ISBN 978-4-909675-47-7

Table of Contents
Guideline for Citation

02

Foreword

03

Abbreviation

04

Session 1

Session 2

Learning Culture in Hospital............................................................................

05

Shifting from Punishment Culture to Learning Culture to Improve Patient Safety05

Establishing Hospital Incident Reporting System........................................... 10

2-1

Establishment of Medical Incident Management System in Bach Mai Hospital

10

2-2

Developing Incident Reporting System in Ha Nam Provincial General Hospital

13

Session 3

Improving Compliance to Timing Standard..................................................... 17
Improving Compliance to Standard Emergency Response Time from 55% to
85% in December 201517

A Topic from Japan.................................................................................................................. 22

Session 4

Session 5
5-1

Eight Core Values in Quality Management in Japan

22

Improving Service Quality in OPD...................................................................

26

Plan to Improve Management and Medical Safety in Prescription for Outpatients26

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

31

5S Implementation in Two Departments in Ninh Binh Provincial General Hospital(Nephro-urological Surgery and Endocrinology Departments)

31

5-2

5S Implementation in Ha Dong General Hospital

35

5-3

Project for 5S Implementation in Thai Binh Provincial General Hospital

42

5-4

Who is customer? 5S

46

Session 6
6-1
6-2

Session 7

Improving Quality in Clinical Departments...................................................... 48
Reducing Ventilator Associated Pneumonia by 5% and Pressure Ulcer by 10%
in ICU within 3 Months

48

Increasing the Rate of Proper Use of Prophylactic Antibiotics in Surgery from 65% to 75%
after One PDCA Cycle

51

Updates from the Ministry of Health..............................................................

59

Applying Hospital Quality Standards to Improve Hospital Quality and Patient Care

59

Forum Outline

63

Program

64

Steering Committee

66

List of Participants

67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.1). Tokyo, Japan: National Center for
Global Health and Medicine (NCGM).

How to cite an abstract/presentation in this book (Example):
Le VN, Nguyen TTC, and Phan TTT. (2018). Challenges in Shifting from Punishment Culture
to Learning Culture to Improve Patient Safety. In Nguyen HA and Murai S (Eds.), Practices in
Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements(Vol.1). Tokyo, Japan: National Center for Global Health and Medicine (NCGM).

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

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.
0U=PL[UHTLќVY[ZHUKWYVNYLZZVM/847:Z[PSSKPќLYPUKPќLYLU[OVZWP[HSZ0MOVZWP[HSZ
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 among
WLVWSL^OVHYLPUJOHYNLVM/847:^V\SKJVU[YPI\[L[VZPNUPÄJHU[HK]HUJLPU/847:PU
Vietnam.
-PUHSS`HZKL]LSVWTLU[WHY[ULYZKV^LYLHSS`RUV^^OH[LќVY[ZVU/847:HYLNVPUNVU
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
VUNVPUNLќVY[ZPUOVZWP[HSZPU=PL[UHT>OLU^LRUV^LќVY[ZHUKKPѝJ\S[PLZPUOVZWP[HSZPU=PL[UHT^LILSPL]L^LJV\SKKPZJ\ZZHUKVќLYIL[[LYPU[LYUH[PVUHSJVVWLYH[PVUPU[OLÄLSKVM
Hospital Quality Management and Patient Safety.
;OLYLZLHYJO[LHTVM=PZ\HSPaH[PVUVMWYVNYLZZVMLќVY[ZVUX\HSP[`HUKZHML[`PUOLHS[OJHYLPUKL]LSVWPUNJV\U[YPLZ

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, 2017

Abbreviation



AMS

Antimicrobial stewardship

CQI

Continuous quality improvement

DI

Diagnostic imaging

DOH

Department of Health

EBM

Evidence-based medicine

ESBL

Extended-spectrum beta-lactamase

FE

Functional examination

GPD

General planning department

HQS

Hospital Quality Standards

ICU

Intensive care unit

IRS

Incident reporting system

KYT

Hazard prediction training (Kiken yochi training)

MOH

Ministry of Health

NAP

National Action Program

OPD

Outpatient department

PDCA

Plan – Do – Check - Act

PS

Patient safety

QI

Quality improvement

QM

Quality management

QMD

Quality management department

RCA

Root cause analysis

SOP

Standard operational procedure

SSI

Surgical site infection

VAP

Ventilator associated pneumonia

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 1 | Learning Culture in Hospital

Session 1

Session 1
Challenges in Shifting from Punishment Culture to
Learning Culture to Improve Patient Safety

Session 2

Le Viet Nho, Nguyen Thi Thach Cam, Phan Thi Thu Thuy
Quality Management Department, Quang Nam Central General Hospital

Session 3

1.

Reason for choosing the topic
Safety culture, the core of which is building up a

voluntarily report medical incidents. On the contrary,gradually increases from April to the peak in August, thenKLJYLHZLZNYHK\HSS`[OLKPќLYLUJLIL[^LLUTVU[OZJHU

Discussion

culture of learning from errors, encourages staff tomonth, but the data is not stable: the number of reports

reach more than 200% (Figure 1):

punishment culture makes staff hide incidents because[OL`HYLHMYHPK[OH[[OLPYWYLZ[PNL^V\SKILHќLJ[LKHUK
especially afraid of being blamed or punished, which does

Session 4

not help create an environment for learning, especiallylearning from mistakes. Punishment culture has rooted
in many hospitals, including Quang Nam Central General
Hospital. Therefore, shifting from punishment culture tolearning culture faces many challenges. The most visible
manifestation is that medical incidents are not reported,
Therefore, we expect to find these real challenges to

05 incidents at level 3b or above were not reported.

develop feasible and effective solutions to shift from- Actual state of incident collection, analysis and response

punishment culture to learning culture to improve patient

shows that:safety (PS).

Implementation plan

Only some incidents at level 3b were root cause analyzed,
providing report and feedback to the system.

- Studying the results of incident collection, handling and- Results of safety culture surveys in April and October

response of the voluntary incident reporting system (IRS)2015:

as well as the alternate incident detection system of the
Quality Management Department (QMD).

Regarding the question “In the hospital, medical incidents
are handled properly”, the rate of “agree” and “strongly
HNYLL¹YLK\JLZMYVT

hospital in two rounds: the first in April 2015 and theround); the rate of “neither agree nor disagree” increases

second in October 2015.

from 19.1% to 26.1%; the rate of “disagree” and “strongly

3-a.

disagree” increases from 3.1% to 9.7%.

ÄYZ[YV\UK[V ZLJVUK

3-b.

Objectives

handling and response as well as QMD’s alternate incident- The average number of incident reports is 10 reports/

Annex- Results of the voluntary IRS’s incident collection,
detection system show that:

Session 7- Surveying staff perception on safety culture in the

Current state

Session 6

2.

Session 5

analyzed and responded sufficiently and properly.

month, with difference within 100%. All reports are

After establishing the IRS, the number of medical incident

analyzed and feedback is given to all staff properly.

reports increases with an average of 7.5 reports per

Reports of incidents at level 3 or above are root causeanalyzed.

- The top leaders of hospital and departments are- Hospital culture changes positively, with the rates ofZ[HќHNYLL[OH[¸TLKPJHSPUJPKLU[ZHYLOHUKSLKWYVWLYS`¹

not yet committed and don’t regularly confirm nonpunishment policy for incident reporting.

increase to more than 80%.

- Hospital policies are not consistent and do not show

4.

(UHS`ZPZVM[OLHɈLJ[PUNMHJ[VYZ

priority for PS.

Causes of punishment culture come from 2 groups:- Healthcare workers, especially doctors, are not

4.1.

6IQLJ[P]LJH\ZLZ!+PɉJ\S[[VJOHUNL

Society: Community still blame individuals for making
mistakes; most people expect to specify who is
responsible for errors that happen.
Legal system and policy:- Incomplete legal system in terms of protection ofpeople who report incidents.
- Policy contradiction is an obstacle for institutions tochange their culture through staff training, especiallyhealth insurance payment policy.
- There are no mechanisms for protection and safetyassurance for reporters when reporting errors.
- There are no independent agencies responsible formonitoring medical incidents.
4.2.

Subjective causes: Can be changed

ILSPL]PUNPU[OLVYNHUPaH[PVUHUKLќLJ[P]LULZZVM09:
84+HUKPUJOHYNLZ[HќSHJRL_WLYPLUJLPUJVSSLJ[PUN
HUKHUHS`aPUNTLKPJHSPUJPKLU[ZHUKNP]PUNMLLKIHJR[VOVZWP[HSZ[HќWYVWLYS`!
0UJOHYNLZ[HќHUK7:UL[^VYROH]LU»[ILLU[YHPULKand organized for proper operation.
- Procedures for receiving, collecting and analyzing
incidents and giving feedback are not complete yet.
Actual state of PS training for hospital leaders andZ[Hќ!
- The number of leaders and doctors who were trainedon PS is small: 8/11 members of QM Council, which
is 73%; 17/38 doctors who are chiefs or vice chiefsof departments, 45%; 4/54 other doctors, 7%; 19/19
head nurses, 100%; 35/35 members of QM network,100%.

The hospital has not developed a safe environment for- Training and communication activities are notreporting or displaying medical incidents:

THPU[HPULKYLN\SHYS`HUKLќLJ[P]LS`

Challenges in shifting frompunishment culture tolearning culture to improve
patient safety
19.7.201
2008
2
BV K TW
Qnam

Le Viet Nho, MD., PhD.
Ng.T.Thach Cam, Phan Thi Thu Thuy
Quang Nam Central General Hospital

Quang Nam Central General Hospital- 2ndlevel hospital, under the
Ministry of Health (MOH)- Scope:+ Planned beds: 600+ Actual beds: 806- Personnel: 732, including 100
medical doctors- Functional departments:+ 20 clinical departments+ 7 para-clinical departments+ 8 functional departments

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 1 | Learning Culture in Hospital

Quality Management Department

Participation in PS training

Session 1

Chief
01 vice chief incharge of PS

01 vice chief incharge of QM

Generaladministrativestaff- Quality indicators- Technical procedures- Protocols compliance- Trainings on developing
quality indicators- Satisfaction survey- Safety culture survey- General administration- Training and practicing- 5S, T, improvement plans

Staff in chargeof riskmanagement- Patient care procedures- Complaints and denunciations- Incident reports- Trainings on root cause
analysis (RCA), KYT

Session 3

Major activities

QM network’smonthly meeting

Session 2

Staff in chargeof quality
indicators

Training andinformation sharing

1. REASON FOR CHOOSING THE TOPIC
Safety culture

implementation, monitoring andevaluation of QM activities according
to MOH’s Hospital Quality Standards(HQS) and internal evaluation
As a permanent member of QM
Council, monitoring and encouraging
departments and units to implement
quality improvement (QI) plans
Conducting safety culture survey andsatisfaction survey

27
17

14 13

T12

T9

T8

T7

T10

T6

T5

T3

T2

T1

Discussion

Learning culture

T11

9 10
6

5
2 2 3 2
T4

Focal point for development,

Punishment culture

Session 4

2. ACTION PLAN

Major activities

Developing and measuring
quality indicators
Qualityindicators

RCA

Session 5

Receiving and handling medical incidents

1.Studying the results of incident collection, handlingand response of the voluntary IRS as well as thealternate incident detection system of the QMD.
2. Surveying staff perception on safety culture in thehospital in two rounds:
Round 1: April 2015
Round 2: October 2015

Session 6

Support departments
to develop PDCA
improvement plans

BEFORE 5S: DRUG CABINET

Session 7

TRAUMA SURGERY DEPARTMENT

3. Actual state of the hospitalS báo cáo

AFTER 5S: DRUG CABINET

Trung v27

1. Voluntary IRS andalternate incident detection
system

17
14

13

2

2

3

5

10

Annex

9

6

2

T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12Monthly average number of incident reports: 7.5 reports
05 incidents at level 3b or above were not reported.
Only some incidents at level 3b were root cause analyzed, providing
report and feedback to the system.

3. Actual state of the hospital

IndividualConservative

2. Results of safety culture surveys in April and October 2015
Regarding the question “In the hospital, medical incidents arehandled properly”

Do not accept change The rate of “agree” and “strongly agree” reduces from
77.9% (first round) to 64.3% (second round); The rate of “neither agree nor disagree” increases from
19.1% to 26.1%;
 The rate of “disagree” and “strongly disagree” increases
from 3.1% to 9.7%.

Objectives

Afraid to create conflicts
and harm colleagues’
prestige.
Not believing in benefitsof change.

