

Monitor vital signs of the patient: blood pressure, pulse,
respiration rate...

Some important contents in 14
developing a procedure

3. The diamond highlights when to make decision.
uComplication management- Specify in order main steps to take when complication
occurs with specific, succinct, and easy-to-understandwriting.
4. The parallelogram represents an input or output. It may
be material, service, participant or ending of a procedure.

- Number each step so that when some steps need to berepeated, only mention their numbers.
u

Evaluation of implementation steps- Write in checklist format: properly followed the orderly
steps in the procedure (yes or no)- Propose to revise the procedure if there are problems
during implementation.

43

Session 3-2
Experience in Developing Standard Operating
Procedures for Management
Huynh My Thu
Quality Management Department, Thu Duc District Hospital

1.

Introduction of hospital
In June 2007: the hospital had 50 beds, 17 medical

doctors, 4 departments: Outpatient, Emergency &Intensive care, Pediatrics – Internal medicine, Pharmacy.
400 outpatients per day, 10 inpatients per day.
On June 5, 2009: the hospital was approved to be a
2nd level hospital.
On November 12, 2014: the hospital was approved to bea 1st level hospital with 10 functional departments, 36 clinicaland para-clinical departments, 800 planned beds, 4,500 –
5,000 outpatients/day, 1,507 staff (as of June 30, 2017).  

2.

State of SOPs in the hospital- There was no standard frameworks for SOPs;

that activities are conducted following the regulation in
the same way. (Guidelines for development of SOPs for
management of laboratory quality in healthcare facilities
issued with Decision number 5530/QD-BYT dated
December 25, 2015 by the Minister of Health)- Management SOPs;- Technical SOPs.

5.

Principles for implementation- Principle 1: Every work should have SOPs.
••

approval, etc.
- Principle 2: Based on documents and guidelines- There was no standardized tasks, staff perform tasks in

issued by MOH, Department of Health (DOH), the hospitaldifferent ways;  

develops detailed SOPs according to its actual state.

- Work was handled by feelings;- Principle 3: SOP is a document for guiding and control- Responsibilities and authorities were not clearly identified.  

3.

Legal basis- QM system – Requirements by National Standards
TCVN 9001:2008;- Decision number 5530/QD-BYT dated December
25,2015 by the Minister of Health guiding development of
SOPs for management of laboratory quality.

4.

Legal basis
SOP (Standard Operating Procedure) is a document

which provides specific guidelines for performing a
specific task in management and technical work to ensure

44

Management SOPs: incident reporting, patientsatisfaction survey, submitting documents for- Technical departments had difficulties in making
documents;

Technical SOPs: doctors, nurses, infection
control, laboratories etc.

but not a barrier to technical work or to delay work.
- Principle 4: Clinicians don’t have to spend much timeand energy to think about administrative documents.
- Principle 5: Users are the center of the SOP, contentsof which are tailored to suit each user group (patients,
healthcare workers): wording, writing style, layout anddesign.
- Principle 6: QMD is the final department to review the(management) SOP before it is submitted to the Directing
Board for approval.
- Principle 7: Review and update SOPs regularly andwhen necessary.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 3 | Standardized Operational Procedures (SOPs)

6.

- Training materials.

a.

9.

Identifying the needs for development/update/revision of an SOP: new emerging tasks; theneeds to standardize implementation steps,
responsibilities, and timing; the needs for
improvement when errors happen…

c.

Identifying the contents and steps for implementation:- Common sense of “only reviewing SOPs when problems
happen”;- Technical staff do not want to follow SOPs nor to give

5W1H2C5M; developing process diagrams andcomments for SOPs;

descriptions: beginning => end.

- In controlling doctors’ compliance to SOPs.

Organizing meetings for development/update/10.

revision of the SOP: with participation ofCollecting comments

Conclusions- Standardization of SOPs is a necessary standard
to evaluate work competency, which helps hospitalmanagers manage the hospital better.

- Versions 1, 2, 3…

- Strengthen vertical checking and monitoring.

- Suitable revisions;- Regularly update to suit the hospital’s actual state.

e.

Session 4- Consensus among departments.

Session 3

departments that need and relevant departments.
d.

- In asking departments to update and revise SOPs;

Session 2b.

Difficulties

Session 1

Steps for developing an SOPApproval- Regular update at the beginning of each year:
review all procedures.
- Development of a new SOP, update and ad-

Session 5

hoc revision of an old SOP: Composers =>Responsible people => the Directing Board.
f.

Issuance- Based on QMD’s proposal, Personnel Department
releases a decision for issuing the SOP.
operation portal.

7.

EXPERIENCE IN DEVELOPING STANDARD
OPERATING PROCEDURES (SOP) FOR MANAGEMENT

Checking and monitoring

Session 6- An announcement is posted on the hospital’s- Horizontally (cross sectional monitoring)
Establish the Checking and Monitoring Committee

PRESENTER: MS. HUYNH MY THU, MSc
CHIEF OF QUALITY MANAGEMENT DEPARTMENT, THU
DUC DISTRICT HOSPITAL

in the hospital;•

Monitor by topic;•

Present and remind inappropriate cases.

Annex

•

- Vertically: QM network, head nurses.

8.

Benefits- Standardized work, reduced errors;- Convenient for checking and monitoring;- Clear regulation about evidence and results of work;- A basis for identifying responsibilities and authorities;- A basis for QI, implementing corrective and preventive
measures;

CONTENTS

1• HOSPITAL INTRODUCTION

2• ACTUAL STATE – LEGAL BASIS

3• OPERATING PRINCIPLES

4• IMPLEMENTATION PROCESS

5• CHECKING AND MONITORING

45

CONCEPTS

THU DUC DISTRICT HOSPITAL• 50 beds¡• 17 doctors• 4 departments• Outpatient• Emergency - ICU

in healthcare facilities issued with Decision number 5530/QD-BYT dated December 25, 2015
by the Minister of Health)• Pediatrics – Internal medicine• Pharmacy

ØManagement SOPs

• Outpatient: 400 patients/ day
28/06/2007

ØTechnical SOPs

• Inpatient: 10 patients/ days

THU DUC DISTRICT HOSPITAL
District hospital
1st level

05/06/2009: 2nd level hospital
12/11/2014: 1st level hospital

SOP (Standard Operating Procedure) is a document
which provides specific guidelines for performing a specifictask in management and technical work to ensure that
activities are conducted following the regulation in thesame way. (Guidelines for development of SOPs for management of laboratory quality

IMPLEMENTATION PRINCIPLES¡ Principle 1: Every work should have SOPs
¡ Technical SOPs: doctors, nurses, laboratory,
infection control, etc.

v Organizational structure: 10
functional departments & 36 technicaldepartmentsv 800 planned bedsv Outpatient: 4,500–5,000 patients/dayv Manpower: 1,507 staff (30/06/2017)¡ Management SOPs:

ACTUAL STATEv No standard frameworks for SOPsv Technical departments meet difficulties in making
documentsv There are no standardized tasks, staff performtasks in different ways;v Work is handled by feelings;v Responsibilities and authorities are not clearly
identified.

SOPs: 358

LEGAL BASIS

IMPLEMENTATION PRINCIPLES¡¡ QM system – requirements by National Standards TCVN

9001:2008;¡

46

Principle 2: Based on documents and guidelines
issued by MOH, DOH, the hospital develops detailed
SOPs according to its actual state.

Decision number 5530/QD-BYT dated December 25,2015 by the Minister of Health guiding development of
SOPs for management of laboratory quality.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 3 | Standardized Operational Procedures (SOPs)¡

Principle 3: SOP is a document for guiding andcontrol but not a barrier to technical work or to delay
work.

IMPLEMENTATION PRINCIPLES¡ Principle 7: Review and update SOPs regularly andwhen necessary.

Session 1

IMPLEMENTATION PRINCIPLESØRegular review: once per yearØAd-hoc review: when there are

emerging issues or mistakes

Identifying the needs fordevelopment/update/revision of an SOP• new emerging tasks• the needs to standardize implementation steps, responsibilities,
and timing• the needs for improvement when errors happen• 5W1H2C5M

Identifying the contents and • Process diagrams (summary) + descriptions: Beginning => End
steps for implementation
Organizing meetings fordevelopment/update/revision of the SOP• Departments that need + relevant departments => Draft

Session 4¡ Principle 4: Clinicians don’t have to spend muchtime and energy to think about administrative
documents.

STEPS FOR DEVELOPING AN SOP

Session 3

IMPLEMENTATION PRINCIPLES

Session 2that need improving.

Session 5

STEPS FOR DEVELOPING AN SOP¡ Principle 5: Users are the center of

the SOP, contents of which are
tailored to suit each user group(patients, healthcare workers)v Wording

Collecting comments

Approvalv Writing stylev Layout and design

Issuance• Versions 1, 2, 3…
• Suitable revisions• Consensus among departments

Session 6

IMPLEMENTATION PRINCIPLES• Regular update at the beginning of each year: review allprocedures.
• Development of a new SOP, update and ad-hoc revision of an old
SOP: Composers => Responsible people => the Directing Board.
• Based on QMD’s proposal, Personnel Department releases a
decision for issuing the SOP• An announcement is posted on the hospital’s operation portal

Annex

IMPLEMENTATION PRINCIPLES¡ Principle 6: QMD is the final department to review

the (management) SOP before it is submitted to the
Directing Board for approval.

CHECKING AND MONITORING¡ Horizontally (cross sectional monitoring)¡ Establish the Checking and Monitoring Committee

in the hospital;¡ Monitor by topic;¡ Present and remind inappropriate cases.
¡ Vertically:¡ QM network, head nurses.

47

BENEFITS¡ Standardized work, reduced errors;¡ Convenient for checking and monitoring;¡ Clear regulation about evidence and results of work;¡ A basis for identifying responsibilities and authorities;¡ A basis for QI, implementing corrective and preventive measures;¡ Training materials.

DIFFICULTIES¡ In asking departments to update and revise

SOPs;¡ Common sense of “only reviewing SOPs

when problems happen”;¡ Technical staff do not want to follow SOPs

nor to give comments for SOPs;¡ In controlling doctors’ compliance to SOPs.

CONCLUSIONS
Ø Standardization of SOPs is a necessary standard to evaluate

work competency, which helps hospital managers manage
the hospital better.

Ø Strengthen vertical checking and monitoring.
Ø Regularly update to suit the hospital’s actual

state./.

48

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 4 | Information Communication Technology

Summary of Discussion
How ICT could support quality management in hospital?
1.

Information Communication Technology (ICT) facilitate collecting, organizing, updating, analyzing, and managing

Session 2

1.

Session 1

Session 4 Information Communication
Technology (ICT)a great deal of information about Quality Management (QM) activities in a hospital. It is especially useful for QM
works such as monitoring MOH’s Hospital Quality Criteria, incident management and so on. ICT increases the(e.g., compared with working with Excel or paper).
1)

ICT helps use of data. For example, Ba Ria Hospital can monitor their implementation of MOH’s Hospital
Quality Criteria, ISO 9001, JCI at the same time by ICT.

2)

ICT helps monitoring a progress of QM activities, e.g., who has or has not completed which tasks. It helps
progress QMD wants.
ICT helps making hospital staff follow hospital’s Standardized Operating Procedures (SOPs) and otherregulations. For example, in Thu Duc District Hospital, the IT system does not allow the staff to skip any step

Session 4

collects evidence for QM activities. Based on this information, QMD can push the intervention to reach the3)

Session 3

effectiveness of QM work while reducing the amount of manual work, human resource, costs, time, and mistakes

in a procedure. Each step is required by IT to be completed before starting the next step. Doctors are notis automatically sent to General Planning Department and the doctor has to explain why he/she did it. If the
protocol needs to be updated, it will be reflected in the IT system accordingly.
4)

ICT helps involving hospital staff in QM activities. For example, after starting the STAR program in Ba Ria

Session 5

allowed to prescribe a drug which is not listed in the protocol. If doctors did not follow the protocol, a report

Hospital, its QMD started to receive a lot of incident reports compared to the previous that received very few
reports. Also their staff enjoy sending evidence such as pictures of their 5S work through the IT system.
ICT helps build a unique QM/PS culture in hospital. For example, in Ba Ria Hospital, by using STAR program,the staff are learning to Stop-Think-Act-Review when an incident happens before reporting to QMD. In Thu
Duc District Hospital, ICT helps to create culture of high compliance to SOPs and other regulations.
2.

Session 6

5)

Infrastructure is important for applying ICT in QM activity. For example, the system, cables, electricity etc. must
be stable. Equipment or supporting systems will be required. For example, Thu Duc District Hospital now
doctors had to memorize or take notes of information of patients before coming back to their computers. Now,
Thu Duc District Hospital is developing new version of a software that can be used on portable devices such as

Annex

conducts experiment of electronic medical record. At the beginning, when doctors input data into a computer,

iPad or smartphone so that doctors can bring these devices when they visit patients.

2.

Further discussion:
1.