ACTUAL STATE OF PS TRAINING FOR
HOSPITAL LEADERS AND STAFF IS LIMITED: The average number of incident reports is 10 reports/month, with difference within 100%. All reports areanalyzed and feedback is given to all staff properly.

 45% of chiefs and vice chiefs of departments (17/38

 100% reports of incidents at level 3 or above are root
cause analyzed.

 100% head nurses (19/19 nurses); Hospital culture changes positively, with the rates of staff
agree that “medical incidents are handled properly”
increase to more than 80%.

 73% QM Council (8/11 members);

doctors);
 7% of other doctors (4/54 doctors); 100% QM network (35/35 members).

Leaders of all levels are not yet

understanding and believing, hesitant tochange, not enthusiastic and impatient.
Time consumingards toTowa re ofu“cult ing”
learn rorserfromSociety’s viewpoint Community
 Media Politicians, policy

makers Hospital colleagues

Still blame individuals for making
mistakes, that someone must be
responsible for an incident that happens.

CausesCultural aspect: Punishment culture has rooted inmany organizations and individuals, that errors areindividual mistakes and someone must be
responsible for incidents that happen.
Roots causes: Leaders of hospital and departments
are not concerned and do not have effective
solutions for developing a culture of learning fromerrors.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 1 | Learning Culture in Hospital

4. Evaluation of implementation
Hospital leaders commit with developing safety
culture in the hospital (culture of learning fromerrors)Do not punish and make individual to takeresponsibility.

Session 3

 Issuing “no punishment” policy

The monthly average number of incident reports
The ratio of voluntary incident reports/mandatory
incident reports
The rate of incidents that are analyzed andresponded out of the total monthly incident reportsSurvey on staff perception on safety culture in thehospital.
Evaluating achieved results and providing solutions
for improvement or maintaining.

Session 2

Step 1: Making plan

Session 1

Solutions“To err is human, to cover up is unforgivable, and to
fail to learn is inexcusable.”

Liam Donaldson

Discussion

for unintentional mistakes.
 Requesting commitment for
involvement of leaders at alllevel and ensuring equity inimplementing “no punishment”
policy.
 Issuing confidential policy andreward policy for people who
provide information on medical
incidents.

Session 4
Session 5

Step 2. Training andcommunication
 Releasing “no punishment” policy to make all

Session 6

hospital staff understand, feel secure andvoluntary to share their mistakes.
 Inviting experts to provide trainings on PS for
doctors and nurses.
 Organizing contests on PS, medical incident
situations.

Session 7

3. Compliance and implementation
 Monitoring and comparing numbers of
mandatory and voluntary incident reports.
 Timely handling reported incidents andidentifying lessons learnt from mistakes.

Annex


Session 2-1
Establishment of Medical Incident Management
System in Bach Mai Hospital
Nguyen Thi Huong Giang, Nguyen Quoc Thai, Doan Ngoc Khanh
Quality Management Department, Bach Mai Hospital

1.

Reason for choosing the topic
In regard to PS, recording medical incidents will help

hospitals to analyze roots causes and generate preventive
measures.

2.

3-b. Objective
To establish a medical incident management system in
Bach Mai Hospital.

4. Cause analysis

Implementation plan

The previous system could not receive much

- Establishing medical incident management system

information because incident report was accompaniedin all departments in the hospital, including detecting,with identifying who was responsible. Recognizing thisreporting, analyzing incidents and giving feedback to help

issue, the new system is established to record unsafe

departments avoid repetition of past incidents.

events, no matter who commit mistakes. Then RCA will

3-a.

Actual state- In 2013, the hospital developed ISO procedure forbe conducted to generate preventive solutions.

5. Action plan

“Handling technical incidents” to provide guidance for

QMD develops an incident reporting form andhandling technical incidents and recording the reporter’s

guidelines for how to fill and send report, analyze root

information and the incident’s severity in “Technicalcauses and giving feedback. The form and the guidelines

0UJPKLU[ 9LWVY[PUN 5V[LIVVR” to identify responsible

will be sent to departments, especially members of QM

individuals. After three years of implementation, thenetwork and QM Council, for comments. After releasing

number of incidents recorded in the notebook was very

and two months of implementation, QMD will evaluate

small and near misses were hardly recorded.

and consider adjustment if necessary.

Introduction of Bach Mai Hospital

ESTABLISHMENT OF MEDICAL INCIDENTMANAGEMENT SYSTEM IN BACH MAI HOSPITAL

Quality Management Department
Hanoi, January 20, 2016

 A special level, complete general hospital There are 2,300 staff and 1,900 planned beds.
 There are 3 institutes, 8 centers, 23 clinical departments and 6
para-clinical departments.
 There are 4,000 inpatients and 4,500 outpatients everyday.
 9 tasks:
1.Providing last level examination and treatment
2.Conducting scientific research
3.Verifying health status
4.Training
5.Directing healthcare activities to low levels
6.International cooperation
7.Epidemic and disaster prevention
8.Hospital quality management
9.Hospital management

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 2 | Establishing Incident Reporting System in Hospital

Organization of hospital QM system

Action plan

QM COUNCIL

Establishing medical incident management system in all
departments in the hospital, including detecting, reporting,analyzing incidents and giving feedback to help
departments avoid repetition of past incidents.

PS COMMITTEE

QMD(Permanent member)

Session 1

3

Detecting &reportingincidents

ExpansionQUALITY
MEASUREMENTCOMMITTEEQI COMMITTEE

Monitoring &evaluation

Implementing
solutions

Session 3

QM ACTIVITIESGenerating
solutions

Actual situation

ISO 15189
ISO 17025

Discussion

In 2013, the hospital developed ISO procedure for“Handling technical incidents” to provide guidance forhandling technical incidents and recording thereporter’s information and the incident’s severity in“Technical Incident Reporting Notebook” to identify
responsible individuals. After three years of
implementation, the number of incidents recorded in
the notebook was very small and near misses werehardly recorded.

ISO 9001: 2008

Session 2

QM NETWORK

RCA

Session 4

In regard to PS, recording medical incidents will
help hospitals to analyze roots causes andgenerate preventive measures.

TO ESTABLISH A MEDICAL INCIDENTMANAGEMENT SYSTEM IN BACH MAIHOSPITAL

Heinrich PRINCIPLE

Implementation plan

Session 6

Objective
Session 5

Reason for choosing the activity

Activities

1

Reviewing the old procedure to findinappropriate points
Reviewing literature and experienceof domestic and foreign hospitals

230 small accidents

4300 near misses
6

5

Developing procedure and regulation
for incident management
Organizing QM network’s meetingsfor comments
QM Council approves

15/12/2015

Annex

3
Important

Deadlines

Session 7

1 serious
accident

No.

DEVELOPMENT OF REGULATION ON
INCIDENT MANAGEMENT

Cause analysis

 Change definition of medical
incident.
 Clearly specify in the regulation that“not aiming to punish any individual”
 Emphasize the “right” and“responsibility” of healthcare workers
to report incidents.
 Encourage to report “unsafe
situation”
 Can report anonymously Incident management procedure:
receiving, analyzing, giving feedback,proposing QI activities, monitoring,evaluation...
 Collect and analyze data, give
feedback to relevant departments andreport to hospital leaders Include confidentiality

 Focus on serious incidents(following definitions oftechnical incident) The procedure focused on
handling incidents. Serious
incidents are handled at
hospital level.
 There was no data collection
and analysis in department
and hospital levels.
 Near misses were notmentioned.
 Recording focused on
information such as people
who commits mistake, whoreports, who witnesses…

IMPLEMENTATION PLAN

QMD MEETINGNo.

QM NETWORK MEETING

Activities

6

Hospital director issues regulation

7

Training for QM network members

8

Implementation (in some pilot departments)

9

Evaluation after 2 months

10

Adjust inappropriate points

Deadlines
31/12/2015

15/1/2016
3/2016

DIFFICULTIES AND CHALLENGES

Encourage departments to report incidentsCollecting information related to the incident is very
important.
Collaboration among relevant departments to analyze
roots causes and to develop QI plans.
Support from the MOH…

QM COUNCIL MEETING

Thank you for your attention!

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 2 | Establishing Incident Reporting System in Hospital

Developing Incident Reporting System in Ha Nam
Provincial General Hospital

Session 1

Session 2-2

Session 2

Phan Anh Phong
Vice Director, Ha Nam Provincial General Hospital

Reason for choosing the topic

Action plan

- IRS and procedure were developed. However, it does
not function as well as expected.

1.

6. (σHFWLYHQHVVDQGVROXWLRQV

2.

Providing information and training about theILULÄ[ZVMYLWVY[PUNPUJPKLU[[VHSSOVZWP[HSZ[Hќ"

3.

Establishing the reporting system;

4.

Implementation

3-a.

Current state1.

2.

)LULÄ[ZVM PUJPKLU[ YLWVY[PUN ^LYL [YHPULK[VHSS
hospital’s core members: the directing board,
chiefs and vice chiefs of departments, headnurses (1/6 hospital manpower).

3.

An IRS was established in the hospital.

4.

Implementation: Very few incident reports, mainly
mandatory reports, voluntary reports are rare.

Objective- 1-2 incident reports are received every day.
- Hospital incident book is published.

(ZZPNUHUPUJOHYNLZ[Hќ- Encourage focal people to work more actively- Actively provide information and trainings and show
LќLJ[P]LULZZ

8. Lessons learned
,Z[HISPZOPUNHU09:PZUV[KPѝJ\S[- Making the system work effectively and bring realILULÄ[ZPZUV[ZPTWSL

Session 7

3-b.

- Make the director pay more attention.

Session 6

Reporting form and procedures for reporting andhandling reports were designed.

7. Solutions to maintain and develp the system

Session 5

Designing reporting form, completing procedures
for reporting and handling reports;- Only some mandatory reports have been received,
therefore it needs to reinforce information sharing and[YHPUPUNHZZPNUHZ[Hќ[VILPUJOHYNLVMPUJPKLU[YLWVY[management, encourage focal people to work more
actively, analyze root causes of reported incidents, protect
reporters, and generate warnings so that people see theILULÄ[ZVMYLWVY[PUN

Session 4

2.

4.

- The directing board and core staff were provided
information. However, only few people have changed theirperceptions.

Discussion

IRS helps to control medical incidents that occur in
hospitals: level, quantity, proportion, frequency, causes...
thereby warnings and solutions will be provided tominimize potential incidents.

5. Proposed solutions and actual implementation

Session 3

1.

Cause analysis

5V[HSSOVZWP[HSZ[HќYLJLP]LK[YHPUPUNZHUKN\PKHUJL- The focal points of the system did not work actively.

Annex- Staff did not report voluntarily, did not understand theILULÄ[ZVMYLWVY[PUNHUK^LYLHMYHPKVMW\UPZOTLU[- Personnel changes in the directing board.

TIMELINE
Activities

22/6

23/6

30/6

15/7

16/7

30/9

Meeting for implementation

Developing incident reporting
system in Ha Nam Provincial
General Hospital
Dr. Phan Anh Phong, MD., MSc.
Vice Director, Ha Nam Provincial General Hospital

REASONS FOR CHOOSING THE TOPICIn charge
Dr. Phong, QMD,
Nursing Department

Studying manpower organization

Personnel Department,
QMD

Developing reporting form

QMD, Nursing
Department, Dr. Phong

Developing template incident
management book

QMD, Dr. Phong

Network meeting
Guide to report writing
Finalize how to collect reports
Finalize how to do analysis

Dr. Phong, QMD,
Nursing Department

Training for all staff
Why reporting incidents
How to write report
How to send report

QMD, Nursing
Department, Training
Department

Implementation

QMD

MEETING FOR PLAN IMPLEMENTATION

“To err is human.”
Previous state in Ha Nam Provincial General Hospital:
 Many medical incidents and errors used to occur and repeat in
the hospital.
 Some incidents were hidden.
 Individuals who committed mistakes had to suffer all
consequences.

Changes of perception after the training in NCGM
 IRS helps hospitals to control medical incidents: level, quantity,
proportion, frequency, causes... thereby warnings and solutions
will be provided to minimize potential incidents.

INCIDENT MANAGEMENT BOOK

PS NETWORKEach department: 1-3 persons
Chief of department, head nurse and some dynamic,
enthusiastic members.
Including all departments

INCIDENT ANALYSIS

INCIDENT REPORTING FORM

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 2 | Establishing Incident Reporting System in Hospital

MEDICAL INCIDENT CLASSIFICATIONCURRENT STATE

2- Reporting form and procedures for reporting and handling
reports were designed.

Session 1

1- Benefits of incident reporting were trained to all hospital’score members: the directing board, chiefs and vice chiefs ofdepartments, head nurses (1/6 hospital manpower).