How to develop and/or choose software that meet the needs of a hospital? How can we evaluate thequality of the software?
1)

QMD needs to answer two key questions. Question 1 is “What does QMD want to manage?” and question
2 is “How does QMD want to manage something that QMD want to manage?”. ICT is a tool so if QMD
staff are not clear about what they want and how they can get something what they want, QMD cannot
effectively work with IT experts to develop a software or IT system that serve QMD’s objective of introducing
ICT.

2)

Since different works in hospital are correlated (e.g., clinical work and testing work), a software should be
open and can be connected to other software or IT systems that has already used in a hospital. Some49

hospitals bought and applied a software that could not be connected and/or not compatible with theexisting IT system in a hospital.
3)

Quality or effectiveness of a software can be reflected in “What extent it meets the expectation (expected
outputs) of QMD staff”, “Whether the results of QM work are good with the software (e.g., more staff
participation, more evidence, less work)” and “feedback of users (e.g., problems met, expected changes),etc.”.

2.

How can QMD staff talk to IT experts when they develop software QMD wants?
IT experts usually see things in a logical and mathematical way (e.g., 1 is 1 and 0 is 0). IT experts may notunderstand the complexity of QM work in reality. Therefore, QM staff need to tell them not only our expected
outputs but also ideas about how to reach there, what can happen on the way and how QMD wants to manage
them. Communication should be as simple as possible.

3.

What can MOH do to guide and assist hospitals in applying IT in their work?
1)

Some hospitals expect MOH’s guidance and assist due to (a) difficulties and huge costs in trial and error
before finding good software that work well and (b) expectation of connecting output data with national
database or IT systems in the future. For example, insurance payment system is expected in the future.

2)

As of now, it is almost impossible for MOH to develop a single software that can be applied and meet theneeds of all hospitals because there are a lot of issues related to overwhelming, confidentiality, conflicts,
regional differences, cultural habits, etc. What has done by MOH so far is a software for patient satisfaction
survey that is largely used by hospitals in the country.

3)

It is expected that MOH can give some recommendations, guidelines and advices for hospitals when thehospitals choose a software.

50

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 4 | Information Communication Technology

How Does Information Technology Support
Hospital Quality Management?

Session 2

Vu Duy Tung
Quality Management Department, Ba Ria Hospital

Support for implementation•

Progress monitoring•

Checking and monitoringfor information management: managing finance like a•

Reportingbank; training like a university; managing goods like a•

Score calculation

A hospital has various and complicated needs

supermarket; managing patients like a hotel; managing
documents like a library, etc.
improvement.

2. Incident management
An application was developed based on safety
sciences in other sectors: oil and gas, car production,
heavy industries, education, etc. Classification is based•

Different kinds of data•

Big data

Classification for Patient Safety.  

•From different sources

At present, there are many channels to receive information•

Through different channels•

Processing data to make reports for different•••

Opinion letters: the opinion box is not wellmanaged (Circular 25/2015/TT-BYT dated

Easy to access and change

October 01, 2015 regulating opinion boxes in

Software groups
Based on HQS, IT should be used to support

Errors, incidents: MOH regulations, HQS (criteria
D2: D2.1. and D2.2.) currently attain 1 point;

healthcare facilities);•

Comments from others - friends, visitors,

implementation of about 437 items. And there are aboutteachers, staff from other facilities, etc. - haven’t

32 modules/applications/programs.  

been paid enough attention;

3.

Some practical examples

1.

Managing HQS implementation
Not only HQS. It can be connected with otherstandard sets. It can help avoid overlaps when applying at•

Information from internet - social networks,
websites - hasn’t been paid attention;•

Letters of thanks haven’t been paid attention;•

Initiatives: Circular 18/2013/TT-BKHCN dated

the same time a number of standard sets because many

August 01, 2013 and Decree number 39/2012/

standard sets have overlapping contents.

ND-CP have many problems and bureaucraticcomplications;Supportive features:•

Evidence

Annex

2.

on WHO’s Conceptual Framework for International

Session 6

purposes

Session 5

It needs basis for improvement and evidence ofSession 4•

Session 3

1. QM/PS activities generate needs for
managing, processing and utilizing information(information technology - IT)

Session 1

Session 4-1•

Staff’s comments and ideas regarding documents,51

policies and improvement haven’t been paid

above:

attention;•

Other comments – e.g., about broken equipment,
reminders, etc. - haven’t been well managed

Very few reports from departments to the IRS. Reasons:Staff don’t have to care about forms•

Automatic approval•

Easy for searching•

Integrate checklists and evaluation of compliance•

Lack of knowledge about incident reporting form•

Afraid of punishment•

Do not want to report others

4.

•

Inconvenient, not ready

Difficulties:•

No feedback, incidences not handled•

Commitment is perfunctory•

No benefits•

Cannot manage before and after•

Time-consuming•

Difficult to create movement  •Incidents, errors are “big” problems•

Considering as unimportant•

Making use of all commitments•

Leaders do not encourage•

Monitoring before and after, “lifetime”•

Don’t know whom to report to•Creating competitiveness for awards based on•

Don’t know how to report•

Don’t see reporting forms•

Don’t know what to report forSTAR program and supporting software programs cansolve the problems above → thousands of incidents werereported in 6 months.  
3.

•Management of Standard Operating Procedure

Policies (SOPPs)
Many barriers to writing SOPP (not having time,
troubles, etc.)
Difficulties for reviewers: too many procedures,composers were careless and did not understand well thein the system. Report directly in the software
program

Benefits:

improvements on software programs: voting,manager’s pick...

4. Coming-up projects (software programs
are available)
1.

KPIs, KQIs
Integrated into daily reports. Weekly, monthly, quarterly

and annual reports are extracted automatically. Displayedin real time.
2.

Regular meeting management (integrating STAR +KPIs, KQIs)
No extra work for departments.
3.

contents, therefore it is time-consuming for reviewers.
•

5S Kaizen management

eLearning
Including competency framework.
All training courses are online to save time for staff.

Difficulties in developing checklists and applying
them to daily check procedures;

They can use their free time.

•

Difficulties in monitoring;  

4.

•

Difficulties to make procedures work in reality;•

Difficulties in arranging suitable activities in eachprocedure;•

And many other software programs
Other management software programs of the hospitalshould be redesigned, reconfigured and equipped withother activities for QM/PS.  

Basic concepts are not clarified: document,
notebook, form, guideline, protocol, treatment
information briefing, technical procedure briefing,technical procedure, administrative procedure
briefing  

Software programs can help overcome the problems

52

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 4 | Information Communication Technology

In  oversea  hospitals: IRS  is  valued
In  Vietnamese  hospitals:  IRS  has  just  been  started,  therefore  limited    Reasons:

Dr. Vu Duy Tung
Ba  Ria  Hospital

0933757190

Quality	
  Management	  Department	
  vuduytung@benhvienbaria.com	
  • Incidents,	
  errors	
  are	
  “big”	
  problems	  • Considering	
  as	
  unimportant	
  	
  	
  	
  
• Leaders	
  do	
  not	
  encourage	  • Don’t	
  know	
  whom	  to	
  report	
  to	
  	
  
• Don’t	
  know	
  how	  to	
  report	  	
  • Don’t	
  see	
  repor<ng	
  forms	  • Don’t	
  know	
  what	  to	
  report	
  for	  	
  • …

  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  -­‐  >  ST        R  program
Not  skipping  steps

	
  6.	
  Survey	
  
	
  7.	
  Communica<on	
  
	
  8.	
  Changes	
  
	
  9.	
  Opinions	
  from	  clients	
  and	
  others	
  	
  10.	
  Reports	
  of	
  drug	  side	  eﬀects…	
  

STAR

Monitoring  and  evalua(onHandling  the  INCIDENT  immediately

Correc<on	
  

Stop	
  –	
  Think	
  –	
  Act	  -­‐	
  Respond	  	  Training	
  (e-­‐learning)	
  Fixing,	
  replacing	
  
…	
  

Systema(c  errorsWork	
  Flow	
  Work	
  Track	  Score	
  Problems	
  SOPPs  –  STANDARD  OPERATING  PROCEDURE  POLICIESResources	
  Handling	  Evalua<on	
  Results	  Introduc@on  of  STAR  program  (1/2)• Receives  comments	
  from	  diﬀerent	
  aspects	  and	
  groups	
  	
  	
  
• Helps	  staﬀ	
  detect	
  and	
  handle  their	
  incidents	
  and	
  those	  of	
  others	  	
  • Detects	  and	
  corrects	
  systemaJc  errors	  • Disseminates	
  good  pracJces    • Helps	  staﬀ	
  more  focused  in	  their	
  work	
  	
  	
  
	
  
àDeveloping  QI  culture  in  the  whole  hospital

Checklist	
  Not  skipping  steps

No  excepJons

Session 4

Integrated  into
1. Department	
  mee<ngs	
  2. Hospital	
  mee<ngs	
  3. Unplanned	
  mee<ngs	
  4. Regular	
  mee<ngs	
  5. Inspec<on	  6. Ini<a<ves,	
  research	
  7. Other	
  programs…	
  Pa<ents’	
  opinions	
  Staﬀ’s	  opinions	
  Error/Incident	
  reports 	  Monitoring	
  &	
  evalua<on 	
  Requests	
  from	  higher	
  managers

ComputerizaJon,  automaJon

STAR  program  collects  informaJon  from  all  sources  and  iniJally  handles  issues:

1.
2.
3.
4.
5.

No  harm

Session 3

STANDARDS:  83  Criteria  (HQS),  JCI,  ISO…

No  excepJons

Session 2• Lack	  of	
  knowledge	
  about	  incident	
  repor<ng	
  
form	
  
• 	
  
Afraid	  of	
  punishment	
  • Do	  not	
  want	  to	
  report	
  others	
  	
  	
  
• Inconvenient,	
  not	
  ready	
  	
  	
  
• No	
  feedback,	
  incidences	
  not	
  handled	  • No	
  beneﬁts	  • Time-­‐consuming	
  

	
  

Session 1

Prac@cal  results  of  “voluntary  error/incident  repor@ng”

How does IT support
hospital quality management?

No  harm

Session 5

Introduc@on  of  STAR  program  (2/2)
How  does  S.T.A.R.  work?  

staﬀ	
  

Thông  Jn  bên  ngoài  (external  informaJon):	  Think	  –	
  think	
  about	
  alterna<ves	
  and	  Áp  dụng  (applicaJon)  to	  acknowledge	
  good	
  

Act	
  –	
  do	
  what	  you	
  think	
  is	
  best.	
  	
  Rà  soát  lại  (review):  one’s	
  work	  and	
  that	  of	
  Respond:  Review,  Report,  Responsibility,  Reply  –	  review	
  the	
  event,	
  report;	
  iden<fy	
  responsibili<es;	
  and	
  feedback.	
  

from	
  all	
  outsiders	
  (hotline	
  +	
  opinion	
  boxes	  +	
  communica<on…)	
  and	
  posi<ve	
  prac<ces	
  that	  should	  be	
  disseminated.	
  	
  	
  

colleagues	
  to	
  improve.	
  	
  consequences/results	  Session 6

What  is  S.T.A.R.?  What  does  it  do?

Sai  sót,  sự  cố  (errors,  incidents):  from	  hospital	
   Stop	  –	
  stop	  abnormal	
  ac<vi<es	
  and	
  situa<ons

Error/Incident  Management  (STAR  program)

Annex

HOSPITAL  MANAGEMENT  SOFTWARE  PROGRAM  	
  Diﬀerent  channels  to  receive  informa@on• Errors,  incidents:  MOH	  regula<ons,	
  HQS	  (criteria	
  D2:	
  D2.1.	
  and	
  D2.2.)	
  currently	
  aaain	  1	  point;	
  • Opinion  leVers:  the	  opinion	
  box	  is	
  not	
  well	  managed	
  (Circular	
  25/2015/TT-­‐BYT	  dated	  October	
  01,	  2015	
  regula<ng	
  opinion	
  boxes	  in	
  healthcare	
  facili<es);	
  • Comments  from  others  -­‐	  friends,	
  visitors,	
  teachers,	
  staﬀ	
  from	  other	
  facili<es,	
  etc.	
  -­‐	  haven’t	
  been	
  paid	  enough	
  aaen<on.	
  	
  	
  
• InformaJon  from  internet  -­‐	  social	
  networks,	
  websites	
  -­‐	
  hasn’t	
  been	
  paid	  aaen<on;	
  • LeVers  of  thanks  haven’t	
  been	
  paid	  aaen<on;	
  • IniJaJves:	
  Circular	
  18/2013/TT-­‐BKHCN	
  dated	
  August	
  01,	  2013	
  and	  Decree	  number	  39/2012/ND-­‐CP	
  have	  many	  problems	
  and	
  bureaucra<c	
  complica<ons.	
  	