3- An IRS was established in the hospital.

Session 3

LIST OF SERIOUS INCIDENTS THAT MUST BE REPORTED
1) S7 c- do phu thut, th4 thut- Phu thut nhm v* trí trên ng1i b(nh- Phu thut nhm ng1i b(nh- Phu thut sai phng pháp trên ng1i b(nh- Sót gc d3ng c3- T6 vong trong ho"c ngay sau khi phu thut th1ng quy2) S7 c- do môi tr1ng- B* shock do i(n git
- B* b,ng trong khi i%u tr* ti b(nh vi(n- Cháy n. ôxy, bình ga, hóa cht /c hi..
3) S7 c- liên quan t0i chm sóc- Dùng nhm thu-c ( s7 c- liên quan 5 úng)- Nhm nhóm máu ho"c sn phm c4a máu- Sn ph3 chuy&n d ho"c chn thng -i v0i sn ph3 có nguy c thp
- B(nh nhân b* ngã trong th1i gian n!m vi(n- Loét do t è giai on 3-4 và xut hi(n trong khi n!m vi(n- Th3 tinh nhân to nhm tinh trùng ho"c nhm tr5ng- Không ch) *nh xét nghi(m, chn oán hình nh dn $n x6 l không k*p th1i
- H 1ng huy$t- Vàng da 2 tr# trong 28 ngày u- Tai bi$n do tiêm/ch+c dò t4y s-ng
4) S7 c- liên quan t0i qun l ng1i b(nh- Giao nhm tr# s sinh lúc xut vi(n- Ng1i b(nh g"p s7 c- y khoa 2 ngoài c s2 y t$
- Ng1i b(nh ch$t do t7 t6, t7 sát ho"c t7 gây hi5) S7 c- liên quan t0i thu-c và thi$t b*- S6 d3ng thu-c b* nhi'm khun, thi$t b* và cht sinh h+c- S6 d3ng các thi$t b* h,ng/thi$u chính xác trong i%u tr* và chm sóc- "t thi$t b* gây t c mch do không khí6) S7 c- liên quan t0i t/i phm
- Do thy thu-c, NVYT ch4 *nh gây sai phm
- B t cóc ng1i b(nh- Lm d3ng tình d3c -i v0i ng1i b(nh trong c s2 y t$

Session 2

4- Implementation: Very few incident reports, mainly
mandatory reports, voluntary reports are rare.

CAUSE ANALYSIS
- Not all hospital staff received trainings and guidance.
 Those who received training changed their perceptions but
have not changed their behaviors.

- The focal points of the system did not work actively.
 Therefore the system does not operate effectively
- There is no staff in charge of PS
- Personnel changes in the Directing Board.

Discussion

- Staff did not report voluntarily, did not understand thebenefits of reporting and were afraid of punishment.

Session 4

REPORTING PROCEDURE
within 72 hours

Levels 3b-5

Membersof PS
within 24 hours network

QMD(PS Council meeting
Analyzing causes
Proposing solutions
Giving feedback)

Very serious or mortality
during normal
working hours

In-charge
vice
directorOn
duty
personOn dutyleaderDirecting Boardon dutyAssign an in-charge staff.
Encourage focal people to work more actively
Actively provide information and trainings and show
effectiveness.
 Protect reporters
 Analyze root causes of reported incidents and generate
warnings so that people see the benefits of reporting.

Session 6

Chief ofdepartmentMake the director pay more attention.

Session 5

Levels 0-3a
Hospital
staff

SOLUTIONS TO MAINTAIN AND DEVELOPTHE SYSTEM

Session 7

OBJECTIVES

Lessons learnt•1-2 incident reports are received every day.

•Establishing an IRS is not difficult.

•Hospital incident book is published.

•Making the system work effectively and bring real benefits
is not simple.
PolicyCultureAnnexPatient safety
Training

EnvironmentThank you very muchPractices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 3 | Improving Compliance to Timing Standard

Improving Compliance to Standard Emergengy
Response Time from 55% to 85% in December 2016

Session 1

Session 3

Session 2

Dr. Pham Viet Thai
Quality Management Department, Ninh Thuan Provincial General Hospital

Session 3

1.

Reason for choosing the topic

3-b. Objective
Improving the timeliness of emergency response
by increasing the rate of staff compliance to standard

workers have the responsibility to examine, diagnose, andemergency response time from 55% to 75% in June 2015

indicate treatment in a timely manner.

and 85% in December 2015.

Besides, according to the criterion A1.4 of the Hospital

4. Cause analysis

Quality Standards, if the hospital’s untimely response to
as death, limb amputation due to necrosis, unrecoverable
injuries...), this criterion is ranked grade 1.

Nurses working in internal medicine departments
did not know how to arrange their work, which caused
delayed specimen collection and transportation.
Some overworking positions due to lack of manpower.

In fact, in the hospital many patients received,TLYNLUJ`SL]LS^HZUV[ZWLJPÄLKZVWHYHJSPUPJHSZ[Hќ

delayed diagnosis and treatment, which caused serious

did not prioritize the work. Specimen collection technique
was not good enough. The regulation on standard

Implementation plan

emergency response time was not comprehended well.

In 2014, the hospital issued regulation on emergency
response time for each step in the emergency response
process. [1]:[Hќ»Z^VYRPUNZWPYP[^HZUV[OPNOLUV\NO5. Action plan
Retraining on the current regulation on standard
emergency response time.

•

Training on specimen collection techniques for nurses.

•;YHPUPUNVU:HSSOVZWP[HS»ZZ[Hќ•

Reviewing personnel, adding nurses for lacking
departments.

admitted in Emergency Department, diagnosed and•Conducting a survey on 300 emergency patients.

transferred to inpatient treatment in Ninh Thuan Provincial•

Reevaluating the compliance to standard emergency
response time.

Results of the survey of 600 medical records about•

Analyzing root causes of non-compliance.

emergency response time in the first 24 hours in the•

Setting objectives and making action plans tocontinue improvement.

•

Reevaluating the compliance to standard emergency
response time.

Checking, monitoring and evaluation of complianceto the timing regulation are conducted monthly andunannounced.

3-a.

Current state

A survey was conducted on patients who were

General Hospital from 4/2015 to 9/2015.

hospital in 2015 show that compliance to the standard
time was only at 55%.

Annex

•

Session 7

Adjusting timing standard for emergency steps.

Session 6•:[Hќ^LYLN\PKLK[VMVSSV^[OL[PTPUNYLN\SH[PVU

Session 5

consequences.

2.

Session 4

emergency patients causes serious consequences (suchDiscussion

The Vietnam Law of Medical Examination andTreatment (Article 55) states clearly that healthcare[1] Ninh Thuan Provincial General Hospital (2014). “Procedure for emergency response”.

The Vietnam Forum on Quality Management and Patient Safety
on January 19th to 21st, 2016.

Dr. Pham Viet Thai, MD.
Chief of Quality Management Department
Ninh Thuan Provincial General Hospital
qlcl.bvninhthuan@gmail.com

2%

15% unsatisfied patients

P

D

A

C

P

D

A

C

10%
P

D

A

C

12/2016

Handwashing

Enhancing timeliness in emergency
response by improving compliance tostandard emergency response timefrom 55% to 85% in December 2016 

CONTINUOUS IMPROVEMENT
Goal: improving patientsatisfaction in Pediatrics
Department

6/2016

11/201502 PDCA cycles

CONTINUOUS IMPROVEMENTOVERVIEW OF NINH THUAN PROVINCIAL
GENERAL HOSPITAL

An example of improvement activity in
Ninh Thuan Provincial General Hospitalin 2016.

85%75%• 2nd level hospital

Goal: staff’s complianceto handwashing in 2016

• Planned beds: 650• Actual beds: 868

55%+ 8 functional
departments+ 7 para-clinicaldepartments+ 17 clinicaldepartments• Staff: 756

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12/2016

6/2016

11/201502 PDCA cycle

The Vietnam Forum on Quality Management and Patient Safety
on January 19th to 21st, 2016.

- QMD was established in December 2013.
- Currently there are 06 staff:+ 01 doctor+ 01 nurse+ 02 secondary pharmacists+ 01 bachelor in hospital management+ 01 bachelor in information system management •

ENHANCING TIMELINESS IN
EMERGENCY RESPONSE BY IMPROVINGCOMPLIANCE TO STANDARD
EMERGENCY RESPONSE TIME FROM 55%
TO 85% IN DECEMBER 2016

Analyzing root causes of non-compliance.

CURRENT STATEDID YOUR HOSPITAL ISSUE REGULATION ON
EMERGENCY RESPONSE TIME?

General satisfaction to provincial hospitalObjective by2016• When reviewing deaths due to late emergency
response, e.g., the nurse forgot to get head CT
scan result after the doctor indicates thisexamination to check subdural hematoma for
emergency operation.

“Very satisfied”
and “Satisfied” >80%• What is timely emergency response?

46%
Not satisfied
14%

Very satisfied
12%

Satisfied
34%
Acceptable
40%

Result of satisfaction survey in OPD in 2015, n=1,350

• Is it necessary to regulate emergency response
time?

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Th c hin r a tay• 32 departments:

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PA

Session 3 | Improving Compliance to Timing Standard

LITERATURE REVIEW

1. Reasons for choosing the topic

In fact, in the hospital many patients received delayed
diagnosis and treatment, which caused serious consequences [3].

Para-clinicaldepartments• Tests,functional
examination(FE),
diagnostic
imaging (DI)Doctors, nurses
First diagnosis,
diagnostic
classification• Check results• Report to doctor• Doctor writes abnormal
results in record.
• Diagnostic consultation
if necessary• Final diagnosis

Additional
interventions• Proper,
timely• Follow-up
patient

 

 

Final
diagnosis

Specimen collection
and transportation

105 minutes - urgent
215 minutes – semi-urgent
310 minutes – non-urgent

Literature review
Examination and treatment procedure [5]Discussion

Article 2. General requirements
1. Emergency response, intensive care and poison control
are very important tasks. 115 emergency units andhealthcare institutes must organize emergency response,
intensive care and poison control timely in every case.

Session 3

EMERGENCY RESPONSE, INTENSIVE CARE AND POISON CONTROL(Issued with Decision No. 01/2008/QD-BYT dated 21/01/2008
by the Minister of Health)Session 2

According to the criterion A1.4 of the Hospital Quality
Standards, if the hospital’s untimely response to emergency
patients causes serious consequences (such as death, limb
amputation due to necrosis, unrecoverable injuries...), thiscriterion is ranked grade 1 [4].

55 minutes – emergency• Clinical examination• First diagnosis,
diagnostic
classification• Identifying
emergency level• Indication of paraclinical tests• Initial response• Collecting specimen• Sending patient toultrasound, X-ray…

Session 1

The Vietnam Law of Medical Examination and Treatment(Article 55) states clearly that healthcare workers have theresponsibility to examine, diagnose, and indicate treatment in atimely manner [2].

EMERGENCY PROCEDURE

However, the Decision does not specify time for eachstep in the emergency procedure.

Session 4

2. Implementation plan- Staff were guided to follow the timing regulation.
- Checking, monitoring and evaluation of compliance tothe timing regulation are conducted monthly andunannounced.

Annex• Semi-urgent: Total time for emergency response insemi-urgent cases, including specimen collection,
01 FE technique and 01 DI technique, is maximum
230 minutes without operation, 260 minutes with
operation.
• Non-urgent: Total time for emergency response inurgent cases, including specimen collection, 01 FE
technique and 01 DI technique, is maximum 310
minutes without operation, 370 minutes with
operation.

Session 7

Literature review
Hospital’s regulation on time for each step inthe emergency procedure

Session 6

LITERATURE REVIEWDIAGRAM ILLUSTRATING THE DIAGNOSTIC AND THEURAPEUTIC LOOPSIN THE DIAGNOSTIC PROCESS• Emergency: Total time for emergency response inemergency cases, including specimen collection, 01
FE technique and 01 DI technique, is maximum 55
minutes without operation, 60 minutes with
operation.
• Urgent: Total time for emergency response inurgent cases, including specimen collection, 01 FE
technique and 01 DI technique, is maximum 105
minutes without operation, 120 minutes with
operation.

Session 5- In 2014, the hospital issued regulation on emergency
response time for each step in the emergency
procedure [1].

Literature review
Hospital’s regulation on time for each step inthe emergency procedureLiterature review
What is non-compliance to emergency response timestandard:
Non-compliance of emergency response timestandard is when there are any cases in which
emergency response within the first 24 hours does notcomply to the timing regulation.