  	
  
• Staﬀ’s  comments  and  ideas  regarding	
  documents,	
  policies	
  and	
  improvement	
  haven’t	
  been	
  paid	  aaen<on;	
  • Other  comments  –	
  e.g.,	
  about	
  broken	
  equipment,	
  reminders,	
  etc.	
  -­‐	  haven’t	
  been	  well	
  managed.	
  Not  skipping  steps

No  excepJons

No  harm

Quality  management

SOPPs

STAR

Receives  comments  from  diﬀerent  groups	
  STANDARD	  Quality  management

Administra*on
Medical  equipment  &  material
Pharmacy  PRPurchase	
  Requisi<on	
  CMControl	
  of	
  Maintenance	
  Systems	
  Administra*on
Medical  equipment  &  material

JCJob	
  Card	  (Study,	  training,	
  task,	  project)	
  General  Planning
Personnel  

2017

2018
Not  skipping  steps

No  excepJons

No  harm

53

SoJware  program  for  online  repor@ng  and  management

Not  skipping  steps

No  excepJons

No  harm

Không  làm  tắtKhông  ngoại  lệ

Không  gây  hạiEach  individual  is  assigned  to  ﬁx  a  problem

54

Not  skipping  steps

No  excepJons

No  harm

Not  skipping  steps

No  excepJons

No  harm

Không  làm  tắtKhông  ngoại  lệ

Không  gây  hạiNot  skipping  steps

No  excepJons

No  harm

Không  làm  tắtKhông  ngoại  lệ

Không  gây  hạiNot  skipping  steps

No  excepJons

No  harm

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 4 | Information Communication Technology

Session 1

No  harm

Not  skipping  steps

No  excepJons

No  harm

Session 3

No  excepJons

Session 2

Not  skipping  steps

Session 4
Session 5

Results

Managing  implementa@on  of  quality  standards

No  excepJons

No  harm

Not  skipping  steps

No  excepJons

No  harm

Annex

Not  skipping  steps

Session 6• 800  reports  (as  of02  Mar  2017)• Job  card
• Root  cause• Monthly  report

SOME  OTHER  SOFTWARE  PROGRAMS  FOR    QUALITY  MANAGEMENT  AND  PATIENT  SAFETY    55Managing  SOPPs

Not  skipping  steps

56

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

No  excepJons

No  harm

Session 4 | Information Communication Technology

Session 1
Session 2
Session 3

5S  Kaizen  management

Session 4

Not  skipping  steps

No  excepJons

No  harm

Session 5
Session 6
Annex
57

58

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 4 | Information Communication Technology

Huynh My Thu
Quality Management Department, Thu Duc District Hospital- Origins from the actual state of implementing MOH’s- Decision number 5573/QD-BYT dated December 29,

Hospital Quality Standards (HQS) in Thu Duc District

2006 of the Minister of Health promulgating “Standards

Hospital.

and contents of some software programs for hospital- Towards a “paperless hospital”.

2. Previous state of HQS implementation
implementing HQS reported results of at least 3% of thetotal items under their responsibility by sending an Excel
file to QMD’s email address.

3. Difficulties in implementing HQS- HQS 2016
- Advanced Microsoft technology: C#, ASP.NET MVC,
HTML5...; Desktop model, Web Application of MQSOFT’s
health management information system.

5. How to apply program’s functionsa.

department(s) and collaborative department(s).
c.

their items by required time (starting on Monday

to extract data directly from original files.  

and finishing on Saturday).
d.

registrations => implementation starts. Worksynthesize and update data many times;

notices are sent to department leaders and their- Difficulties in strictly controlling the timing and progressof HQS implementation;- Departments forgot to or did not actively reportin-charge staff.
e.

At the end of the week, departments report theirprogress with evidence, QMD staff check reports

implementation progress of HQS => QMD had to remindand click “approve” => items are completed.

them by calling or sending emails.

Note: For items that need long time, more than
one week, to be completed, in-charge staff in→ In order to manage the progress of HQS implementation,

departments register their completion time.

it required time, responsibility, effectiveness andparticipation.

QMD staff summarize and approve departments’Annexmanually (in Excel), so every week QMD staff had toEvery week, staff in charge in departments
register and report the progress of implementing

transferring data to another file because it was impossible- Statistics and reports from departments were createdEach item in the HQS is assigned to responsible

Session 6b.

- Extra work and extra costs for printing reports;- Statistical work and making graphs/charts required

Functions are integrated into the hospital’s web
portal, with all contents of the HQS.

- It required much personnel to manage, monitor,
summarize and report changes in implementing HQS;

Session 5

Every week, the departments in charge ofmanagement”.

Session 4

4. Basis for IT application

Session 3

1. The idea

Session 2

Applying IT in Managing and Monitoring
the Implementation Progress of Hospital Quality
Standards in Thu Duc District Hospital

Session 1

Session 4-2

f.

A function for making graphs/charts displaying
HQS implementation progress.

59

DIFFICULTIESAPPLYING IT IN MANAGING AND MONITORING
THE IMPLEMENTATION PROGRESS OFHOSPITAL QUALITY STANDARDS (HQS)v It required much personnel to manage, monitor, summarize andreport changes in implementing HQS;v Extra work and extra costs for printing reports;v Statistical work and making graphs/charts required transferring
data to another file because it was impossible to extract data
directly from original files.
v Statistics and reports from departments
were created manually (in Excel), so every
week QMD staff had to synthesize and update
data many times;

PRESENTER: MS. HUYNH MY THU, MSC
CHIEF OF QUALITY MANAGEMENT DEPARTMENT, THU DUC DISTRICT HOSPITAL

Contents

1• THE IDEA

2

• ACTUAL STATE, LEAGAL BASIS

3• APPLYING IT IN MANAGING AND
MONITORING THE IMPLEMENTATIONOF HQS

THE IDEA

DIFFICULTIESv Difficulties in strictly controlling the timing and progress of
HQS implementation;v Departments forgot to or did not actively report
implementation progress of HQS => QMD had to remindthem by calling or sending emails.

SOLUTIONS FORMANAGING THE PROGRESSOF HQS IMPLEMENTATION• Origins from the actual state of implementing
HQS in Thu Duc District Hospital.
• Towards a “paperless hospital”.

Responsibility

TimeParticipation
HQS

Scien
ce

PREVIOUS STATE OF
HQS IMPLEMENTATION	
  • Every week, the departments in charge of implementing
HQS reported results of at least 3% of the total items under
their responsibility by sending an Excel file to QMD’s email
address.

60

BASIS FOR IMPLEMENTATION• HQS 2016
• Advanced Microsoft technology:
C#, ASP.NET MVC, HTML5...; Desktop
model, Web Application of MQSOFT’s
health management information system.
• Decision number 5573/QD-BYT dated
December 29, 2006 of the Minister of
Health promulgating “Standards andcontents of some software programs for
hospital management”.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

EffectivenessSession 4 | Information Communication Technology

List of items assigned to a department

Session 1

INTRODUCTION

Session 2

Departments registering to implement HQS

Session 3

CONTENTS OF HQS’S CRITERIA

Session 4

Registration
function

Session 5

CONTENTS OF ITEMS UNDER CRITERIA

Departments registering to implement HQS

Session 6

Edit button
Delete button
Assignment
buttonPrioritized criteria

Annex

Assigning departments to be in charge of
implementing each item

Only prioritized criteria havethe registration button. All
prioritized criteria must be
registered before others canbe registered.

Departments registering to implement HQS

61

List of items registered with QMD by a department

Notices sent to departments’ in-charge staff
Send noticeabout a task
missing its
registereddeadline

Notice is sent
to department
leaders andtheir in-charge
staff

QMD approves registered items

Departments reporting implementation results

Attachevidence

QMD approves registered items

List of items completed by a department

Send the file
guiding
implementation of
the sub-standards

Deadline for
implementationApproveregistration

Notices sent to departments’ in-charge staff

Overall statistics of HQS implementation
Edit button
Delete button
Statistics button
for details of items
implementation

Obtained scoreof the criteria

62

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 4 | Information Communication Technology

Overall statistics of HQS implementation

Session 1
Session 2
Session 3

Detailed statistics of items implementation

Session 4
Session 5

Advantages

Session 6• Easy to make statistics and report• Easy to monitor the progress of HQS implementation• Save manpower and printing costs
	
  

Annex

Existing problems• All tasks are performed on the hospital’s
web portal, so they depend on theinternet speed and stability of thesystem.
• Some functions are newly developed,
many ideas emerging during
implementation requires time to update
and improve the system.

63

Session 5 Patient Safety Culture
Summary of Discussion
1.

Concept of culture
1.

Culture is invisible but culture manifests in daily behaviors especially on our habits. People follow their habits. For
example, when they hear that an incident has just occurred, the first common reaction is asking who did it andwhere it happened.

2.

This reaction happens with people who has even knowledge of incident management and even know thatimportant questions about incidents is “what happened and why did it happen?”.

2.

Building up patient safety culture1.

In hospital, patient safety culture can be fostered step by step with knowledge and actions among hospitalleaders and staff. This process takes time and QMD staff should be patient.

2.

To foster patient safety culture in a hospital, promoters need to change themselves first. QMD staff need tochange themselves every day.

3.

It is very important that hospital leaders act as a role model to make their staff follow patient safety practices.
Hospital leaders should regularly talk about patient safety with their staff in hospital meetings. QMD has a role ofconvincing the hospital leaders to promote patient safety in a hospital.

4.

Another approach is a training but the training should be not only provided but also repeated to change staff’s
perspectives and attitudes.

5.

Patient safety should be integrated in hospital policies and regulations. Clinical and professional proceduresshould be appropriately designed so that high compliance of such procedures contributes to safety of patients.

3.

Punishment
Hospital leaders may have different perspectives on punishment and rewards when the leaders manage andencourage their staff. Some leaders may minimize punishment while other leaders may maintain punishment forsome extent. If the same staff often commit mistakes, the manager should consider whether that staff was suitable
for the current position or job.

4.

Patient satisfaction survey
Patient satisfaction survey is an important source of information of what need to be improved in a hospital.

5.

Patient safety culture survey
Patient safety culture survey can reveal specific weaknesses of patient safety culture in a hospital that should be
improved for a safer environment for patients. In Vietnam, Vietnamese version of “Hospital Survey on Patient Safety
Culture” is available. This questionnaire was originally developed by Agency for Healthcare Research and Quality(AHRQ), USA. Department of Health, Ho Chi Minh City tested applicability in Vietnam context and translated thequestionnaire into Vietnamese. This questionnaire is used in the patient safety culture survey in Bach Mai Hospital(2017). Other Vietnamese hospitals such as Children’s Hospital 1, Tu Du Hospital etc. had conducted similar surveys
using the same questionnaire1.

1 On 12/05/2016, Ho Chi Minh City Department of Health released an official Vietnamese translation of this questionnaire (approved by AHRQ) and encouraged
hospitals in Ho Chi Minh to use it to survey their hospitals (Decision no. 4233/SYT-NVY).

64

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 5 | Patient Safety Culture

6.

How to involve doctors and other health staff in QM activities?
topic of patient safety is serious and people would like to avoid. As a result, about 20% of all doctors and 20% of all
nurses and midwives participate in patient safety activities in Tu Du hospital.

Session 1

Tu Du Hospital made activities and trainings of patient safety fun (e.g., in gameshow format) although usually the

Session 2
Session 3
Session 4
Session 5
Session 6
Annex
65

Session 5-1
Survey on Patient Safety Culturein Bach Mai Hospital in 2017
Nguyen Thi Huong Giang
Quality Management Department, Bach Mai Hospital

Patient Safety (PS) is an important area in hospital QM

their departments had PS problems, 84.8% consideredsystem. WHO states that the biggest challenge in healthcare

PS at an average level, 11% considered it at excellent

today is to become safer in its extremely complicated andand good levels. Research of Dr. Tang Chi Thuong, Vicehigh pressure environment. This challenge became visible

Director of Ho Chi Minh City DOH, on “Patient safety

at the end of the 1990s by two influential reports – "Toculture survey in Pediatrics 1 Hospital, Ho Chi Minh City in

err is human" published in 1999 by Institute of Medicine,
USA and another one published in 2000 by a British nongovernmental organization. Both reports recognized thaterrors were commonly seen in the process of providing
healthcare services, which occurred to about 10% ofadmitted patients. In some cases, the consequences oferrors were very serious, even fatal. PS has become a2012” reveals several problematic areas with low scores insome criteria such as incident reporting frequency (64%),
collaboration among departments (61%), collaboration
among departments in handing over and transferring
patients (57%), information transparency about errors(55%), shortage of human resources (52%) and especially“no blaming when errors happen” (51%).

concern in developed and developing countries.
Besides, consequences of unwanted medical incidents
prolong patients’ hospital stay and increase of treatment
costs, e.g., 800,000,000 GBP in UK, 19.5 billion USD in
USA and 13-24 billion Euro in Europe a year (Famolaro,2012). How is the situation in developing countries?
Although no statistics has been published, based on
difficulties in infrastructure, medical equipment, manpower
or drug quality, WHO estimates that developing countries
cannot avoid the same situation, or even worse. Data
from research on medical incidents and errors as well as
treatment complications in hospitals in developed countries
show that treatment complication rates among admitted
patients vary from 3.2% to 16.6%. More than 50% of theseincidents were preventable (WHO, Nieva, 2003).
    In Vietnam in recent years, the biggest challenge
towards to a safety healthcare system is to change frompunishment culture to safety culture in which errors are
not considered individual failures but opportunities toimprove the system and prevent consequences. The
research of Dr. Nguyen Cam Hang in Dong Thap General
Hospital in 2012 shows that 31.5% of staff agreed that

66

Bach Mai hospital is the first special-levelcomprehensive general hospital in the country, which was
assigned by MOH to direct technical activities for hospitals
in Northern provinces and cities. It has 1,900 planned
beds and 2,500 healthcare workers. Every day, thehospital has more than 5,000 outpatients, more than 4,000
inpatients. Bed occupancy rate is always high (>200%).
In such a high pressure working environment, what is thestate of PS culture among healthcare workers? Basedon this situation, QMD in Bach Mai hospital conducteda survey on “Patient safety culture of healthcare workers
in Bach Mai Hospital in 2017”, addressing the following
aspects of a safety culture:
1. Awareness of PS level in departments.
2.