3a. Current state
A survey was conducted on patients who were admitted in
Emergency Department, diagnosed and transferred to inpatient
treatment in Ninh Thuan Provincial General Hospital from4/2015 to 9/2015.
Results of the survey of 600 medical records about
emergency response time in the first 24 hours in the hospital in2015 show that
Incompliance to emergency response time standards accounts for 45%.

Literature review
Time standards in the emergency procedure- Time for doctor to examine and initially handle since receiving
patient, calculated based on the time in medical record, is maximum
20 minutes for level 4;- Time for laboratory tests, calculated based on the time in the result
paper attached with the medical record:+ Time for nurse to collect and send specimen since doctor gives
indication is maximum 50 minutes for level 4;+ Time for test turnaround since specimen is received is maximum
180 minutes for level 4;+ Time for nurse to check test results and inform doctor to write
down abnormal results that affect diagnosis, is maximum 30 minutes
for level 4;+ Time for doctor to intervene after receiving test results is
maximum 30 minutes without operation, 90 minutes with operation
for level 4.

3a. Current state
Among the results:- For emergency patients in servere state that need quick
emergency response (emergency levels 1, 2): incompliance rate
regarding this group was very high (89.2%).
- Internal medicine departments (ICU, 02 internal medicine
departments and Pediatrics Department) had incompliance rates
of 67%.
- Average time for FE turnaround: 418.3 minutes; DI turnaround:327.4 minutes; which were much longer than in the regulation.

Literature review
Time standards in the emergency procedure- Time for FE, ultrasound, endoscopy, ECG, calculated
based on the time in the result paper attached with the
medical record:+ Time for nurse to transfer patient to FE or arrange
bedside ultrasound, calculated since doctor gives
indication, is maximum 60 minutes for level 4;+ Time for FE turnaround since request or patient isreceived is maximum 90 minutes for level 4.

3a. Current state
Among the results:- Specimen collection and transportation account for 70%.
- Patients above 60 years old account for 76.1%.
- Most patients were hospitalized out of normal working time
(77.5%) but the incompliance rates towards patients received
during and out of normal working time are not statisticallysignificant. Which means incompliance tends to associate withstaff’s discipline rather than the number of healthcare workers, orthere may be something wrong in work division during normal
working hour.

3b. Objectives

Literature review

85%- Time for DI, X-ray, CT, MRI, calculated based on the time in the
result paper attached with the medical record:+ Time for nurse to transport patient to DI or arranged bedside X-ray,calculated since doctor finishes examination, is maximum 60
minutes for level 4;+ Time for DI turnaround since request or patient is received is
maximum 90 minutes for level 4.
- Time for nurse to report results to doctor and doctor to intervene
after receiving FE and DI results, calculated based on the time in the
medical record, is maximum 30 minutes without operation, 90
minutes with operation for level 4.

55%

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11/2015 Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

P

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P

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S

12/2016

Compliance to standard emergency response time

75%

Time standards in the emergency procedureSession 3 | Improving Compliance to Timing Standard

4. Causes of incompliance to standard
emergency response time
Lack of manpowerin some departments

The regulation on
standard emergency
response time was
not comprehended
wellSpecimen collection
technique was notgood enoughStaff’s working
spirit was not highenoughActivities

Review manpower, adding nurses for M a n p o w e r 01/2016
lacking departments
Development
Council6

Conducting a survey on 300 emergency QMD
patients

7

Reevaluating the compliance to standard
QMD
6/2016emergency response time.
IT Department
Analyzing root causes of non-compliance.

8

Setting objectives and making action plans Dr. Thai
to continue improvement.

9

Reevaluating the compliance to standard
QMD
12/2016
emergency response time.
IT Department
Analyzing root causes of non-compliance.

Implem
ented

03-06

7/2016

Session 3

06 BASIC ISSUES MAKING PATIENTS SATISFIEDSURVEY DESIGN
Target of study: Inpatients in Ninh Thuan Provincial General
Hospital from March to October 2016.

Healthier and happier patients
Staff satisfaction

Time

5

Prof. Dr. HANDA Yujiro, Japan

Moral
MoraleResponsibility

Session 2

Emergency level was
not specified so
para-clinical staff did
not prioritize thework

5. Action planNo.

Session 1

Nurses working ininternal medicine
departments did notknow how to arrange
their workStudy method: Descriptive, cross sectional study with analysis

Service manner, attitude, morale

5

Resources, equipment, consumable materials, methods

Continuous improvement to reduce waste and overload



Sample size: Calculated by the formula:=Z2(1 - /2) p (1 – p)d2

Of which:  = 0.05 : confidence interval 95%, Z(1-/2) = 1.96
d: acceptable error (desired precision) is 4%  d = 0.04

Standardization and output control
Teamwork Improved working environment 

1Discussion

Productivity, quality, price, distribution, safety and ethics

p = 0.85 : compliance rate to standard timing
From the above formula, n # 300

Session 4

Objective: 85% of healthcare workers comply to emergency
response time standard

Training to change service manner and attitude to
improve hospital staff’s working spirit
Retraining on the current regulation on emergency response time.
Training on specimen collection technique and 5S for staff.

Improve working environment: implement 5S

Session 7

5. Action plan
No.

1

2

4

Responsibility

Time

Adjusting the regulation on time S c i e n t i f i c 2/2015
standard for each step in the Council
emergency procedure
02/2016Retraining on the hospital’s Dr. Thai
regulation on standard emergency
response time
Training on specimen collection N u r s i n g 2/2015
techniques for nurses
Department,
Laboratory
Training on 5S knowledge for staff 5
S 0 1 Committee 02/2016

Implemented

THANK YOU FOR YOUR ATTENTION

Annex

3

Activities

Session 6

Re-standardize the emergency response procedure[1] Ninh Thuan Provincial General Hospital (2014). “Procedure for
emergency response”.
[2] Vietnam Law on Medical Examination and Treatment – No.
40/2009/QH12.
[3] Archive of minutes/reports of technical reviews and medical
record reviews in Ninh Thuan Provincial General Hospital in 2014.
[4] Hospital Quality Standards (Issued with Decision no. 4858/QDBYT dated 03 December 2013 by the Minister of Health).
[5] Satid Thammasitboon, MD,
Supat Thammasitboon, MD,
Geeta Singhal, MD. System-Related Factors Contributing toDiagnostic Errors. Curr Probl Pediatr Adolesc Health Care. 2013 Oct;43(9):242-7. doi: 10.1016/j.cppeds.2013.07.004. Review. Erratum in:Curr Probl Pediatr Adolesc Health Care. 2014 Feb;44(2):52. PMID:
24070581.

Session 5

Review manpower, adding nurses forlacking departments

REFERENCES

08/8/201432



A Topic from Japan
Eight Core Values in Quality Managementin Japan
Shinsuke Murai
Bureau of International Health Cooperation, NCGM, Japan

Japanese products are known by their quality in

how to provide best services to doctors and nurses in

the world. In industry, service and healthcare sectors,

the hospital.” (5) “Quality must be built in process” says

Japanese people share core values in QM. Yamanotethat the services provided to patients are accumulated

Subway and Udon noodle restaurant work with the same

results of a series of inter-related activities in the hospital.

core values in their management of quality and services.

What we need to improve is not result but the process

These core values are the principles of QM.

that produced bad results. (6) “Management by facts” orThere are eight typical core values in Japan. (1)¸8\HSP[`ÄYZ[¹TLHUZ[OH[V\Y[VW^VYRNVHSPZ[VWYV]PKL
quality services. (2) “Customer oriented” means using
customers’ expectations to set objectives for service
quality. Customers’ demands are reflected in yourservices. However, in hospitals we also need to consider
quality of clinical work, of which objectives are frommedical knowledge. (3) “Vital few (prioritization)” implies
H JVUJLU[YH[PVUVU[OLML^[OH[HќLJ[T\JOX\HSP[` >Lcannot work for everything. For example, importance
HUK\YNLUJ`HYLKPќLYLU[TH[[LYZ¸;OLUL_[WYVJLZZ
is also your customer” means that staff in your hospitalare also customers. For example, staff in charge of
medical equipment and materials need to think about

Vietnam Forum on Quality Management
and Patient Safety 2016


“Talk with facts (data)” means that our decisions should
not rely only on our intuition, experience and braveness22+I\[ZOV\SKHSZVYLS`VUMHJ[Z[OH[HYLJVUÄYTHISL
Facts are easy to share among team members. (7)“Failures are a treasure land (learn from failures)” meansthat failure analysis is for prevention of repeating the same
failure in another day. To promote “learning from failure”, alearning culture should be fostered in your organization. (8)“Respect for humanity (participatory QI)” says that nobody
is born a bad person. We trust and rely on people.
Teamwork will enhance your QI capability, as you involve
WLVWSL^P[OKPќLYLU[YLZWVUZPIPSP[PLZPU[OLWYVJLZZMost of these eight core values are not new toVietnam. Core values exist in our culture and daily life.

Bach Mai Hospital 20-21/01/2016

Eight core values inquality managementin Japan
Program for International Promotion of Japan’s Healthcare Technologies and Services
Strengthening Healthcare Staff’s Capability of Quality Management in Healthcare in Viet Nam

Dr. MURAI Shinsuke
National Center for Global Health and Medicine
Tel: +81-3-3202-7181

Core values of
KAIZEN(Quality improvement)

E-mail: s-murai@it.ncgm.go.jp


Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

A Topic from Japan

Session 1

Core value 2

Core value 1

Quality first

Customer oriented

We work for Quality
Money comes after that “Customer isGod”
Session 2

Saying in Japanese industry

Session 3
Discussion

9$(,!,'

Session 4
Session 5

Are you customer?

Do you know what customers want?

Session 6
Session 7

To think of “Quality”
is to think of “Objectives”(Naruo UEHARA, 1993)

Definitions of Quality

9><=A$(,!,'Annex• Quality is the element of something that guarantees
achievement of objectives or expected outcomes• Quality is measured by the degree of achievementof objectives


9$(,!,'><=A

 



Core value 3:

Core value 4:

Vital fewThe next process is stillcustomerActivity

Activity

Prioritized
activity

Activity

Activity

Doctor

Pharmacist

Nurse

Patient

Error inindication

Requestwrong drug

Wrong drug

Patient takes
wrong drug

Engineer

DoctorDoctorPatientRarely takecare ofmedicalequipmentRequestexamination

Machinedoesn’t work

Patient is
notexamined

UrgentCore value 5:





!



Quality must be built in the process• The number of defects isn’t going down! What’s
going wrong?
• Although we’ve given strict orders of the goal tobe achieved, we still can’t achieve our targets!
• I’ve told them again and again to follow the safety
procedures, but they still commit accidents!

Important-""#$/'"6 74 #&'%-#$)&").4 $ $)'$*%$"%',#%$H)"KJ$$).$ ")'4#$'4><=A4&)#'>D4

Quality is built in process

People tend to concentrate exclusively on the result.
OutputInput
Process
(way of work)

Bad results!
$

People forget about the process that produced the bad result.
Hosotani, K. 1989

9><=A$(,!,'

'%-%() 1,''. 4 ")'),3 '$$'%#)%'#&'%-#$)4$'$(%13 %((.5((2><==1=B4

©Shinsuke Murai

Wrong design (way of work) will cause bad result

!
$

“The Design of Everyday Things” (2002)
9><=A$(,!,'

9><=A$(,!,'Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1A Topic from Japan

Core value 6:

Core value 8:

BeforeKanKeiken

Dokyo

Experience

Your responsibility

Braveness

Talk to facts+
Others’responsibilities

Can tackle bigger
problems

Participatory quality improvementEight core values in quality management inJapan

Discussion

1. Quality culture (Quality first)
2. Customer-oriented (From manufacturing – to market)
3. Vital few (Prioritization)
4. The next process is still customer(Way of thinking)1. Management by facts (Fact-based decision making)
2. Respect humanity (Participation)
3. Quality must be built in the process (System thinking)
4. Errors (defects) are treasure (improvement
opportunities)

Session 3

Asakusa temple has lanterns
Asakusa temple is beautifulSession 2

KKD (""
$
Later
Intuition

Respect humanity

Session 1

Management by facts

Session 4

Core value 7:

Core values are easy to talk about but
difficult to implementProblems

But not impossible,

Session 5

Errors are treasure=

As we see efforts in this forum

Session 6

Improvement opportunities

Respect humanity

Your responsibility

Eight

八

Wide

Annex

Can tackle small
problems

Narrow

Session 7

Core value 8:Session 4
Plan to Improve Management and Medical Safety
in Prescription for Outpatients
Tran Quang Hien
An Giang Hospital of Obstetrics, Gynecology and Pediatrics

1.