Information exchange among healthcare workers
in departments.

3.

Perceptions and practices of PS in departments.

4.

PS promotion policies of departments’ leaders.

5.

PS promotion policies of the hospital’s leaders.

6.

Incident reporting frequency

Collected data would help generate solutions todevelop and promote PS culture in Bach Mai Hospital.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 5 | Patient Safety Culture

General information
1%
4%

Main doctors

1% 2%

27%

12%

Surgeons
Nurses7%

Technicians2%

Nursing
assistants

Dr. Nguyen Thi Huong Giang, MD, MSc
Chief of Quality Management Department
Bach Mai HospitalIntern doctors
Pharmacists
Dietetic staff
Managers

Respondents’ working positions

Session 3

General information

General information
Emergency andintensive care
departments
11%

No direct
contact withpatients
8%

Direct contact
with patients
92%
Internal medicine
and pediatrics
departments
46%

Surgery andobstetrics
departments
12%

Session 4

Laboratories,functional
exploration, X-ray,
Pharmacy
15%

Session 2

43%

Other clinical
units
16%

Session 1

SURVEY ON
PATIENT SAFETY CULTURE
IN BACH MAI HOSPITAL IN 2017

Work feature

Questionnaire distribution by department group

Session 5

General information
Working experience in the hospital

Table 1: Opinions about communication within department

Working experience in department

No.

140
123

117

120

105108100

2Number

80
70 71

60
40
20

19

81

3

77

4

51

27

38

5

0

< 1 year

1-5 years

6-10 years

16-20
years

> 21 years

No.

Content

6

Staff hesitate to raise questions
when something does not seem
right

General information
No.

Content

1 The department has enoughstaff to handle the workload

305% Agree,Strongly Agree% Don'tknow% Disagree,
Strongly disagree% Agree, Strongly
Agree% Don’t know

% Disagree, Strongly
Disagree2 When a lot of work needs to bedone quickly, department staff
work together as a team to get
the work done

250
200
150

3 Department staff treat eachother with respect

1000% Disagree,
Strongly Disagree

Table 2: Opinions about departments/units

350

50

% Don’tknow

The department organize discussions
about countermeasures to prevent errors
from happening again

Respondents’ working experience in the hospital & department

300% Agree,Strongly Agree

Annex

11-15
years

Content

Department staff are given feedback
about changes put into place based on
event reports
Staff will freely speak up if they see
something that may negatively affectpatient care
Staff are informed about errors that
happen in their department
Staff feel free to give opinions for
decisions or actions of department/
hospital leaders

Session 6

1

4 Staff in this department work
longer hours than required totake care of patients best99
3
< 20 hours

1218
20-39 hours

40-59 hours

60-79 hours

80-99 hours

7> 100 hours

5 The department is actively
doing things to improve patient
safety6 The department uses moreagency/temporary staff to takecare of patients best

Respondents’ hours of work per week67

Table 5: Opinions about hospital leaders

Table 2: Opinions about departments/units (cont’d)
No.

Content

7

Mistakes have led to positivechanges in the department

8

When one area in thedepartment gets busy, others
help out

9

After making changes toimprove patient safety, thedepartment evaluates theireffectiveness% Agree,% Don't know
% Disagree,
Strongly Disagree
Strongly Agree

10 The department puts patient
safety firstNo.

Content1

2

Hospital leaders often
mention about patient
safety activities
Hospital management
activities show thatpatient safety is the top
priority

No.

Content

3

11 The department has effective
procedures and measures toprevent errors fromhappening

Content% Agree

12 Department staff feel
prejudice against them dueto their mistakes
13 It is just by chance that
serious mistakes don’t
happen in the department
14 When an incident happens, itfeels like the person is being
written up, not the problem
for RCA
15 Department staff work in“crisis mode” trying to do a
lot of work so quickly

27.3% Don't know

% Disagree

17.4

55.3

16 Staff worry that their errors
are recorded in theirpersonal CVs
17 The department has somepatient safety problems

Content1

Department leaders always
encourage when their staff
comply to patient safety
procedures

2

Department leaders seriously
consider staff’s suggestions
to improve patient safety

No.

Content

3

When pressure increases,
department leaders want
their staff to work faster, even
if it means skipping someprocedure steps

4

Department leaders overlook
patient safety problems that
happen over and over

1

2

68

% Agree,Strongly Agree% Don't know

% Disagree,
Strongly Disagree

Hospital leaders seeminterested in patient
safety only after aserious event happens

No.

Content1

Staff hesitate to ask questions when something does not seem right

31.6% (agree)2

Department staff feel prejudice against them due to their mistakes

27.3% (agree)3

When an incident happens, it feels like the person is being written up, 23.6% (agree)
not the problem for RCA

4

Staff worry that their errors are recorded in their personal profiles

60.9% (agree)

5

Departments do not collaborate well with each other

26.7% (agree)

6

Many things are skipped when transferring patients from one
department to another27.8% (agree)

7

It is often uncomfortable when working with staff from otherdepartments

22% (agree)

8

There are many problems in information exchange among
departments across the hospital

37.9% (agree)9

The department has enough staff to handle the workload

32.6% (disagree)% Agree,Strongly Agree% Agree,Strongly Agree% Don't know % Disagree, Strongly
Disagree% Don't know

% Disagree,
Strongly DisagreeContent% Agree, Strongly
Agree% Don'tknow

Important information about
patient treatment and care isoften lost during shift changes

4

It is often uncomfortable whenworking with staff from otherdepartments

5

There are many problems in
information exchange among
departments across the hospital

32.7% (disagree)- Incorporate PS culture into policies andregulations of the hospital and departments.
- Strengthen awareness trainings for healthcare
workers.
- Leaders should be role models.
- Develop regulations and procedures forcollaboration between departments/units.
- Develop safety indicators in terms of manpower.
- Propose to MOH about issuing regulations about
PS, incident reporting… soon.

% Disagree,
Strongly Disagree

Departments in the hospital do
not collaborate well with each
otherMany things are skipped whentransferring patients from one
department to another3% opinions

Solutions

Table 4: Opinions about collaboration between departments
No.

% Disagree,
Strongly Disagree

10 The department has to use more temporary staff to best take care ofpatients.

Table 3: Opinions about department leadersNo.

% Don't know

Existing problems that need to be changed

Table 2: Opinions about departments/units (cont’d)No.

% Agree,Strongly Agree

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 5 | Patient Safety Culture

Developing a Learning Culture Through Analysing
Medical Incidents
Medical Center, School of Medicine and Pharmacy, Da Nang University(Former Vice Director, Quang Nam Central General Hospital)

Session 2

Le Viet Nho

Session 1

Session 5-2

Session 3

some surface causes, not root causes of the incident.

challenging task, especially when hospital leaders are

As a result, no one can learn any lessons and it is also

spending more time for clinical work, development ofdifficult to generate suitable preventive measures. If any,high technologies, and looking for more income sources
rather than developing and enhancing QM/PS. In sucha general situation, QMD in Quang Nam Central General
Hospital has managed to implement some activities togradually develop a safety culture in the hospital. One ofthat contributes to strengthening a culture of learning fromerrors, a foundation for a safety culture in the hospital.
Since November 2014, QMD has been managing
to develop and operate an IRS. Owing to this system,
medical incidents, especially RCA for incidents at 3b
or higher levels (Figure 1). Previously, after detecting
an incident, the hospital organized review meetings or
mortality audits according to hospital regulations. Thisis the quickest way to solve problems but it mainly aims

Consequently, staff hide and do not report medical
incidents, leaders of department make excuses and thehospital could not detect systematic errors to correctthem.
On the contrary, if causes analysis, especially RCA, isfacilitated by a knowledgeable chairperson and a team of
excellent experts, the meeting atmosphere will be more
comfortable for participants to discuss freely, without
focusing on individual responsibilities, reducing chancesof events being hidden and missing finding root causes
of incidents. Everyone should also involve in developing
effective interventions. RCA also helps staff, especially
doctors, develop teamwork, respect different opinionsfrom others, improve communication, better empathizewith colleagues, and especially learn continuously. This is

Annex

at identifying individual responsibilities or could only findis a typical operation way in a punishment culture.

Session 6

QMD helps detect systematic errors through analyzing

atmosphere and stressful relationship among staff.  This

Session 5

them is analyzing medical incidents, a worthwhile activity

maybe some people learnt how to avoid legal troubles
from their work while the hospital had to suffer from heavy

Session 4

Developing a lear ning culture in hospital is a

an important condition to gradually shift from punishment
culture to learning culture.
Therefore, in order to gradually develop a learningand safety culture in the hospital, hospital leaders andfunctional departments, with General Planning Department
and QMD as focal points, should gradually shift from
review meetings and mortality audits to analyzing root
causes and systematic causes of incidents to generate
solutions to prevent similar incidents to happen in the
future.

Figure 1: An RCA meeting69

Session 5-3
Some Activities Helpful for Strengthening Patient
Safety Culture in Ha Dong General Hospital
Nguyen Thi Huong Lien
Quality Management Department, Ha Dong General Hospital

1. What should we do with traditional
attitudes and habits that are impeding hospitalquality improvement?
It is really difficult to change attitudes and habits of anindividual and it is even more difficult to change those of ateam. Due to healthcare workers’ hesitation to change, tomake it easier for hospital staff to accept and participate
in QI, Ha Dong General Hospital have some following
ways:

cardboard boxes turned into trays for stamps, boxes
for remote controls, shelves for slippers, trays for tests
categorization; or old containers of test tubes turned into
drug cabinets, etc. These creative ideas also origin from
actual work problems in departments.

2. How to involve doctors in QM activities?
Involving doctors in QM activities is very difficult. In our
hospital, only some young doctors are involving in some
activities such as conducting patient satisfaction survey or- Conducting trainings on topics related to hospitalwriting QI projects for their departments.

quality for healthcare workers:
Pharmaceutical alert and rational use of antibiotics

3. How to collaborate with nurses and other
healthcare workers in the hospital?

to enhance treatment quality; 5S to make departments

Doctors are the ones who give medical indications

cleaner and more tidy, avoiding waste and ensuring
PS; clinical nutrition to have better and proper diets forpatients, enhancing their physical health and shortening
hospital stay; hand-washing to prevent nosocomial
infections.
- Improvement activities must be based on actual
situations:and nurses are the ones who implement. Therefore,
collaboration between doctors and nurses is necessary.
In Ha Dong General Hospital, we are implementing somefollowing activities:•

Doctors and nurses conduct ward rounds
together.

•Some medical incidents were due to lack of

Improvement of toilets in some departments camecollaboration between doctors and nurses.

after the result of a patient satisfaction survey; training on

These incidents were analyzed in meetings ofanaphylactic shock management was conducted and thechiefs and vice chiefs of departments as well as

relevant protocol was changed after analyzing incident

in meetings of head nurses to generate lessons

reports on patients’ anaphylactic shock after an antibiotic

learnt.

injection.
-Helping healthcare workers realize the benefits of QI
activities and that not all of them require a big budget:
The hospital organized 5S Day in some pilot
departments, such as Biochemistry, Hematology, Internal
Medicine - Nephrology. On the 5S Day, there were many
creative ideas utilizing available materials as unused

70

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 6 | Role of QMD as a Communicator In and Out of Hospital

Summary of Discussion
What are roles of QMD?
1.

What QMD should have for QM/PS work is supports from the hospital leaders, especially those from the hospital

Session 2

1.

Session 1

Session 6 Role of QMD as a Communicator
In and Out of Hospital

director. To be recognized by their leaders, QMD could start from small things to show evidence that QMD’s
work are effective and meaningful for QM/PS in a hospital.
To convince hospital leaders, especially changing their perspectives on QM/PS issues, QMD needs to bepatience. QMD staff should work consistent and persistent. For example, at the beginning, it is very hard for
hospital leaders to accept that his hospital has incidents because of systematic errors. Hospital leaders tend
to think all incidents occur because of individual errors. With patience, some QMD staff have successfully

Session 3

2.

convinced their leaders to understand and accept that incidents were caused by systematic errors, too.
“Field work” in a hospital is very important. QMD leaders and staff should visit departments to observe and study
the current status there. Actual visits can help QMD staff to detect problems, understand their colleagues’ work
better, and generate ideas for improvement.
4.

When tackle with improvement opportunities, QMD staff should approach them technically and practicallySession 4

3.

with good understanding of the context. Technically, measurement of indicators maybe required. For example,

they could work with the IT system to generate necessary data quickly. Clear data can help convince hospitalleaders to support solving the problem.
5.

Session 5

improvement for waiting time of patients requires measurement of the numbers of patients waiting at different
points of time. Such work depends on technical capacity of a hospital and QMD. If QMD staff had IT knowledge,

QMD can generate ideas for improvement through analysis of data, learning from others and better
understanding of the situation around the problem. When choosing solution, it requires practical consideration
improved”. For example, to accelerate the specimen collection process in crowded mornings, Cho Ray Hospitalencourages some night shift nurses to help with specimen collection in the morning with extra time work policy

Session 6of what was available resources and policies as mentioned by speakers “not all measurable things can beinstead of the low-paid overtime work policy.

2.

What hospital director could support QMD?
1.

Hospital leaders’ devotion to QM/PS in a hospital, especially that of hospital director, is very important. If a

Annex

(From hospital leaders’ point of view:)
director is not really committed to QM/PS, even QMD was established, it is redundant in a hospital. If a director
is committed:
1)

the director can appoint some staff for the QM team to take charge of QM/PS work in a hospital;  

2)

to strengthen capability of QM/PS in a hospital, the director can send QM staff to trainings and send themvisits to other hospitals both in domestic and in foreign countries;3)

the director can make good policies for QM staff such as rewarding;4)

the director can help to establish a position of QMD in the hospital so that QMD’s voice is listened by otherstaff. This is because many hospital staff in other departments do not understand what QMD do. Many staff
are not happy to see QM staff come to their departments to investigate their work. Another reason for theimportance of this support is that QMD can do their work well when QMD had supports from other hospital
staff. Some hospital leaders, such as those in Vinh City General Hospital, determined that QM/PS was not71

only a work of QMD and the directing board but the work of all hospital staff.
2.

When invited, the director should attend short trainings on QM/PS (half a day or one day) organized by MOH,
DOH or other recognized institutions to understand QM/PS work better, instead of sending their vice directors toattend on their behalf.

3. What support and collaboration with DOH can help hospitals to achieve and sustain
hospital quality?
1.

Collaboration between DOH and hospitals require contributions from both sides. DOH can direct, guide, andmonitor hospital activities while hospitals should use their resources to implement necessary activities.

2.

DOH can survey actual states of their hospitals to understand their positions, strengths and weaknesses. MOH’s
Hospital Quality Criteria and patient satisfaction online survey is useful tools for DOH to know the situation.

3.

DOH can issue requiring and guiding documents and provide trainings to support hospitals do QM/PS. Hospitals
should also organize trainings by themselves, inviting recognized teachers from other healthcare institutes in andout of their city/province.

4.

DOH should keep up with quality improvement activities in hospitals to provide necessary support when suitable.

5.

DOH can use advanced experiences in some hospitals to train and help other hospitals. For example, Thai Binh
Provincial DOH is using experience in Thai Binh Provincial General Hospital in 5S and IRS to help other hospitals
start their own systems.

6.

72

Collaboration work between DOH and hospitals should follow PDCA cycles and continuous improvement.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 6 | Role of QMD as a Communicator In and Out of Hospital

The Role of Quality Management Department in
Improving Waiting Time in OPD

Session 1

Session 6-1

Session 2

Ton Thanh Tra
Quality Management Department, Cho Ray Hospital

Session 3

QMDs in hospitals are established based on Circular
19 by MOH in 2013, which clearly specifies many

Session 4

functions and tasks of QMD. However, the size andoperation of QMDs vary, depending on actual situation.
Among many improvement activities, improvement of
waiting time in OPD is a key task. OPD is the hospital’sgate, face and major source of income. According to
Decision number 1313 by MOH, hospitals have to makeSession 5

efforts to improve examination procedures and shorten
waiting time of patients to enhance patient satisfaction.
In Cho Ray Hospital, OPD receives from 5,000 – 6,000
patients/day, 75% of whom come from provinces outsideof Ho Chi Minh City with more than 50% having health
December 2016 show that patients’ waiting time has not

Interventional solutions
1.

examination from new patients in registration.

met some standards in Decision number 1313 by MOH.

2.

Therefore, the Directing Board has determined to improve3.

the examination procedure in OPD. However, to create
effective improvements, QMD needs to monitor, measure
1.

Monitored indicators
1.

The number of daily outpatient visits, the average

2.

The duration of each step in the examination

4.

The number of patients waiting at various pointsof time during the day.

Start examination at 6AM in departments whichusually have a lot of patients.

5.

Add more consultation desks in departments
which usually have more than 100 patients per
day.

6.

Ask night-shift nurses from Emergency
Department to help collect blood samples in theprocedure.
3.

Add more desks for registration and payment;
start receiving patients at 5AM.

numbers of outpatients in each specialty andeach consultation desk.

Registration via phone number 1080

Annex

data and propose interventional solutions.

Separate patients who come back for re-

Session 6

insurance. Results of monitoring and measurement since2.

next morning in OPD.
7.

Shorten turnaround time for paraclinical tests.

8.

Organize monthly meetings to solve existing
problems and difficulties. The results show thatpatients finish examination earlier and their waitingtime was shortened.

73

3.

Conclusions
QMD, by giving advice to the directing board andcollaborating with other departments in QI activities, hashelped improved waiting time in OPD and bring patientsatisfaction.

THE ROLE OF QUALITY MANAGEMENTDEPARTMENT IN IMPROVING WAITING TIME
IN OPD

Average: 59 patients/doctor
Not including:+ Top experts’ examination rooms+ Physiotherapy+ Examination for hospital staff

Dr. Ton Thanh Tra
Quality Management Department, Cho Ray Hospital

NUMBERS OF OUTPATIENTS FROM 2012 TO 2016

74

Duration of each step in examination

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 6 | Role of QMD as a Communicator In and Out of Hospital

INTERVENTIONAL ACTIVITIESRESULTSpatients in registration.

u Registration via phone number 1080u The number of outpatients is increasing.
u The number of outpatients who are examined within oneu Add more desks for registration and payment; start receiving patientsat 5AM.

day is increasing.

u Start examination at 6AM in departments which usually have a lot ofu Waiting time has been shortened (8 minutes).

u Add more consultation desks in departments which usually haveu Some parts of the procedure that need improvement andpatients.

more than 100 patients per day.

u Ask night-shift nurses from Emergency Department to help collectu Shorten turnaround time for paraclinical tests.

procedures that need further improvement have been
identified.
u Combined with patient satisfaction survey results tou Organize monthly meetings to solve existing problems anddifficulties.

evaluate improvement’s effectiveness.

CONCLUSIONSu The number of outpatients is increasing.

u QMDu The number of outpatients who are examined within one

day is increasing.

is like an advisor to the Directing Board in

Session 3

RESULTS

Session 2

blood samples in the next morning in OPD.

Session 1u Separate patients who come back for re-examination from new

improvement activities.
u It requires specific measured indicators to generateu Some parts of the procedure that need improvement andinterventional solutions.

procedures that need further improvement have beenu Continue to measure after an intervention.

identified.

u Propose solutions for further improvement.

u Combined with patient satisfaction survey results to

Session 4u Waiting time has been shortened (8 minutes).

evaluate improvement’s effectiveness.

Session 5

DISTRIBUTION OF EXAMINATION DURATIONS (daily average data)
Patients/day(Cái gì không đo lường đượcthì không cải tiến được)Session 6KHÔNG PHẢI TẤT CẢ CÁI GÌ ĐO LƯỜNG ĐƯỢC CŨNG CẢI TIẾN ĐƯỢC(Not all measurable things can be improved)
Ton Thanh Tra
Ba Ria – Vietnam 2017

Annex

Numbers of patients at each point of time ± 5%

Waiting time before being examined (Received -> Examined)No

Examination room

Desk

Average
Averagenumber of
waiting timepatients/day
120
0:28
116
0:29
109
0:31
220
0:31
177
0:31
132
0:32
16
0:32
38
0:34
12
0:35

1 General I.M. 9
2 General I.M. 2
3 General I.M. 31
4 Gastroenterology I.M.
5 Neurosurgery
6 General I.M. 30
7 Tropical diseases
8 Thoracic - Vascular
9 General I.M. 7

3
3
4
2
2
4
1
1
1

33 Pain relief treatment
34 Peritoneal dialysis
Interventional
cardiovascular
36 ENT
37 Endocrinology
38 Cardiosurgery
39 Gamma Knife
40 Musculoskeletology
41 Radiology

1
1

20
27

1:17
1:19

2
2
3
2
1
3
1

237
195
287
157
37
333
82

1:19
1:21
1:35
1:49
1:49
2:24
3:41

35

<30’

30-60’

>60’

69%
68%
77%
71%
68%
81%
73%
55%
66%

23%
23%
10%
18%
15%
9%
16%
28%
26%

9%
10%
13%
12%
17%
10%
11%
17%
9%

27%
16%

27%
24%

45%
60%

25%
16%
24%
15%
21%
12%
10%

25%
27%
25%
17%
14%
14%
8%

50%
57%
52%
68%
66%
74%
82%

Average waiting time is 1:07’

75

Session 6-2
The Relationship Between Department of Healthand Hospitals in QM/PS
Tran Thi Quynh Anh
Department of Technical Medicine, Thai Binh Department of Health

1. Reasons for selecting the topic
In healthcare sector, QM/PS is not new yet very
important, affecting greatly the quality of medical services,
benefits of patients and prestige of the sector. However,
implementation of QM/PS activities in hospitals in Thai

3. Collaboration between DOH and hospitals
3.1.

DOH’s activities:

Binh Province is still limited. It may be due to DOH’s

Scoring hospitals’ quality in 2016:

leadership and hospitals’ interest. Therefore, it requires•

close collaboration between DOH and hospitals to

2. Actual state of QM/PS activities in
hospitals in Thai Binh before 2017

hospitals to organize QM/PS activities.  
•General Hospital obtained 3.09 points while

Issuing documents to direct implementation:

Hai District General Hospital). Other hospitals•

Only Provincial General Hospital had assigned
staff to work full time for QMD. Other hospitals
only had staff working part time for QMD or only
names were given without actual work.

•

criteria scored 1 point in each hospital.

Dong Hung District General Hospital and Tien
established QM unit.
•

other hospitals scored 2 points or lower, with 3-8

In the whole province, 3/25 hospitals had
established QMD (Provincial General Hospital,

QM councils and QM networks had been
established in most hospitals but their activities
were not effective. Some even had no activities at

QM/PS activities:••

Only Provincial General Hospital established andoperated an IRS and obtained some initial results.

Issued plans for building capacity in QM/PS andsocial affairs to improve service quality.

Training:•

Organized trainings on applying 5S to improve
hospital quality.

•

Organized trainings on establishment andoperation of IRS.

•

many QM/PS activities.
•

Issued documents directing how to survey
satisfaction of patients and healthcare workers.

The hospitals did not understand well the tasks
and functions of QMD/QM unit and did not have

Issued documents about establishing IRS in
hospitals.

all.

•

According to scores of Section D in HQS
version 2.0 by MOH in 2016, only the Provincial

Resources for implementation:•

Purpose: to evaluate actual state of hospitals
to propose collaborative measures and guidestrengthen QM/PS activities.  

76

DOH’s direction and guidance and some initialactivities in the hospitals

Organized 4-day trainings to grant QM
certificates.  

•Organized trainings on evaluation of laboratory
quality.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Session 6 | Role of QMD as a Communicator In and Out of Hospital--

Initial activities in the hospitals:

enough.

After receiving the evaluation results of 2016,
some hospitals have actively invited experts from--

Hanoi Medical University to conduct training on

and nursing care is still limited.

QM for key staff in early 2017 (Pediatrics Hospital,--

Quynh Phu District General Hospital, Kien Xuong
District General Hospital). Other hospitals sent

haven’t been paid enough attention.

their staff to hospital QM trainings organized by

Checking and monitoring IRSs:

DOH.

•

catch up with serious incidents and help hospitals
find causes of the incidents.  

Hospital, Provincial General Hospital, Dong Hung•--

5S practices have been implemented in hospitals,--

administrative areas.

worker satisfaction survey and have entered data
into MOH’s online software program. As a result,

Monitoring satisfaction survey of patients andhealthcare workers:•

DOH often accesses MOH’s online software
program to be updated about the hospitals’survey results.

•

DOH’s checking and monitoring activities andResults: we noticed that, by 18 August 2017, 7
hospitals had not conducted satisfaction survey

plans for improving QM/PS in the next period

nor entered data into the program.

Monitoring through evaluation of the first 6 months

3.2.2.

in 2017:

next period

DOH established 2 teams to check hospitals’
healthcare quality, focusing on compliance totechnical regulations, QM and PS.

Plan for August - September 2017:•

Results:--

and correct satisfaction survey of patients andhealthcare workers and to conduct a pilot survey

QM activities haven’t been paid muchof patient satisfaction using mobile phone... As aattention, very few improvement activities toresult, by 5 September 2017 Thai Binh province

enhance service quality in hospitals.
---

ranked 5/64 in the country in terms of the number

There is little interest and limited resources
invested for QM/PS activities.
IRSs have been established but not operated
effectively.  