Reason for choosing the topic
Our provincial general hospital receives about 1,000

outpatient visits a day. A study shows that on average
there were about 60 inappropriate prescriptions out of

4. Solutions
4.1. Personnel:- Training and updating treatment protocols

120 randomly selected prescriptions, accounting for- Reinforcing prescription check by pharmacists

about 50% of prescriptions that didn’t follow treatment(double check)

protocols, such as wrong dose, interacting drugs,

4.2. Machine:

wrong indication and unnecessary drugs… This may
HќLJ[WH[PLU[»ZOLHS[OPUJYLHZLTLKPJHSJVZ[ZHUKJH\ZL
medical errors if there are no interventions.

2.

Objective
Inappropriate prescriptions in OPD are reduced by- Employing a prescription software that can checkdrug interactions.
4.3. Procedure:- Issuing standard operation procedure (SOP)

50% from 2nd quarter of 2015.

- SOP for prescription check and monitoring

3.

4.4. Environment:

Identifying causes of errors in prescription- Implementing 5S
4.5. Measurement:- Developing reporting and statistics system
4.6. Policy:- Developing pharmaceutical manual- Issuing planPractices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 4 | Improving Service Quality in OPD

5.

Division of work

7. Achieved results

AugustSeptember

OctoberNovember

Total outpatientturns

40,17336,65836,78941,031

38,526

22,81020,931

20,46022,004

20,864

57

80

93

73

83

Outpatient turns
in internal
medicine
Compliance rates
to treatment
protocols (%)

Month

ABC/VEN analysis and outpatient prescription review

Session 2

July

Session 1

Compliance rates
to treatment
protocolsfrom July 2015 to present:
Results:

Implementation+ The number of prescriptions with mistakes reduced

1.

25% on average.

Issuing policy- The directing board issued implementation plan;- The director issued documents on updating and+ Outpatient prescription indicator: decreased from 6.2
to 2.75.
+ Drugs cost reduced from 72% (2013) to 62% (2015)

hospital’s disease pattern, MOH’s documents and+ Antibiotics cost: reduced from 60 billion (2013) to 39

evidence based medicine (EBM);

billion (2015).

Applying information technology

Discussion

developing new treatment protocols based on the2.

Session 3

6.

- Hsoft, which can check drug interactions for OPD,

3.

Session 4

has been employed
Implementing 5S- Drug stores and pharmacies have been arranged
following 5S.
Developing reporting system:

PRESENTATION
PLAN TO IMPROVEMANAGEMENT AND MEDICAL SAFETYIN DISPENSING DRUGS TO PATIENTSIN OUTPATIENT DEPARTMENT

5.

Training, checking, monitoring

After the plan was issued, QMD have been
conducting trainings, monitoring quality indicators,
and monitoring implementation.

Annex- Our provincial general hospital receives about
1,000 outpatient visits a day. A study shows that on
average there were about 60 inappropriateprescriptions out of 120 randomly selectedprescriptions, accounting for about 50% ofprescriptions that didn’t follow treatment protocols,such as wrong dose, interacting drugs, wrong
indication and unnecessary drugs…
- This may affect patient’s health, increase medical
costs and cause medical errors if there are nointerventions.

Session 7

I. NECESSITY

Session 6

Dr. Tran Quang Hien, MD., PhD.
Director of An Giang Hospital of Obstetrics,
Gynecology and Pediatrics

Session 54.

II. OBJECTIVE

IV. SOLUTIONS (3)Inappropriate prescriptions in OPD are reduced by
50% from 2nd quarter of 2015.

5. Measurement:- Developing reporting and statistics system
6. Policy:- Developing pharmaceutical manual- Issuing plan

III. CAUSE IDENTIFICATION

V. WORK DIVISION AND PROGRESS

Ishikawa (Word)

VI. Implementation
IV. SOLUTIONS

A. Issuing policy

1. Personnel:- Training and updating treatment protocols- Reinforcing prescription check by pharmacists(double check)
2. Machine:- Employing a prescription software that can checkdrug interactions.

B. Developing protocols and SOPs
IV. SOLUTIONS (2)3. Procedure:- Issuing standard operation procedure (SOP)- SOP for prescription check and monitoring
4. Environment:- Implementing 5SPractices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 4 | Improving Service Quality in OPD

C. Prescription software

G. ABC/VEN analysis

Session 1
Session 2
Session 3

D. Implementing 5S

Discussion
Session 4

E. Developing reporting system
Session 5
Session 6
Session 7

F. Training and checking

Annex


H. Results
MonthCompliance rates totreatment protocols

July

AugustSeptemb
October
er

November

Total outpatient turns

40,17336,65836,78941,031

38,526

Outpatient turns ininternal medicine

22,81020,931

20,46022,004

20,864Compliance rates totreatment protocols
(%)

57

80

93

73

83

H. Results
ABC/VEN analysis and outpatient prescription review from
July 2015 to present:
Results:+ The number of prescriptions with mistakes reduced 25%
on average.
+ Outpatient prescription indicator: decreased from 6.2 to
2.75.
+ Drugs cost reduced from 72% (2013) to 62% (2015)+ Antibiotics cost: reduced from 60 billion (2013) to 39
billion (2015).

THANK YOU

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 5 | 5S

Session 1

Session 5-1
5S Implementation in Two Departments
in Ninh Binh Provincial General Hospital

Session 2(NEPHRO-UROLOGICAL SURGERY AND ENDOCRINOLOGY DEPARTMENTS)
Vu Thuy Giang
Quality Management Department, Ninh Binh Provincial General Hospital

Session 3

1.

Reason for choosing the topic
The hospital expects to improve quality throughenvironment to contribute to enhance the spirit andworking manner of medical staff and to build a good

points in 5S score.

4. 5S implementation plan
December 2015
- QMD makes and submit the plan to the directingof 5S in two departments, it will be expanded to allboard for approval.

departments.

- Establish 5S Steering Committee and task force

2.

- QMD develops a 5S checklist and guidelines forState before implementation- The number of patients and patient family members who

implementation.

take care of the patients is large, the workload of medical- Evaluating current state

staff is huge, leading to disordered work environment,

From January to March 2016

The arrangement is not logical enough, causing healthcare- Week 1: Guiding the two departments to implement^VYRLYZZWLUKTVYL[PTL[VÄUKULJLZZHY`[OPUNZMVY[OLPY

5S

work.

- Week 2 to week 10: The task force evaluates using
the 5S checklist twice a week and gives advice to 5S

the QMD):

implementation.

Nephro-Urological Surgery Department: 54/100 points
Endocrinology Department: 48/100 points

3.

Objective- Week 11 and 12: Summarizing the results of 5S
implementation in the two departments, reporting to

Session 6- 5S evaluation scores (using the checklist developed by

Session 5

redundancy of items not handled and untidy workplaces.

Session 4

image for the hospital. After successful implementation

Discussion

developing a logical, convenient and effective working

March 2016, the two departments achieve more than 80

the Steering Committee to generate lessons leant andAfter 3 months of implementation, from January to

direction for expansion in the entire hospital.

5S IMPLEMENTATION
LE
EME
MEN
NT
IN TWO DEPARTMENTS IN
NINH BINH PROVINCIAL GENERAL HOSPITAL*Planned beds: 600*Actual beds: 1,007

Organization*37 departments+ 09 functional
departments+ 06 para-clinicaldepartments+ 22 clinicaldepartments*715 staff

Personnel*Doctors: 172*Pharmacists: 46*Nurses: 339*Technicians: 34*Other staff: 124

Annex

Dr. Vu Thuy Giang, MD, MSc
Chief of Quality Management Department

Norm

Session 7

FEATURES OF
NINH BINH PROVINCIAL GENERAL HOSPITAL

Ninh Binh Provincial General HospitalINTRODUCTION OF QMDActual state before implementation

QMD was established in November 2014 with 10 staff,
including:-2 first degree specialists-1 master of pharmacy-1 master of IT-1 environmental technology engineer-1 college nurse- The number of patients and patient family members who take care of thepatients is large, the workload of medical staff is huge, leading todisordered work environment, redundancy of items not handled anduntidy workplaces. The arrangement is not logical enough, causing
healthcare workers spend more time to find necessary things for theirwork.
- 5S evaluation scores (using the checklist developed by the QMD):
Nephro-Urological Surgery Department: 54/100 points
Endocrinology Department: 48/100 points-2 secondary nurses-2 other staff

CONTINUOUS QUALITY IMPROVEMENT (CQI)

2. Enhance QM capability
for hospital staff

3. Develop newtechniques to improve
quality of treatment

1. Employ Hospital
Quality Standards

Objectives
8. Patient safety

7. Improve working
environment (workplace) following 5S

Patient-centered

4. Improve instruction
system for patients

After 3 months of implementation, from January to March 2016, thetwo departments achieve more than 80 points in 5S score.

6. Change working spirit
and manner
5. Enhance the hospital’s
trademark





5S implementation plan

Masterplan

4. Pilot in 2
departments

5S

2. PlanDecember 2015
- QMD makes and submit the plan to the directing board forapproval.
- Establish 5S Steering Committee and task force- QMD develops a 5S checklist and guidelines for implementation.
- Evaluating current state3.
Instruction

Reasons for choosing the topic
The hospital expects to improve quality through developing a
logical, convenient and effective working environment tocontribute to enhance the spirit and working manner of medical
staff and to build a good image for the hospital. After successful
implementation of 5S in two departments, it will be expanded to
all departments.



5S implementation plan
From January to March 2016
- Week 1: Guiding the two departments to implement 5S- Week 2 to week 10: The task force evaluates using the 5S checklist
twice a week and gives advice to 5S implementation.
- Week 11 and 12: Summarizing the results of 5S implementation in
the two departments, reporting to the Steering Committee togenerate lessons leant and direction for expansion in the entire
hospital.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 5 | 5S

After

Before

Session 1

Pilot implementation in two departments and compare between
before and after implementation 

5S guidelines

Session 2

After

Total

Evaluator:

score:

Date of evaluation:

Session 3

Before5S evaluation checklist
Department:

Score
Place

#

Item

Evaluation contents
1 234 5

1

Desks/Chairs

Are they clean and tidy?

2

Cabinets

Are they clean and labelled clearly?

Medical records, X-ray films, notebooks,
documents, stationary

Are they clean, stored and placed logically?

Discussion

3

Computers, printers, telephones, wire, cable

Admini4

strative

wire and other equipment

Are they clean, tidy, suitable and well-maintained?

room

5

Lamps, air-conditioners, fans

Are they clean, safe and arranged appropriately? Do they work?

6

Walls, windows, floor, ceiling

Are they clean and well-maintained?

Information boards and papers attached to the7

Are they clean, arranged appropriately and updated?

wall

8

Beds (blanket, bed sheet, pillow)

Are they clean and tidy?

9

Bedside cabinets

Are they clean and tidy?

Wards

Session 4

Place

Items #
10

Medical equipment

Contents of evaluation 
Are they clean, tidy and in good condition?
Are they clean, safe and arranged appropriately? Do they

Score 1 2 3 4 5    

Walls, windows, floor, ceiling

Are they clean and well-maintained?

    

13

Injection trolleys

Are they clean and organized tidily and logically?

    

Drug cabinets

Are they clean, labelled for classification?

    

Cabinets and shelves

Are they clean, labelled for classification?

    

Are they clean, tidy and in good condition?

    

Medical equipment
Lamps, air-conditioners, fansWalls, windows, floor, ceiling

19

Organizing

20

Redundant, broken, unused things

Wards

Are they clean, safe and arranged appropriately? Do theywork?
Are they clean and well-maintained?
Are things in the storage organized logically, easy to find andeasy to get?
Are they separated, arranged logically and labelled red
following the regulation?

Session 6

* 5S is a new concept and not well known, which came to Vietnam 10
years ago but not many healthcare facilities have applied it. Therefore
it is difficult to explain and convince people to implement.
* Compliance and working manner is not so good at working places,
which is difficult to change in a short time
* Staff have not received systematic trainings, detailed instructions
and consultancy from experts.
* Limited budget to improve the working environment (work place)

Session 5

Lamps, air-conditioners, fans

1214
Injection and15
proced16
ureroom

Difficulties and challenges inimplementing 5S program    

Wards 11

work?

        

Proposed solutions

Annex•Increasing 5S knowledge :- Conducting training courses- Giving direct instructions in departments- Providing 5S materials and pictures•Organizing contests of 5S implementation•Strengthening 5S monitoring in departments

Session 7

Evaluation of actual state and images before implementation





Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 5 | 5S

5S Implementation in Ha Dong General Hospital

Session 1

Session 5-2

Session 2

Nguyen Thi Huong Lien
Quality Management Department, Ha Dong General Hospital

Session 3

1.