Issuing document number 636/SYT-NVY dated
August 22, 2017 directing hospitals to maintain

Annex

•

Plans for enhancing QM/PS activities in the

Session 6

3.2.1. Checking and monitoring activities•

Session 5

according to the program statistics by 18 August
2017, Thai Binh ranked 7/64 in the country interms of the number of submitted answer sheets.
3.2.

medical records.

Session 4

most hospitals started patient and healthcare

DOH received information about someincidents via media, hotline and checking

After receiving DOH’s direction in Document
number 143/SYT-NVY dated 23 March 2017,

No hospitals have reported their medical
incidents1.

especially with injection trolleys, drug cabinets,•

Results:

Session 3

District General Hospital, Vu Thu District General
Hospital).

DOH requests hospitals to summarize and reporttheir incidents every month so that DOH can

All hospitals have established IRS. Some havereceived voluntary incident reports (Obstetrics•

Technical procedures and treatment protocols

Session 2•

Quality of diagnosis, treatment, monitoring

Session 1•

Quality of medical records is not goodof submitted answer sheets.
•

Establishing an IRS network from DOH to thehospitals, including 145 members, in which eachhospital has 6 network members as follows:  

1. Incidents is defined as "an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient in the system*. "The definition does not mention
causes of an incident. However, in Vietnam, historically incidents that seemed to be caused by medical practices were called "medical incidents", which has been handled byGeneral Planning Department in a hospital. Incidents that seemed to be caused by other than medical practices have been handled by newly established Quality Management
Department (QMD) since 2013. To distinguish these two types of incidents, the term "medical incidents" is used in Vietnam.
*: Jennifer Cooper et al. Classification of patient-safety incidents in primary care. Bulletin of the World Health Organization. Vol.96, Number 7: 2018, 441-512.

77

•

--

QMD/QM unit: 01 doctor--

General Planning Department: 01 doctor--

Nursing Department: 01 nurse--

Internal medicine: 01 nurse--

Surgery: 01 nurse--

Para-clinic: 01 nurse/lab technician

Planning and organizing trainings on PS using

RELATIONSHIP BETWEENDEPARTMENT OF HEALTH AND HOSPITALS INQUALITY MANAGEMENT AND PATIENT SAFETY

DR. TRAN THI QUYNH ANH, MD, 1ST DEGREE SPECIALIST
Thai Binh Department of Health

MOH’s program and materials for the IRS
network.
Plan for the 4th quarter of 2017 and the year of 2018:•

Guiding development of QI plans following PDCA
cycles.

•Guiding 5S practice for quality improvement.

•

Pushing, monitoring and checking activities.

•

Guiding development of treatment protocols.

•

Workshop for enhancing quality of medical records.

•

Guiding development of technical procedures.

I. REASONS FOR SELECTING THE TOPIC
Servicequality
Hospitals’
responsibilities

DOH’s
responsibilities
QM/PS

Patients’rightsandbenefits

Prestige

4. Lessons learnt
•

2	
  

Apply PDCA cycles in collaboration between DOH
and hospitals in enhancing QM/PS.  

•Results of QM/PS activities cannot be obtained ina short time yet it requires a long road for positive

I. REASONS FOR SELECTING THE TOPIC

results to possibly show.
•

Both DOH and hospitals are responsible foris responsible for directing, guiding, pushing,monitoring and checking the implementation of3	  making QM/PS activities operate effectively. DOH

FIt requires close
collaboration between
DOH and hospitals to

hospitals to adjust timely. Hospitals are responsible

strengthen QM/PS

for investing resources, organize implementation,

activities.

generate lessons learnt from QI activities.
•

Training activities to improve the quality of humanresources and to change perceptions on QM/PS
are essential.
II. ACTUAL STATE BEFORE IMPLEMENTATION
Before 2017
Resources• 3/25 hospitals had
established QMD• 01 hospital had assigned
staff to work full time for QMD• QM councils and QM
networks did not work
effectively

78

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Activities• Did not understand well
the tasks and functions.
• Not many activities• 01 hospital operated an
IRS
4	
  

Session 6 | Role of QMD as a Communicator In and Out of Hospital

Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Annex
79

Forum Outline
3rd Vietnam Forum on Quality Management and Patient Safety
Ho Chi Minh City & Ba Ria City, 2017

Introduction:
Vietnam Forum on Quality Management and Patient Safety is one of the three main
activities of the project Strengthening Management Capability for Quality and Safety
in Healthcare, under the Program for International Promotion of Japan’s Healthcare
Technologies and Services, funded by Japan’s Ministry of Health, Labor and Welfare.
The project is implemented by National Center for Global Health and Medicine (NCGM)
with assistance from NCGM – Bach Mai Hospital Medical Collaboration Center (MCC). The
co-hosts of the third forum (September 2017) were Ba Ria Hospital, Hung Vuong Hospital,
and Thu Duc District Hospital.

Objectives:
1.

To share experience of achievements and challenges in quality management andpatient safety in hospitals in Vietnam;

2.

To discuss practical solutions to tackle challenges; and3.

To enhance communication among graduates and their colleagues who areinterested in quality and safety in healthcare.

Venue:
Ba Ria Hospital, Ba Ria - Vung Tau, Vietnam

Program:80

19/09/2017 (Tuesday)

Hospital tours in Hung Vuong Hospital				

Hospital tour in Thu Duc District Hospital

20/09/2017 (Wednesday)

Presentations and discussion (Day 1) in Ba Ria Hospital

21/09/2017 (Thursday)

Presentations and discussion (Day 2) in Ba Ria Hospital

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Annex

Session 1

ProgramHospital Tour Program at Hung Vuong Hospital on 19/9/2017
Welcome08:00 - 08:05

Introduction of participantsSession 2

07:45 - 08:00

Speech by NCGM representative
08:05 - 08:15

Speech by delegation representative
Dr. Pham Van Son, Vice Director, Vinh City General Hospital
Speech by Hung Vuong Hospital representative
Dr. Hoang Thi Diem Tuyet

09:00 - 11:00

Visiting departments

09:00 - 09:20

Postpartum Department A

09:30 - 09:45

Kangaroo Unit, area for breast feeding in Neonatal Department

09:45 - 10:10

Labor and Delivery Department

10:15 - 10:30

Pharmacy Department

10:30 - 11:00

Surgery Room B

11:00 - 11:30

IQ&A, feedback

11:30 - 13:00

Session 5

Introduction of Hung Vuong Hospital and quality management activities

Lunch

08:45 - 08:55

WelcomeOpening – Introduction of participants
Thu Duc District Hospital representative

Speech by project representative

Ms. Emiko Tateishi, Project Manager
Speech by delegation representativeAnnex

08:55 - 09:00

Session 6

Hospital Tour Program at Thu Duc District Hospital on 19/9/2017
08:30 - 08:45

Session 4

08:25 - 08:55

Session 3

08:15 - 08:25

Ms. Miki Matsufuji, Bureau of International Health Cooperation, NCGM

Dr. Pham Huu Thuong, Director, Hanoi Lung Hospital
General introduction of the hospital - Experience in quality management in Thu
09:00 - 09:45

Duc District Hospital
Ms. Huynh My Thu, Head of QMD, Thu Duc District Hospital
Visiting Thu Duc District Hospital:

09:45 - 10:30

a) Introduction of OPD procedure;b) Introduction of IT system - electronic medical records;c) Introduction of model for feedback - customer care.

10:30 -11:15

Exchange of experience

11:15 -11:30

Summary

11:30 - 13:00

Lunch

81

Program 20/09/2017
08:00 - 08:30

Reception and registration

08:30 - 08:40

Welcome speech

Dr. Nguyen Van Huong, Director of Ba Ria Hospital

08:40 - 08:45

Welcome speechOpening speech

Ba Ria Department of Health
Associate Professor Luong Ngoc Khue, MD, PhD

Objective of the Forum

Director, Medical Services Administration, Ministry of HealthDr. Shinsuke Murai, NCGM

08:45 - 08:50
08:50 - 08:55[Keynote]
08:55 - 09:15

Update from MOH on policy and orientation to improve quality of health careservices in Vietnam
Associate Professor Luong Ngoc Khue, MD, PhD
Director, Medical Services Administration, Ministry of Health

09:15 - 09:30

Q&A

09:30 - 09:45

Group photo

09:45 - 10:00
Session 1

Coffee Break
Incident Reporting Systems

10:00 - 10:10

Challenges in Implementing Incident Reporting System in Quy Hoa National
Leprosy - Dermatology Hospital

10:10 - 10:20

Dr. Nguyen The Toan, Quy Hoa National Leprosy - Dermatology HospitalThree Stages of Developing Incident Reporting System in Quang Nam Central
General Hospital

10:20 - 10:30

Dr. Tran Quang Dat, Quang Nam Central General Hospital
Applying WHO Incident Classification in Incident Reporting System in Hung Vuong
Hospital

10:30 - 11:10

Panel Discussion

11:10 - 11:30

Open Discussion

Dr. Phan Thi Hang, Hung Vuong Hospital

11:30 - 11:40

Summary

11:40 - 12:00

Display of Equipment and Poster Session

12:00 - 13:30
Session 2
13:30 - 13:40

13:40 - 13:50

13:50 - 14:00

Lunch
5S
Applying 5S in Restructuring An Giang Hospital of Obstetrics, Gynecology and
Pediatrics
Dr. Le Van Duc, An Giang Hospital of Obstetrics, Gynecology and Pediatrics
Difficulties in Implementing S4 and S5 in Ha Dong General Hospital
Dr. Nguyen Thi Huong Lien, Ha Dong General Hospital
Sustaining 5S in National Hospital of Obstetrics and Gynecology
Dr. Vu Van Du, National Hospital of Obstetrics and Gynecology

14:00 - 14:40

Panel Discussion

14:40 - 15:00

Open Discussion

15:00 - 15:10

Summary

15:10 - 15:30
15:30 - 16:00

Coffee BreakDisplay of Equipment and Poster Session[Meeting]

16:00 - 17:00

82

What is future of Vietnam Forum?
Meeting among the graduates of Japan Trainings on Hospital Quality Management andPatient Safety

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

Annex

Program 21/09/2017

08:30 - 08:40

Standardized Operating Procedures (SOPs)
Developing SOPs in Saint Paul Hospital
Dr. Uong Thanh Tung, Saint Paul Hospital
Experience in Implementing Managerial SOPs in Thu Duc District Hospital
Ms. Huynh My Thu, Thu Duc District Hospital

08:50 - 09:30

Panel Discussion

09:30 - 09:50

Open Discussion

09:50 - 10:00

Summary

Session 4
10:20 - 10:30

Coffee BreakInformation Communication Technology
Applying IT in QM/PS in Ba Ria Hospital

Dr. Vu Duy Tung, Ba Ria Hospital

Applying IT in Monitoring and Managing Compliance to MOH's Hospital Quality
Standards
Ms. Huynh My Thu, Thu Duc District Hospital
Panel Discussion

11:10 - 11:30

Open Discussion

11:30 - 11:40

Summary

11:40 - 13:00
Session 5

Session 5

10:40 - 11:10

Lunch
Patient Safety Culture
Patient Safety Culture Survey in Bach Mai Hospital
Dr. Nguyen Thi Huong Giang, Bach Mai Hospital

13:10 - 13:40

Panel Discussion

13:40 - 14:00

Open Discussion

14:00 - 14:10

Summary

14:30 - 14:40

Coffee BreakRole of QMD as a Communicator In and Out of Hospital
Roles of QMD in Improving Waiting Time in OPD

Dr. Ton Thanh Tra, Cho Ray Hospital

14:40 - 14:50

Collaboration between Department of Health and Hospitals in QM/PS
Dr. Tran Thi Quynh Anh, Thai Binh Department of Health

14:50 - 15:20

Panel Discussion

15:20 - 15:40

Open Discussion

15:40 - 15:50

Summary

15:50 - 16:00
16:00 - 16:10

Annex

Session 6

Session 6

13:00 - 13:10

14:10 - 14:30

Session 4

10:30 - 10:40

Session 3

10:00 - 10:20

Session 2

08:40 - 08:50

Session 1

Session 3

Summary of the forum
Dr.Duong Huy Luong, Medical Services Administration, Ministry of Health
Closing Remarks by Ba Ria Hospital83Organization
Hospital tour at Hung Vuong Hospital:Dr. Hoang Thi Diem Tuyet, MD, PhD, Director, Hung Vuong Hospital
Dr. Phan Thi Hang, MD, MSc, Vice Director, Head of Quality Management Department,
Hung Vuong Hospital
Hospital tour at Thu Duc District Hospital:
Dr. Nguyen Minh Quan, MD, Director, Thu Duc District Hospital
Ms. Huynh My Thu, MSc, Head of Quality Management Department, Thu Duc District
Hospital
Ba Ria Hospital:
Dr. Nguyen Van Huong, MD, 2nd Degree Specialist, Director
Dr. Vu Duy Tung, MD, 1st Degree Specialist, Head of Quality Management Department
Dr. Le Minh Hieu, MD, 2nd Degree Specialist, Head of General Planning Department
Session 1: Incident Reporting System
Chair:
Dr. Nguyen Thi Huong Giang, MD, MSc, Head of Quality Management Department, BachMai HospitalPresenters and panelists:
Dr. Nguyen The Toan, MD, PhD, Head of General Planning Department, Quy Hoa Central
Leprosy – Dermatology Hospital
Dr. Tran Quang Dat, MD, 2nd Degree Specialist, In charge of Quality Management
Department, Head of Intensive Care Unit, Quang Nam Central General Hospital
Dr. Phan Thi Hang, MD, MSc, Vice Director, Head of Quality Management Department,
Hung Vuong Hospital
Panelists:
Dr. Phan Anh Phong, MD, MSc, Vice Director, Head of Emergency Department, Ha Nam
Provincial General Hospital
Dr. Nguyen Thi Huong Lien, MD, MSc, 2nd Degree Specialist, Head of Quality
Management Department, Ha Dong General Hospital
Dr. Dang Hoang Nga, MD, MSc, 2nd Degree Specialist, Head of Quality Management
Department, Vice Director of Center for Training – Direction of Healthcare Activities, Thai
Nguyen Central General Hospital
Ms. Huynh My Thu, MSc, Head of Quality Management Department, Thu Duc District
HospitalDr. Tran Nguyen Nhu Anh, MD, MSc, Deputy Head of Quality Management Department,
Tu Du Hospital
Dr. Do Thi Thu Hien, MD, MSc, Deputy Head of Outpatient Department, Hanoi Obstetrics
and Gynecology Hospital
Session 2: 5S
Chair:
Dr. Tran Thi Quynh Anh, MD, 1st Degree Specialist, Technical Medicine Department, Thai
Binh Department of Health84

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

AnnexPresenters and panelists:

Dr. Nguyen Thi Huong Lien, MD, MSc, 2nd Degree Specialist, Head of Quality
Management Department, Ha Dong General Hospital

Session 1

Dr. Le Van Duc, MD, 2nd Degree Specialist, Head of Quality Management Unit, An Giang
Hospital of Obstetrics, Gynecology and Pediatrics

Dr. Vu Van Du, MD, PhD, Head of Quality Management Department, Head of Treatment
Services Department, National Hospital of Obstetrics and Gynecology
Dr. Le Viet Nho, MD, PhD, Lecturer, School of Medicine and Pharmacy, Da Nang
University
Dr. Dang Hoang Nga, MD, MSc, 2nd Degree Specialist, Head of Quality Management
Department, Vice Director of Center for Training – Direction of Healthcare Activities, Thai
Nguyen Central General Hospital

Dr. Pham Van Son, MD, 2nd Degree Specialist, Vice Director, Vinh City General Hospital

Session 3

Ms. Nguyen Thi Thu Ha, MPH, Head of Quality Management Department, National Heart
Institute, Bach Mai Hospital

Session 2

Panelists:

Session 3: Standard Operation Procedure (SOP)
Chair:

Presenters and panelists:

Session 4

Dr. Tran Quang Hien, MD, PhD, Director, An Giang Hospital of Obstetrics, Gynecology
and Pediatrics
Dr. Uong Thanh Tung, MD, MSc, Head of Quality Management Department, Saint Paul
General Hospital

Panelists:
Dr. Phan Anh Phong, MD, MSc, Vice Director, Head of Emergency Department, Ha Nam
Provincial General Hospital

Dr. Pham Viet Thai, MD, 1st Degree Specialist, Head of Quality Management Department,
Ninh Thuan Provincial General Hospital

Session 6

Dr. Ton Thanh Tra, MD, MSc, Head of Quality Management Department, Cho Ray
Hospital

Session 5

Ms. Huynh My Thu, MSc, Head of Quality Management Department, Thu Duc District
HospitalDr. Tran Nguyen Nhu Anh, MD, MSc, Deputy Head of Quality Management Department,
Tu Du Hospital

Session 4: Information Technology

Annex

Dr. Do Thi Thu Hien, MD, MSc, Deputy Head of Outpatient Department, Hanoi Obstetrics
and Gynecology Hospital
Chair:
Dr. Phan Thi Hang, MD, MSc, Vice Director, Head of Quality Management Department,
Hung Vuong HospitalPresenters and panelists:
Dr. Vu Duy Tung, MD, 1st Degree Specialist, Head of Quality Management Department,
Ba Ria Hospital
Ms. Huynh My Thu, MSc, Head of Quality Management Department, Thu Duc District
Hospital
Panelists:
Dr. Duong Huy Luong, MD, PhD, Deputy Head of Quality Management Department,
Medical Services Administration, Ministry of HealthDr. Le Viet Nho, MD, PhD, Lecturer, School of Medicine and Pharmacy, Da Nang University

85Dr. Tran Quang Dat, MD, 2nd Degree Specialist, In charge of Quality Management
Department, Head of Intensive Care Unit, Quang Nam Central General Hospital
Dr. Pham Viet Thai, MD, 1st Degree Specialist, Head of Quality Management Department,
Ninh Thuan Provincial General Hospital
Dr. Pham Huu Thuong, MD, MPH, Director, Hanoi Lung Hospital
Ms. Nguyen Thi Thu Ha, MPH, Head of Quality Management Department, National Heart
Institute, Bach Mai Hospital
Session 5: Patient Safety Culture
Chair:
Dr. Le Viet Nho, MD, PhD, Lecturer, School of Medicine and Pharmacy, Da Nang
University
Presenter and panelist:
Dr. Nguyen Thi Huong Giang, MD, MSc, Head of Quality Management Department, BachMai Hospital
Panelists:
Dr. Pham Huu Thuong, MD, MPH, Director, Hanoi Lung Hospital
Dr. Tran Nguyen Nhu Anh, MD, MSc, Deputy Head of Quality Management Department,
Tu Du Hospital
Dr. Uong Thanh Tung, MD, MSc, Head of Quality Management Department, Saint Paul
General Hospital
Dr. Thai Thi Thanh Thuy, MD, 2nd Degree Specialist, Deputy Head of Quality Management
Department, Da Nang Hospital for Women and Children
Dr. Vu Duy Tung, MD, 1st Degree Specialist, Head of Quality Management Department,
Ba Ria Hospital
Session 6: The Roles of Quality Management Department In and Out of Hospital
Chair:
Dr. Duong Huy Luong, MD, PhD, Deputy Head of Quality Management Department,
Medical Services Administration, Ministry of HealthPresenters and panelists:
Dr. Ton Thanh Tra, MD, MSc, Head of Quality Management Department, Cho Ray
HospitalDr. Tran Thi Quynh Anh, MD, 1st Degree Specialist, Technical Medicine Department, Thai
Binh Department of HealthPanelists:
Dr. Pham Van Son, MD, 2nd Degree Specialist, Vice Director, Vinh City General Hospital
Dr. Thai Thi Thanh Thuy, MD, 2nd Degree Specialist, Deputy Head of Quality Management
Department, Da Nang Hospital for Women and Children
Coordinator:
Dr. Shinsuke Murai, DDS, PhD, NCGM
Secretariat:
Ms. Nguyen Thi My Linh, Quality Management Department, Ba Ria Hospital
Ms. Le Thi Hai Yen, Quality Management Department, Ba Ria Hospital
Ms. Nguyen Hong Anh, MSc, MCC
Ms. Le Thi Thu Phong, MCC
Dr. Nguyen Thi Le Hang, MD, PhD, MCC
Ms. Pham Thi Phuong Thuy, MPH, MCC

86

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

AnnexNo.

Name

Session 1

List of participants
Affiliation

3

Le Hong Trung

Vinh Phuc Provincial General Hospital4

Do Duy Cuong

Vinh Phuc Provincial General Hospital

5

Dao Ngoc Chinh

Vinh Phuc Provincial General Hospital

6

Pham Hong Tuan

Vinh Phuc Provincial General Hospital

7

Tran Ngoc Hai

Vinh Phuc Provincial General Hospital

8

Nguyen Thi Huong Giang

Bach Mai Hospital

9

Nguyen Thi Thu Ha

National Heart Institute, Bach Mai Hospital

10

Truong Thi Thu Huong

Bach Mai Medical College

11

Vu Van Du

National Hospital for Obstetrics and Gynecology

12

Nong Minh Hoang

National Hospital for Obstetrics and Gynecology

13

Nguyen Thi Yen Le

National Hospital for Obstetrics and Gynecology

14

Pham Huu Thuong

Hanoi Lung Hospital

15

Uong Thi Mai Loan

Hanoi Lung Hospital

16

Nguyen Thi Thu Huyen

Hanoi Lung Hospital

17

Uong Thanh Tung

Saint Paul General Hospital

18

Nguyen Trong Nghia

Saint Paul General Hospital

19

Nguyen Cong ThanhSaint Paul General Hospital

20

Do Thi Thu Hien

Hanoi Obstetrics Hospital

21

Nguyen Thi Thu

Hanoi Obstetrics Hospital

22

Dinh Thi Le

Hanoi Obstetrics Hospital

23

Nguyen Thị Huong Lien

Ha Dong General Hospital

24

Nguyen Thu Hang

Ha Dong General Hospital

25

Ngo Huu Phuong

Duc Giang General Hospital

26

Phan Anh Phong

Ha Nam Provincial General Hospital

27

Tran Thi Quynh AnhThai Binh Department of Health28

Nguyen Huu Thien

Thai Binh Pediatrics Hospital

29

Pham Xuan Anh

Vinh International Hospital

30

Tran Thi Huyen Trang

Vinh International Hospital

31

Nguyen Thi Dung

Vinh International Hospital

32

Pham Van Son

Vinh City General Hospital

33

Phung Ngoc Duc

Vinh City General Hospital

Annex

Thai Nguyen Central General Hospital

Session 6

Dang Hoang Nga

Session 5

2

Session 4

Medical Services Administration, Vietnam Ministry of Health

Session 3

Duong Huy Luong

Session 2

1

87

No.

88

Name

Affiliation

34

Le Viet Nho

Medical Center, Da Nang University

35

Nguyen Thi Thu Hien

Medical Center, Da Nang University

36

Thai Thi Thanh Thuy

Da Nang Hospital for Women and Children

37

Nguyen Thi Thanh Hong

Da Nang Hospital for Women and Children

38

Huynh Duc Bac

C17 Military Hospital, Da Nang

39

Tran Quang Dat

Quang Nam Central General Hospital

40

Phan Thi Thu Thuy

Quang Nam Central General Hospital

41

Dang Trong

Quang Ngai Provincial Mental Hospital

42

Dinh Thanh Tung

Quang Ngai Provincial Mental Hospital

43

Vu Tuan Anh

Quy Hoa National Leprosy – Dermatology Hospital

44

Nguyen The Toan

Quy Hoa National Leprosy – Dermatology Hospital

45

Tran Xuan Vy

Quy Hoa National Leprosy – Dermatology Hospital

46

Tran Xuan Viet

Quy Hoa National Leprosy – Dermatology Hospital

47

Pham Viet Thai

Ninh Thuan Provincial General Hospital

48

Nguyen Nu Dai Trang

Ninh Thuan Provincial General Hospital

49

Nguyen Thi Thu Duyen

Ninh Thuan Provincial General Hospital

50

Phan Thi Hang

Hung Vuong Hospital

51

Tran Thi Thanh Thuy

Hung Vuong Hospital

52

Ngo Thanh Ha

Hung Vuong Hospital

53

Dien Ngoc Trang

Hung Vuong Hospital54

Luc Boi Ngoc

Hung Vuong Hospital

55

Nguyen Huynh Thai Duong

Hung Vuong Hospital

56

Bui Thi Thanh Hong

Hung Vuong Hospital

57

Nguyen Thanh Danh

Hung Vuong Hospital

58

Huynh Ngoc Phuoc

Hung Vuong Hospital59

Vo Thi Ngoc Diep

Hung Vuong Hospital

60

Phung Thi Thanh Van

Hung Vuong Hospital

61

Pham Thi Ngoc Tuyen

Hung Vuong Hospital

62

Huynh Thi Ngoc Dung

Hung Vuong Hospital

63

Pham Ngoc Doan Trang

Hung Vuong Hospital64

Tran Nguyen Nhu Anh

Tu Du Hospital

65

Nguyen Thi Kim Yen

Tu Du Hospital

66

Duong Thi Kim Tuyen

Tu Du Hospital

67

Melody Martin

Tu Du Hospital

68

Huynh My Thu

Thu Duc District Hospital69

Lam Ngoc Minh Thanh

Thu Duc District Hospital

70

Van Thi Thuy Trang

Thu Duc District Hospital

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

AnnexNo.