Reason for choosing the topic
At present, departments in our hospital (including

Responsibilities: developing and implementing a
5S program in the three laboratories.
2.2. Studying actual state of the three laboratories

unused things are not placed in order. Therefore, to ensure(with taking pictures):effective work and comfortable working environment, I
decide to implement 5S in three laboratories: Hematology–- Facility:- Human resource:

December 2015 to May 2016 (6 months).

- Working environment and condition:

2.

Implementation plan

Time: 01/2016

Time: 12/2015

2.3. Training on 5S for the Steering Committee and all

2.1. Establishing a 5S Steering Committee includingZ[HќVM[OL[OYLLSHIVYH[VYPLZ

17 members.

2.4. Implementing 5S: under current condition.

Pharmacy Department, Infection Control Department
are members.

3. Objective
To develop a habit of applying 5S in the threelaboratories.

Session 5

The director or a vice director is the chairman,
chiefs of functional departments, 3 laboratories,

Session 4

Blood Transfusion, Biochemistry, and Microbiology from

Discussion

three laboratories) are not arranged in tidy manner, many

Session 6

5S IMPLEMENTATION IN
HA DONG GENERALHOSPITAL 1st level hospital under Hanoi Department of Health.

Session 7

INTRODUCTION OF
HA DONG GENERAL HOSPITAL

 570 beds. 700 outpatients/day. 670 inpatients/day.
 39 departments: 09 functional departments, 20 clinicaldepartments, 10 para-clinical departments

Nguyen Thi Huong Lien
Chief of Quality Management Departmente-mail: huonglienhhtm@gmail.com

masters; 40 doctors and pharmacists who are first degree
specialists; 69 doctors; 337 nurses, midwives andAnnex There are 647 staff (19 PhDs & 2nd degree specialists; 28

technicians).

QM System

Reasons for choosing the topic• QM unit:
5S can improve the mood, improve working condition andJuly 2014

atmosphere, and complete the working environment.
- 5S is an improvement method that is simple, easy tounderstand, easy to implement, not costly but very
effective in mobilizing manpower; increasing productivity,
quality and effectiveness; and reduce waste.

QM System
QM Council: 22 people, including chiefs ofActual state before implementing 5S- As a satellite hospital of Bach Mai hospital: 12

departments were implementing ISO.

departments and some clinical departments.
QM Network: 1 staff/department

A QI plan has been developed andimplemented.

- The hospital was employing MOH’s HQS.

=> Since October 2015: there have been remarkablechanges.
Actual state of hospital Quarterly evaluation of the quality of departments in2015 using MOH’s “Hospital Quality Standards”
 QM monitoring activities are integrated with regularmonitoring activities of the hospital every Wednesday
afternoon.

Reasons for choosing the topic

Hospital has been
implementing “Hygienic hospital”
and hanging hygiene slogans indepartments.
- The hospital director requests
departments to actively implement
5S.
- The hospital established a steeringcommittee to liquidate broken orunused properties.


Actual state in three laboratories- Departments in our hospital (including three laboratories)- Facility: narrow rooms, lack of computers and printers, noare not arranged in tidy manner, many unused things are
not placed in order.

- Manpower: not well aware of organizing and arrangement- To ensure effective work and comfortable working

environment, it needs to implement 5S in threelaboratories: Hematology–Blood Transfusion,
Biochemistry, and Microbiology from December 2015 to
May 2016 (6 months). After that, it should be expanded to
the whole hospital.

-cabinets nor shelves for documents, procedures, etc.
in rooms, not recognize benefits of 5S implementation;shortage of manpower so they have to cover different jobs.
- Environment: Untidy and illogical arrangement; many
unnecessary things in the working space.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 5 | 5S

Actual state of 5S implementation in the hospital
Waiting area for patient family

To develop a habit of applying 5S in the three laboratories:

Session 1

3. Objective

Hematology-Blood Transfusion, Biochemistry,
Microbiology Departments.

Session 2

4. 5S implementation plan

Session 3

Actual state of hospital
Setting up centralized linen storage- In December 2015:

Discussion+ Establishing a 5S Steering Committee including the director
or a vice director as the chairman, chiefs of departments (3laboratories) are members.
Responsibilities: developing and implementing a 5S programin the three laboratories.
+ Studying actual state of the three laboratories (with taking
pictures): Facility
 Human resource Working environment and condition

Session 4- January to March 2016:

Session 6

Actual state of hospital

Session 7

Actual state of 5S implementationin the hospital

Actual state of hospital
Session 5+                  .
+ Implement 5S in the 3 laboratories:
Under current condition: facility, equipment+ Monitoring – evaluation:
Internal evaluation group Report- May 2016:+ Evaluation. Fixing problems.
+ Revise the procedure if it is not appropriate+ Maintain 5S activities

Annex





Actual state of 5S implementation in
3 laboratories

Actual state of Hematology –Blood Transfusion Department

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 5 | 5S

Actual state of Hematology –Blood Transfusion Department

Actual state of 5S in Hematology –Blood Transfusion Department

Session 2

Actual state of 5S in Hematology –Blood Transfusion Department

Session 1

Actual state of Hematology –Blood Transfusion Department

Session 3
Discussion
Session 4

Actual state of Hematology –Blood Transfusion Department

Actual state of 5S in Hematology –Blood Transfusion Department

Session 5
Session 6

Actual state of 5S in Hematology –Blood Transfusion Department

Session 7

Actual state of Hematology –Blood Transfusion Department

Annex


Actual state of 5S in Hematology –Blood Transfusion Department

Actual state of 5S in
Microbiology Department

Actual state of 5S in
Microbiology Department

Actual state of 5S in
Microbiology Department

Actual state of 5S in
Microbiology Department

Actual state of 5S in
Microbiology Department



Actual state of 5S in
Microbiology Department

Actual state of 5S in
Microbiology Department

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 5 | 5S

Actual state of 5S in
Microbiology Department

Actual state of 5S in
Biochemistry Department

Session 2

Actual state of 5S in
Biochemistry Department

Session 1

Actual state of 5S in
Microbiology Department

Session 3
Discussion
Session 4

Actual state of 5S in
Microbiology Department
Session 5
Session 6

THANK YOU!

Session 7

Actual state of 5S in
Biochemistry Department

Annex


Session 5-3
Plan for Implementing 5S in Thai Binh Provincial
General HospitalTran Thi Quynh Anh
Quality Management Department, Thai Binh Provincial General Hospital

1.

Reason for choosing the topic- Implementation in other departments

To create a logical and comfortable working- Duration: 03 months, from 01 September 2016 to

LU]PYVUTLU[MVYOVZWP[HS»ZZ[HќHUK[VJYLH[LHJSLHUHUK
safe environment for examination, caring and treatment
for patients is very important to our hospital’s quality.

2.

Actual state before 5S implementation- Departments were not clean and tidy.

30 November 2016
4.2. Activities:

STT

Time

Activities- Evaluate actual state of1

Week 1

departments- Take pictures2

Week 2- 5S training

3

Week 3- Assign one person in charge of each

Week 4area for 5S implementation- Implement 5S in departments- Inappropriate arrangement of injection trolleys, drug
cabinets, medical record store, etc.
- Many unnecessary things in departments.
- Toilets were dirty and untidy.

3.

.YV\W^VYR^P[OKLWHY[TLU[ZZ[Hќ

Objective
100% departments in the hospital implement 5S by

30 November 2016.

4.

4

Action plan
4.1. Stage division:•

Stage 1: Pilot implementation5

to- Check, monitor and pushweek 10

implementation- Evaluate implementation

Week 11- Organize a workshop to present

toweek 12- Select 5 departments for pilot implementation:
General Surgery Department, Endocrinology
Department, Oncology Department, Pharmacy
Department and General Planning Department)- Duration: 03 months, from 01 March 2016 to 30
May 2016.
•

Stage 2: Expansion- Departments voluntarily register to implement 5S- Duration: 03 months, from 01 June 2016 to 30
August 2016•

Stage 3: Comprehensive implementation

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

implementation results- Generate lessons learnt, improveand make next implementation plans.

Session 5 | 5S

THAI BINH PROVINCIAL GENERAL HOSPITALAND QM ACTIVITIES• Developing documents on PS:- Incident reporting form

PROJECT FOR
5S IMPLEMENTATION
IN THAI BINH PROVINCIAL GENERAL HOSPITAL IN 2016

- Incident reporting procedure- Incident management procedure- Regulation on PS: regulations on correct patient- PS bulletin board

THAI BINH PROVINCIAL GENERAL HOSPITALAND QM ACTIVITIESDiscussion

1st level hospital, the top level in Thai Binh province+ Hospital’s structure: 41 departments (23 clinicaldepartments, 05 para-clinical departments, 13 functional
departments)+ Human resource: 919 staff (231 doctors, 450 nurses,
75 technicians, 35 pharmacists)+ 1,000 planned beds; 1,180 actual beds
+ Bed occupancy rate: 178% planned beds; 105%
actual beds

Session 3

THAI BINH PROVINCIAL GENERAL HOSPITALAND QM ACTIVITIES

on surgical safety, on fall prevention

Session 2

identification, on drug usage, on handover among staff,
Dr. Tran Thi Quynh Anh, MD, 1st degree specialist
Vice chief of Quality Management Department
Email: tranthiquynhanh1980@gmail.com

Session 1

THAI BINH DEPARTMENT OF HEALTHPROVINCIAL GENERAL HOSPITAL

Session 4

THAI BINH PROVINCIAL GENERAL HOSPITALAND QM ACTIVITIES- The hospital QM system is quite complete, including: Patient satisfaction survey using MOH
questionnaire Develop QI projects
 Implementing QI activities:* QM Council: 04 committees (of professional quality,
infrastructure, manpower development and patient satisfaction)* QMD: 06 staff (05 doctors, 01 nurse - 3 full-time staff and
03 part-time staff)* QM network: 42 members• Incident reporting system:

1. REASONS FOR CHOOSING THE TOPIC- To create a clean, tidy and convenient working
and treatment environment.
- To reduce waste of time to concentrate on
professional and patient care activities.
- To reduce incidents related to illogical working

Annex- Focal point for receiving and handling reports: QMD- RCA group : QMD, GPD, Nursing Department andrelevant departments- Sources to collect incidents: voluntary reports,
hospital meetings, medical records, monitoring in
departments.
- Reporting way: email, hospital server, direct report,
telephone

5S PROJECT

Session 7

THAI BINH PROVINCIAL GENERAL HOSPITALAND QM ACTIVITIES

Session 6- Improving waiting area in OPD- Install 50 cameras in emergency rooms to monitor
patients- Install centralized oxygen supply system in 100%
clinical departments- Install a queue machine in laboratory area

Session 5

THAI BINH PROVINCIAL GENERAL HOSPITALAND QM ACTIVITIES

environment5S PROJECT

5S PROJECT
2. OBJECTIVE
 100% departments in the hospital implement 5S by 30
November 2016.
3. ACTUAL STATE BEFORE 5S IMPLEMENTATION Departments were not clean and tidy.
 Inappropriate arrangement of injection trolleys, drug
cabinets, medical record store, etc.
 Many unnecessary things in departments.
 Toilets were dirty and untidy.

4. ACTION PLAN
4.1. Preparation stage* Duration: 01 month (March 2016)* Contents:- Making plan- Establishing a QI group to implement 5S- Discussion- Developing documents- Preparing training materials…

5S PROJECT

5S PROJECT

4. ACTION PLAN
4.2. Implementation stage

3. ACTUAL STATE BEFORE 5S IMPLEMENTATION

Pilot implementation(03 months, from
01/4/2016 to 30/6/2016)

Expansion(03 months, from
01/7/2016 to
30/9/2016)

Select 5 departments forpilot implementation:
General Surgery
Department,
Endocrinology
Department, Oncology
Department, Pharmacy
Department and GPD)

Departments
Implementation involuntarily register to other departments
implement 5S

5S PROJECT

5S PROJECT
3. ACTUAL STATE BEFORE 5S IMPLEMENTATION

Comprehensive
implementation (03months, from01/10/2016 to
30/12/2016)

5. Activities
STT

Time

Activities-

Evaluate actual state of departments

1

Week 1-

Take pictures2

Week 2-

5S training-Group work with departments staff

3

Week 3-

Assign one person in charge of each area for 5S-Implement 5S in departments

4

Week 4 to week 10-Check, monitor and push implementation-

Evaluate implementation-

Organize a workshop to present implementation results-

Generate lessons learnt, improve and make next

implementation

5

Week 11 to week 12

implementation plans.