Name

Affiliation

Tu Huynh Hoang Tu

Thu Duc District Hospital74

Ton Thanh Tra

Cho Ray Hospital75

Ho Khanh Thanh

Cho Ray Hospital

76

Nguyen Anh Tuan

Cho Ray Hospital

77

Tran Hong Diem

Cho Ray Hospital

78

Phung Thanh Phong

Cho Ray Hospital

79

Dinh Quang Minh

Cho Ray Hospital

80

Nguyen Thi Kim Lien

Cho Ray Hospital81

Dang Hoang Vu

Cho Ray Hospital

82

Dinh Thi Ngoc Yen

Cho Ray Hospital

83

Pham Thi Thuy Dung

Cho Ray Hospital84

Ho Thi Hong

Cho Ray Hospital

85

Nguyen Xuan Canh

Cho Ray Hospital

86

Hoang Lan Phuong

Cho Ray Hospital87

Le Ngoc Anh

Cho Ray Hospital

88

Bien Huynh San Dan

Cu Chi Regional General Hospital

89

Nguyen Nhat Hung

Cu Chi Regional General Hospital

90

Nguyen Hong Lac

Cu Chi Regional General Hospital

91

Nguyen Thi Thuy Huong

Cu Chi Regional General Hospital

92

Nguyen Tan Phuong

Cu Chi Regional General Hospital

93

Nguyen Thi Ngoc Hanh

Hanh Phuc International Hospital94

Le Thi Thu Thao

Hanh Phuc International Hospital

95

Karim Mohammad Zakirul

Hanh Phuc International Hospital

96

Tran Thi Tuyet Lan

Van Phuc 2 General Hospital

97

Tran Bao Ngan

Van Phuc 2 General Hospital

98

Nguyen Minh Hung

Ho Chi Minh City Oncology Hospital99

Vo Hong Minh Phuoc

Ho Chi Minh City Oncology Hospital

100

Huynh Phi Ho

Mekong Obstetrics Hospital

101

Tran Quoc Dung

Mekong Obstetrics Hospital102

Ho Van Cong

Mekong Obstetrics Hospital103

Vo Thi Dan Tram

District 3 General Hospital, HCM City

104

Nguyen Thanh LuanHCM City Medical Pharmaceutical University Hospital

105

Nguyen Thi Be Phuong

HCM City Medical Pharmaceutical University Hospital

106

Nguyen Hung Anh

FV Hospital

107

Nguyen Truong Phuoc Kim Anh

FV Hospital

Annex

73

Session 6

Thu Duc District Hospital

Session 5

Tran Thi Bich Bo

Session 4

72

Session 3

Thu Duc District Hospital

Session 2

Hoang Thi Oanh

Session 1

71

89

90

No.

Name

Affiliation

108

Tran Thi Phuong Nga

FV Hospital

109

Alice Veyrie

FV Hospital110

Vo Viet Duc

Thong Nhat Hospital

111

Pham Thi Hong Ha

Thong Nhat Hospital

112

Tran Thi Thanh TamThong Nhat Hospital

113

Bui Thi Thu Thuy

Thong Nhat Hospital

114

Tran Quang Hien

An Giang Hospital of Obstetrics, Gynecology and Pediatrics

115

Le Van Duc

An Giang Hospital of Obstetrics, Gynecology and Pediatrics

116

Quach Truong Son

An Giang Hospital of Obstetrics, Gynecology and Pediatrics

117

Nguyen Chi Thien

An Giang Hospital of Obstetrics, Gynecology and Pediatrics

118

Tran Thai Duy

Binh Duong Provincial General Hospital

119

Nguyen Thi Kim Yen

Binh Duong Provincial General Hospital

120

Nguyen Thi Thuong

Binh Duong Provincial General Hospital

121

Truong Thi Bich Ngoc

Dong Thap Provincial General Hospital

122

Nguyen Tri Dung

Dong Nai Provincial General Hospital123

Vo Van Hung

Ba Ria – Vung Tau Department of Health124

Nguyen Van Huong

Ba Ria Hospital125

Le Minh Hieu

Ba Ria Hospital

126

Bui Quan TuanBa Ria Hospital

127

Nguyen Thi Anh Minh

Ba Ria Hospital128

Le Van Huy Cuong

Ba Ria Hospital

129

Vu Duy Tung

Ba Ria Hospital

130

Do Ngoc Anh

Ba Ria Hospital131

Huynh Thi Bich Thao

Ba Ria Hospital

132

Nguyen Thi My Dung

Ba Ria Hospital

133

Vu Thi Tin

Ba Ria Hospital

134

Huynh Thi Thanh Thuy

Ba Ria Hospital

135

Nguyen Thi Huyen

Ba Ria Hospital

136

Nguyen Van Trong

Ba Ria Hospital137

Le Thi Khanh Quy

Ba Ria Hospital

138

Pham Thanh Trung

Ba Ria Hospital

139

Trinh Thi Van Tra

Ba Ria Hospital

140

Tran Thanh Dat

Ba Ria Hospital

141

Tran Thi Kim Nhung

Ba Ria Hospital

142

Vuong Quang Thang

Ba Ria Hospital

143

Duong Thi Ngoc Huong

Ba Ria Hospital

144

Nguyen Duc Hien

Ba Ria Hospital

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volume 3

AnnexAffiliation

Ba Ria Hospital

147

Tien Vu Tung

Ba Ria Hospital148

Cao Van Cu

Ba Ria Hospital

149

Pham Thi Vinh Phuc

Ba Ria Hospital

150

Nguyen Quoc Tien

Ba Ria Hospital

151

Dinh Thi Mai Huong

Ba Ria Hospital

152

Dao Thi Ngoc Cam

Ba Ria Hospital

153

Nguyen Van Thinh

Ba Ria Hospital

154

Truong Thanh Kim Phung

Ba Ria Hospital

155

Pham Trung Thao

Ba Ria Hospital156

Do Thi Hoang Guong

Ba Ria Hospital

157

Nguyen Van Hung

Ba Ria Hospital

158

Nguyen Thi Kim LienBa Ria Hospital

159

Le Thi Hong Que

Ba Ria Hospital

160

Nguyen Van Phuc

Ba Ria Hospital161

Le Thi Kim Nga

Ba Ria Hospital

162

Vu Ngoc Diep

Ba Ria Hospital

163

Nguyen Thi Doan Trang

Ba Ria Hospital

164

Tran Thi Thu Van

Ba Ria Hospital165

Le Thi HiepBa Ria Hospital

166

Phan Minh Hien

Ba Ria Hospital

167

Nguyen Van Thang

Ba Ria Hospital168

Vo Thi Minh Hien

Ba Ria Hospital

169

Doan Thuan Yen

Ba Ria Hospital

170

Nguyen Vinh Tho

Ba Ria Hospital

171

Nguyen Mong Hai Dang

Ba Ria Hospital

172

Nguyen Thi My Linh

Ba Ria Hospital173

Le Thi Hai Yen

Ba Ria Hospital

174

Vu Thi My Vy

Ba Ria Hospital175

Le Hoa My

Ba Ria Hospital

176

Tran Thi Thu

Tan Thanh District Medical Center, Ba Ria – Vung Tau Province177

Le Van DoanTan Thanh District Medical Center, Ba Ria – Vung Tau Province

178

Nguyen Minh Nguyet

Tan Thanh District Medical Center, Ba Ria – Vung Tau Province

179

Nguyen Lien

Tan Thanh District Medical Center, Ba Ria – Vung Tau Province180

Ho LocBa Ria – Vung Tau Provincial Mental Hospital

181

Nguyen Van Binh

Ba Ria – Vung Tau Provincial Mental Hospital

Annex

Le Cao Thai

Session 6

146

Session 5

Ba Ria Hospital

Session 4

Nguyen Thi Thao Mai

Session 3

145

Session 2

Name

Session 1

No.

91

No.

Name

Affiliation

182

Le Thi Thu

Ba Ria – Vung Tau Provincial Mental Hospital

183

Nguyen Dang Dien

Ba Ria – Vung Tau Provincial Mental Hospital184

Le Thi Bich Nga

Long Dien District Medical Center, Ba Ria – Vung Tau Province

185

Duong Van Muon

Long Dien District Medical Center, Ba Ria – Vung Tau Province186

Vu Van Nam

Xuyen Moc District Medical Center, Ba Ria – Vung Tau Province

187

Phan Cao Dong

Xuyen Moc District Medical Center, Ba Ria – Vung Tau Province

188

Tran Thanh Hoai Phuong

Dat Do District Medical Center, Ba Ria – Vung Tau Province

189

Le Thi Thuy Quyen

Dat Do District Medical Center, Ba Ria – Vung Tau Province

190

Phan Chau Thanh

Chau Duc District Medical Center, Ba Ria – Vung Tau Province

191

Tran Van Bay

Le Loi Hospital, Ba Ria – Vung Tau Province

192

Nguyen The Hung

Le Loi Hospital, Ba Ria – Vung Tau Province

193

Tran Thi Le Van

Le Loi Hospital, Ba Ria – Vung Tau Province

194

Vo That Lap

Le Loi Hospital, Ba Ria – Vung Tau Province

195

Vuong Khai Khoa

Vung Tau City Medical Center, Ba Ria – Vung Tau Province

196

Pham Cong Chi

Vung Tau City Medical Center, Ba Ria – Vung Tau Province

197

Ton That Cac

Vung Tau City Medical Center, Ba Ria – Vung Tau Province

198

Le Dinh Minh Duc

Vung Tau City Medical Center, Ba Ria – Vung Tau Province199

Lam Quoc Phong

Ba Ria - Vung Tau Provincial Traditional Hospital

200

Nguyen Thi Thu Thuy

Ba Ria - Vung Tau Provincial Traditional Hospital

201

Nguyen Thi Van

Vietnam Productivity Institute202

Nguyen Lan Huong

Vietnam Initiative203

Dang Duc Anh

Vietnam Initiative

204

Nguyen Phuong Thuy

Vietnam Initiative

205

Megumi Ikarashi

JICA

206

Koji Wada

JICA

207

Jun Moriyama

JICA

208

Pham Kim Hong

JICA

209

Nguyen Thuy Thuc Doan

JICA

210

Vo Thi Thu Uyen

JICA

211

Manivanh Savatdy

Minstry of Health, Lao PDR

212

Somchanh Thounsavath

Minstry of Health, Lao PDR

213

Chanheme Songnavong

University of Health Sciences in Lao PDR (UHS)214

Anousone Sisoulath

University of Health Sciences in Lao PDR (UHS)215

Ketsomsouk Bouphavanh

University of Health Sciences in Lao PDR (UHS)216

Somyoth Douangphachanh

Vientiane Provincial Hospital

217

Vanpheng Phanthanalay

Vientiane Provincial Hospital

218

Phonexay Khounemala

Champasak Province Health OfficeAnnexAffiliation

Champasak Provincial Hospital

221

Vilavanh Khoummavong

Salavan Province Health Office

222

Kongsith Ounchith

Salavan Provincial Hospital

223

Kong Sayasinh

Salavan Provincial Hospital

224

Somphong Duanghorm

Sekong Province Health Office225

Lathsamee Souphanethong

Sekong Provincial Hospital

226

Daophasone Sihalath

Sekong Provincial Hospital

227

Nouphat Phomkenthao

Attapeu Province Health Office228

Hongkham Sisavath

Attapeu Provincial Hospital

229

Vongvilay Phongsamouth

Attapeu Provincial Hospital

230

Shiho Tobita

QHC Project, Lao PDR

231

Satoko Jimbo

QHC Project, Lao PDR

232

Aki Hashizume

QHC Project, Lao PDR

233

Bansay Saysouphanh

QHC Project, Lao PDR

234Somphy Phoummathep

QHC Project, Lao PDR

235

Latsamy Thepthepha

QHC Project, Lao PDR

236

Noimaniphone Lorbliayao

Interpreter

237

Syda Philavong

Interpreter

238

Shinsuke Murai

NCGM, QHC Project, Lao PDR

239

Emiko Tateishi

NCGM

240

Miki Matsufuji

NCGM

241

Yukiko Nakano

NCGM

242

Nguyen Thi Le Hang

MCC

243

Le Thi Thu Phong

MCC

244

Nguyen Hong Anh

MCC

245

Nguyen Viet Thang

Interpreter

246

Nguyen Van Thang

Photographer

247

Nguyen Huu Thuan

Photographer

Annex

Bounthanh Phaytanavanh

Session 6

220

Session 5

Champasak Provincial Hospital

Session 4

Khithsaveng SisoulathSession 3

219

Session 2

Name

Session 1

No.

93

Practices in Hospital Quality Management and Patient Safety
in Vietnam: Challenges and Achievements
Volume 3

Based on Proceedings and Discussions in the 3rd Vietnam Forumon Quality Management and Patient Safety, Ba Ria - Vung Tau, Vietnam in September 19-21, 2017
Edited by Ms. Hong-Anh Nguyen1 and Dr. Shinsuke Murai2
1. NCGM - Bach Mai Hospital Medical Collaboration Center, Hanoi, Vietnam
		

2. National Center for Global Health and Medicine, Tokyo, Japan

National Center for Global Health and Medicine (NCGM)
1-21-1, Toyama, Shinjuku-ku
Tokyo, Japan
www.ncgm.go.jp

The document was printed in October in 2018.
The document was made in the research on "Visualization of progress of efforts on quality and safety in healthcare in developing countries(T.Nakasa and S.Murai)" funded by The Grant for National Center for Global Health and Medicine (27 Shitei 2).