5S PROJECT

5S PROJECT

3. ACTUAL STATE BEFORE 5S IMPLEMENTATION

6. ADVANTAGES AND CHALLENGES
6.1. Advantages
 Hospital leaders always care and give direction to all QI
activities, especially 5S implementation.
 Members of QM system and staff of QMD are very
enthusiastic.
 QI activities in the hospital are receiving collaboration
and agreement of healthcare workers.
 The hospital has a budget for 5S activities from the
Norred project.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 5 | 5S

5S PROJECT

 The issues raised for improvement in the project are urgent andnecessary to improve to enhance quality and effectiveness of

Session 1

6. ADVANTAGES AND CHALLENGES
6.1. Advantages

examination, treatment and patient care activities.
 Therefore, the Project is suitable, sustainable and able to beextended in the whole hospital and to share experience for otherSession 2

hospitals.

6. ADVANTAGES AND CHALLENGES

Discussion

6.2. CHALLENGES- Expectation from hospital leaders- Manpower- Working habit- Maintaining 5S

Session 3

5S PROJECT

Session 4
Session 5
Session 6
Session 7
AnnexSession 5-4
WHO IS CUSTOMER?
5S
Megumi Ikarashi
Bureau of International Health Cooperation, NCGM, Japan   !   %,

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 #*      " "!   +'& &( *   "    ( (Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 5 | 5S

Session 1

  

Session 2
Session 3  

Discussion
Session 4  
Session 5
Session 6- Session 7  
  

Annex


Session 6-1
Reducing Ventilator Associated Pneumonia by 5%
and Pressure Ulcer by 10% in ICU within 3 months
Tran Quang Dat
ICU, Quality Management Department, Quang Nam Central General Hospital

1.

Reasons for improvement activitypressure ulcer in ICU.

Ventilator associated pneumonia (VAP) is the

2. Action plan: starting from February 2016

pneumonia that occurs after 48 or more hours of hospital
admission in patients who are not in incubation period

Establishing an improvement group

nor acquired at admission. This is a common healthcare

Surveying the rates of VAP (the number of pneumonia

associated infection in Intensive Care Unit (ICU) and apatients/1,000 days of mechanical ventilation) andleading cause of mortality (30–70%) among nosocomial

bedsore (the number of pressure ulcer patients/1,000

infections, prolonging hospital stay and increasing

days of hospital stay).

treatment costs.

Analyzing root causes and proposing improvement

In Viet Nam, a national survey over 19 hospitals

solutions.

in 2005 showed that VAP rates were especially highRe-surveying the rates of VAP and bedsore after 3

in patients in ICU (43-63.5/1,000 days of mechanicalmonths of improvement.

ventilation). Hospital acquired pneumonia is a leading
cause of mortality among nosocomial infections (30-70%),
prolonging hospital stay to 6-13 more days and increasing
costs from 15 to 23 million VND for one case.
In our hospital in 2015, the number of patients with
VAP was large (36%), which is not improving. In ICU,
the risk of pressure ulcer for patients was also high,which was a cause of increased mortality and treatment
costs and longer hospital stay. Therefore, we conduct
improvement activity to reduce the rate of VAP andQUALITY IMPROVEMENT

3. Objective
100% departments in the hospital implement 5S by
30 November 2016.

3_a. Current state
The VAP rate in ICU in our hospital in 2015 was 36%.

3_b. Targets for achievement
The rate of VAP in ICU in 2016 is reduced by 5% andthat of bedsore by 10% after 3 months of improvement.

Quang Nam Central General Hospital

Reducing ventilator associatedpneumonia by 5% and pressure ulcer
by 10% in ICU within 3 months
Dr. Tran Qung Dat, 1st degree specialist
Chief of ICU
Vice Chief of Quality Management Department
Quang Nam Central General Hospital

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1• 2nd level hospital• Scale: 600 planned beds, 806
actual beds.
• 20 clinical departments, 07
para-clinical departments and
08 functional departments.
• 732 staff

Session 6 | Improving Quality in Clinical Departments

QMD

REASONS FOR IMPROVEMENT ACTIVITY

Receiving and handling
medical incidents

Implementing 5S

Quality indicators

Discussion

Conduct roots cause analysis• In our hospital in 2015, the number of patients with
VAP was large (36%), which is not improving.
• In ICU, the risk of pressure ulcer for patients was also
high, which was a cause of increased mortality andtreatment costs and longer hospital stay.
• Therefore, we conduct improvement activity to
reduce the rate of VAP and pressure ulcer in ICU.

Session 3

REASONS FOR IMPROVEMENT ACTIVITY

Session 2

QMD’S MAJOR ACTIVITIES

Session 1

There are 6 members
Chief : Vice director(part-time)Vice chief : chief of
ICU (part-time)Vice chief : a collegenurse
1 doctor
1 bachelor of hospitalmanagement
1 nurse• Ventilator associated pneumonia (VAP) is the pneumonia
that occurs after 48 or more hours of hospital admission
in patients• This is a common healthcare associated infection in ICU.
• n Viet Nam, a national survey over 19 hospitals in 2005
showed that VAP rates were especially high in patients in
ICU (43-63.5/1,000 days of mechanical ventilation).
• Hospital acquired pneumonia is a leading cause of
mortality among nosocomial infections (30 -70%),
prolonging hospital stay to 6-13 more days andincreasing costs from 15 to 23 million VND for one case.

Developing and measuring
quality indicators

Session 4

Organizing trainings on PS

OBJECTIVES

Session 5

Training,
sharing information• Reducing VAP by 5% within 3 months.
• Reducing bedsore by 10% within 3 months.

Monthly QM
network meetings

Session 6

ICU:
25 beds
5 doctors
22 nurses

No.

Activities

1

Establishing an improvement group
Surveying the rates of VAP per 1,000

Improvement group

bedsore per 1,000 days of hospitalstay
Analyzing root causes and proposing

3

2 weeks

improvement solutions
Training and implementing solutions

2 weeks

4

5

Improvement groupand doctors in ICU
Dr. Dat andimprovement groupRe-surveying the rates of VAP and

After 1, 2, 3 months Improvement group

bedsoreof interventions

Annex






1 monthIn charge

days of mechanical ventilation and2

Nurses are divided into 3
shifts (each shift has 4nurses), 4 groups.

Time

Session 7

ACTION PLAN



CAUSE ANALYSISPROPOSED IMPROVEMENT MEASURES

Focus on infection factors• Developing, training and monitoring implementationof bedsore prevention procedures for nurses.
• Using more bedsore prevention devices, especiallyfor high-risk patients.
• Conducting nutrition assessment and providing
proper interventions.

Equipment

MethodEnvironment

Identify
Identifying
theprob
problem:
VA
VA
VAP

Manpower

CAUSE ANALYSIS FOR PNEUMONIA

POST-INTERVENTION EVALUATION

Employing fishbone diagram and 5 WHY, we identified
some following causes:• Nurses did not follow the procedure for taking care ofpatients with mechanical ventilation.
• Lack of devices such as: tracheal tube, bag mask,
cuffed tracheal tube…
• Cleaners: no procedure for treatment of ventilator
after use• Environment of ICU was not treated regularly.

• Post-intervention evaluation: VAP and bedsore havebeen improved compared with at the time of survey.
• Causes of remaining problems are identified forfurther improvement.

PROPOSED IMPROVEMENT MEASURES

CHALLENGES• Retraining for old and new nurses and trainees in thedepartment on mechanical ventilation procedure.
• Strengthening monitoring to ensure that nurses follow
the procedures properly.
• Buying more devices: sterilized tracheal tube, bagmask, etc.
• Developing procedures for treatment of ventilator
after use.
• Developing collaboration procedure: Infection
Control Department, ICU and Administrative
Department.

• The number of patients with mechanical ventilation
per month is small  data might be inaccurate.
• Buying more equipment  more costs.

CAUSE ANALYSIS FOR BEDSORE
Causes are related to nursing care.
• Nurses did not follow properly procedures forbedsore prevention.
• Lack of bedsore prevention devices.
• Patient’s nutrition status was not assessed fully forintervention.



Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 6 | Improving Quality in Clinical Departments

Ton Thanh Tra

Session 2

Antimicrobial Stewardship Program Helps Increase
the Rate of Proper Use of Prophylactic Antibiotics
in Surgery from 65% to 75% after One PDCA Cycle

Session 1

Session 6-2

Quality Management Department, Cho Ray Hospital

Session 3

1.

Introduction
Overuse of antibiotics, especially in operation patients,

is one of the reasons leading to increased treatment

PUMLJ[PVU::0YPZRZ[YH[PÄJH[PVU^HZJVUK\J[LKV]LY planned surgeries. However, 80% patients were indicatedantibiotics after surgery without evidence of infection.

costs and antimicrobial resistance, especially in top

4. Cause analysis

level hospitals. On World Health Day on 7 April 2011,- Surgeons have increased awareness on antibiotics use.

World Health Organization called to combat antimicrobial

4VUP[VYPUNHJ[P]P[PLZZLLTLќLJ[P]L

tomorrow”. In this context, Cho Ray Hospital started an- Setting objectives to gradually improve after PDCA

antimicrobial stewardship (AMS) program in 2012. After

cycles.

collecting microbiological data, developing guidelines forand trainings on antibiotics use, the AMS program started- Regulation is clear about reward and punishment.
Why is surgeons’ compliance rate not high?

of proper use of prophylactic antibiotics in surgery (clean- They are too busy to care.

and clean-contaminated) only accounted for 65%.
Objective: The rate of proper use of prophylactic
antibiotics in surgery increases from 65% to 75% after
one PDCA cycle.

Activities- Organizing trainings on proper use of prophylactic
antibiotics in surgery for all surgeons.
- Releasing announcement of guidelines on using- Organizing a group to monitor antibiotics prescription indaily operation approval.
- Evaluating and reporting monitoring results at the end ofeach month.

Results
After implementing different solutions, the rate ofproper use of prophylactic antibiotics in patients withclean or clean-contaminated surgeries increased from- They lack trust in infection control and hospitalenvironment.
- Not enough evidence to convince surgeons not to use
antibiotics after surgery.
- There may be other causes.

5. Next plan
- Strengthening infection control- Studying SSI rates, comparing compliant group andnon-compliant group- Strengthening monitoring activities- Organizing meetings to review antibiotics indication in
medical records

Annex

3.

- They are not highly aware of antimicrobial resistance.

Session 7

prophylactic antibiotics in surgery.

KPѝJ\S[[VJOHUNL

Session 6

2.

- The longtime habit of using antibiotics after surgery is

Session 5

in 2015. However, monitoring results show that the rate

Session 4

resistance with the motto “No action today, no cure

Discussion

is common in developing countries like Viet Nam. This

65% to 79% after one PDCA cycle. Besides, surgical site

- Setting objective for a new PDCA cycle (80%) in thenext 2 months and the rate of improper use of antibiotics
after surgery reduces from 80% to 50%.

6.

Conclusion

Applying PDCA cycle to improve quality in AMS seems
easy to understand, easy to implement and to bring
LќLJ[P]LULZZ:L[[PUNZOVY[[LYTVIQLJ[P]LZKL]LSVWPUNH
detailed action plan, evaluating the outputs and analyzing
causes in one cycle help make plan for the next.

INCREASING THE RATE OF PROPERUSE OF PROPHYLACTIC ANTIBIOTICSIN SURGERY FROM 65% TO 75%
AFTER ONE PDCA CYCLE

Cho Ray Hospital• Overloaded• Sometimes 2 surgeries take place at the sametime in one operating room

Dr. Ton Thanh Tra, MD., MSc.
Quality Management Department
Cho Ray Hospital, Ho Chi Minh City, Viet Nam• Indicating antibiotics after surgery is common

PRESENTATION CONTENTS• Context• Developing quality objectives in PDCA cycle• Introduction of AMS program• Lessons learnt• Conclusions








Cho Ray Hospital

ANTIMICROBIAL RESISTANCE OCCURS RAPIDLY
Antimicrobial resistance may make infections incurable• Special level general hospital• 120-150 surgeries per day• > 200 surgeons• Surgeons are able to perform more than 2surgeries per day

5. Pray LA Insight Pharma Reports 2008,
52008 in Looke D ‘The Real Threat of Antibiotic Resistance’ 2012Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 6 | Improving Quality in Clinical Departments

ANTIMICROBIAL RESOURCES BECOME
MORE AND MORE LIMITEDRESISTANCE SITUATION OF K.PNEUMONIAE

Session 1– Bacteria resist better over time– Irrational antibiotics use– Not many new types of antibiotics- ESBL : 58%- Most of antibiotics are resisted by > 50%- Amikacin; Netimycin, carbapenem : 35 %   

1. Accessed from www.idsociety.org, from Spellberg, CID 2004 (modified)  

  

Session 2

The numbersof FDAapproved
antibiotics

Session 3

AMS PROGRAM- Guideline for antibiotic use was developed in 2010 and
updated in 2013.
- Trainings were conducted in 2013-2014- Pilot implementation in 6 clinical departments:
Respiratory Internal Medicine Department, ICU, Tropical
Diseases Department, Urology Surgery Department,

Discussion- Monitoring from June 2014 to present.

Gastroenterology Surgery Department and Hepatology“No action today, no cure tomorrow” adopted from WHO World Health Day 2011

Surgery Department.

Session 4

INTRODUCTION OF AMS PROGRAM

5 PATHOGENIC BACTERIA

44.7%

45%

39%

2012 (n =713)

2013 (n= 577)2014 (n= 1,069)



AMS Program(n=379

A.baumanii



10.6%

13.4%

8.5%

11.9%
8.6%

8.0%


10.5%

12.0%

8.5%

2013

2014

2%



2012

E.coliP.aeruginosa
A.baumanii

doctors study medical
records with antibiotics
indication for inpatients in

P.aeruginosa

pilot departments

S.aureus- Organizing monthly

E.coli

2015

Session 6

5%

11.0%
8%

14%

7.9%

collaboration with clinical

12.9%
K.peumoneae- Clinical pharmacists in

Session 551%



meetings

S.aureus
K.peumoneae     

  NUMBERS OF SPECIMENS
Wards

     

Total

4B1

101

40

15

36

35

28

14

12

17

298

4B3

110

37

18

20

49

25

15

31

36

341

5B1

107

42

29

24

29

24

20

16

8

299

16

36

38

360

28

37

287

8B1

118

31

28

14

42

37

BND

91

37

29

25

20

20

ICU

76

26

23

23

18

34

13

32

18

263

Total

603

213

142

142

193

168

78

155

154

1,848

Annex

- Most of antibiotics are resisted by > 70%- Doxycline < 35% Rifampin< 10% Colistin <5%

Batch
Batch 5 Batch 6 Batch 7 Batch 8 Batch 9 Batch 10 Batch 11 Batch 12
1-4(11/2014) (12/2014) (01/2015) (02/2015) (03/2015) (05/2015) (06/2015) (07/2015)(9/2014)

Session 7

RESISTANCE SITUATION OF A.BAUMANNII  



THE RATES OF SENDING SPECIMEN FOR
CULTURE BEFORE INDICATING ANTIBIOTICS%

PRE-OPERATIVE ANTIBIOTICS USE
Pre operative AB prophylasis

120

73,9%

100

80
4B1
60

4B3
5B1

40

26,1%

8B1
BN
ICU

20

-

Antibiotics used

THE RATES OF CHOOSING THE FIRSTANTIBIOTICS FOLLOWING THE
HOSPITAL’S GUIDELINE

Antibiotics not used

RATE OF PROPER USE  




35,0%

 

 





 

65,0%




 

 

ProperImproper

PROPHYLACTIC ANTIBIOTICS
Department
3B1

Total number of
medical records
26

3B3

31

4B1

63

4B3

17

5B1

53

5B3
Total number of
medical records

18

Our stepsanaredso smalls so
our progres

Slow

One Step

208

SSI RISK STRATIFICATION
49,2

Surgical site stratification

16,9

2,3

Clean Clean-Contaminated Contaminated



0,3

Dirty

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Progress This Way

Session 6 | Improving Quality in Clinical Departments

APPLICATION OF PDCA CYCLEIN HOSPITALS IN VIETNAM

INTERVENTIONS• Organizing a group to monitor antibiotics
prescription in daily operation approval.
• Evaluating and reporting monitoring results at
the end of each month.

Session 2

CONTINUOUS QUALITY IMPROVEMENT

PRE-OPERATIVE PROPHYLACTIC
ANTIBIOTICS USE
Clean

Cleancontaminated

65%

4B1

134

37

27

4B3

44

24

10

CO
CONTINUOUS
ONTINUOUS
IMPROVEMENTIMPPROVEMENT

5B1

120

59

31

Total

298

120

68

Discussion

Number of
medicalrecord75%

Session 3

PDCA CYCLE

Session 1

Objective

Session 4

RESULTSThe rate of proper use of prophylactic antibiotics• SSI risk stratification was conducted overin surgery increases from 65% to 75% after one
PDCA cycle.

100% planned surgeries.
• 188/298 (63%) surgeries were clean or clean-

Session 5

OBJECTIVE

contaminated• Compliance rate to guideline on antibiotics use

PROPER ANTIBIOTICS USE• Organizing trainings on proper use ofprophylactic antibiotics in surgery for all
surgeons.
• Releasing announcement of guideline on using
prophylactic antibiotics in surgery.

Session 7

INTERVENTIONS

Session 6

was 79%Annex
PRE-OPERATIVE ANTIBIOTICS USE

WHY SURGEONS DID NOT COMPLY?

Following hospital’s guideline
120%
100%

• Too busy to concern.

95%

91%

79%

80%

• Longtime habit of using
antibiotics after surgery is

60%

40%
40%

difficult to change

20%• Not fully aware of

0%

4B1

4B3

5B1

Toàn
Totalb

Most cases used only 1 kind of antibiotics. Only one case was indicated 2 kinds ofantibiotics (Meronem + Tinidazole) due to being diagnosed with pneumonia/
diabetes type 2
In general, surgery approval and preoperative antibiotic use have been improved
much, without any medical records showing long use of antibiotics before surgery.

POST-OPERATIVE ANTIBIOTICS USE
DURATION OF ANTIBIOTICS USE AND
ANTIBIOTICS COMBINATION
45
40
35
30
25
20
15
10
5
0

150

antimicrobial resistancesituation

WHY SURGEONS DID NOT COMPLY?
• Lack trust in infection control and hospital

27

environment• Not enough evidence to convince surgeons not to use
6

5,1

post-operative antibiotics
using KSSCasesca s dng
antibiotics
sau PT
after surgery

Antibiotics
Phihp 2 KS
combination

Diagnosed
Có chnoán NK SDuration
ngày TBofs
withantibiotics
use
sau
m
dung
KS sauPT
infection
after surgery(ngày) (days)• There may be other reasons

Antibiotics were indicated after surgery without diagnosis ofinfection:• 150 cases (80%) continued to use antibiotics after surgery• 27 cases combined 2 kinds of antibiotics

NEXT PLAN

POST-OPERATIVE ANTIBIOTICS USE• Although pre-operative
antibiotics use has
improved, antibiotics arestill indicated after surgery,
mainly because theoperations were significant
and long.
• Many medical records did
not include the reasons for
antibiotics indication.

• Strengthening infection control• Studying SSI rates, comparing compliant
group and non-compliant group• Strengthening monitoring activities and IT
application

IT APPLICATIONCAUSE ANALYSIS• Strong direction from the directing board• Close monitoring• Clear objectives• Specific interventions• Combine different ways of monitoring

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 6 | Improving Quality in Clinical Departments

APPLICATION ON SMARTPHONE

Session 1
Session 2
Session 3

Conclusions• Applying PDCA cycle to AMS seems to be effective• Set clear and feasible short-term objectives

lessons learnt and set objectives for the next cycle.

Discussion• After one PDCA cycle, analyze results, generate

Session 4
Session 5
Annex

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

Session 7

WELCOME TO VIETNAM FORUMON QUALITY MANAGEMENT
AND PATIENT SAFETY 2016

Session 6

THANK YOU AND ENJOY YOUR TIMEHAPPY NEW YEAR 2016





Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 7 | Updates from the Ministry of Health

Session 1

Session 7
Applying Hospital Quality Standards to Improve
Hospital Quality and Patient Care

Session 2

Duong Huy Luong
Vice chief of QMD, Medical Services Administration, MOH

Session 3
Discussion

HOSPITAL QUALITY MANAGEMENTAPPLYING HOSPITAL QUALITY STANDARDSTO IMPROVE HOSPITAL QUALITY AND
PATIENT CAREHOSPITAL QUALITY FORUM
NCGM – BACH MAI HOSPITAL4“IMPROVING MEDICAL SERVICES QUALITYWITH PATIENT CENTEREDNESS FOR PATIENTS’
SAFETY AND SATISFACTION"
MSA, 2014

Document number 13 KCB - QLCLOn announcement and guidance for submitting
applications for outstanding hospitals (to encourage
hospitals to improve their quality)

5

Session 7

A SERIES OF “REFORMS” HAVE BEEN BEING
IMPLEMENTED
Reform in management: establishing QM systems in all
hospitals (Circulars 19, 01)
 Reform in knowledge: learning from advanced countries
 Reform in viewpoint: patients are put at the center of nursing
care and treatment
 Reform in way of work: improving examination procedures,
reducing administrative procedures (Decision 1313, Directive05)
 Reform in method: replacing annual hospital check by hospitalquality evaluation following the new 83 criteria (Decision 4858)
 2015: Reforms in service manner, uniform…

Session 6

TITLE OF OUTSTANDING QUALITY HOSPITAL
Improved examination procedures
Patient care
Active in reducing overload and keeping commitment of no bed
sharings among patients
Infection controlled, clean and green
Developed human resource
IT application
Developed techniques and professional qualifications
Practising clinical nutrition
Improved laboratory quality
Rational drug use
Active in scientific research
Ensured PS
Active in QI
Receiving and handling patients’ feedback effectively

Session 5

NEW VIEWPOINTS

Session 4

Dr. Duong Huy Luong, MD., PhD.
Vice chief of QMD, Medical Services
Administration, MOH

POLICIES AND TOOLS ISSUED IN 2015
TO ENHANCE HEALTHCARE SERVICESQUALITY

Annex

6



TENTATIVE ACTIVITIESReaching objective 2: To develop and issue quality
standards and tools to evaluate and measure services
quality of healthcare institutions, healthcare
practitioners and professional qualifications

NATIONAL ACTION PROGRAM (NAP) TO
IMPROVE QM CAPACITY TILL 2025 (Issued with Decision number 4276/QD-BYT
dated 4 October 2015 by the Minister of Health)

2.1. Develop HQS and quality standards for other healthcare
institutions.
2.2. Develop competency standards for practitioners: General
doctors, specialized doctors, technicians, midwives.
2.3. Develop some specialized quality standard sets for:nursing care, infection control, reproductive health, etc.

7

TENTATIVE ACTIVITIESNAP’S SPECIFIC OBJECTIVES
1.

2.

3.

4.

To develop and complete legal framework, policy andorganizing system to strengthen QM;
To develop and issue quality standards and tools toevaluate and measure services quality of healthcare
institutions, healthcare practitioners and professional
qualifications;
To promote application of QM methods andimplementation of interventional programs to enhance QM
capacity;
To enhance awareness of QM in healthcare, graduallydeveloping quality culture in healthcare institutions;

TENTATIVE ACTIVITIESReaching objective 1. To develop and complete legal framework, policy
and organizing system to strengthen QM
1.1. Develop, issue and monitor implementation of legal documents related
to healthcare services quality.
-Circular guiding management of medical incidents-
Hospital quality standards (HQS)-Medical services quality standards for communal health centers1.2. Develop policies to encourage improve quality of healthcare
institutions and healthcare practitioners-Promote and facilitate the establishment of a healthcare accreditation
organization-Update and adjust regulations on granting practising certificates andassessing professional qualifications and ethics.

2.4. Develop, conduct a pilot, evaluate and release the HQS.
2.5. Develop the lists of common diseases, emergency diseases, chronic
diseases, high-tech services accounting for 80% of inpatient and outpatient
treatment costs.
2.6. Develop, update and issue guidelines for diagnosis and treatment,
technical procedures, nursing care, and professional procedures inaccordance with the above lists (2.5).
2.7. Update the above guidelines every 2 years. Develop technical guidelines
for diseases, techniques accounting for 80% of inpatient and outpatient
treatment costs.
2.8. Survey satisfaction of patients and healthcare workers.
2.9. Develop database on manpower, finance and professional activities ofhealthcare institutions and software supporting doctors in examination andtreatment

TENTATIVE ACTIVITIESReaching objective 3: To promote application of QM
methods and implementation of interventional programs
to enhance QM capacity
3.1. Support hospitals to develop plans/projects and apply QM
methods
3.2. Develop and approve materials for QM continuing
education.
3.3. Conduct QM training courses for in-charge staff andquality evaluators.
3.4. Develop and implement measurement projects and release
the HQS.

TENTATIVE ACTIVITIESTENTATIVE ACTIVITIESTo develop and complete legal framework, policy and organizing
system to strengthen QM
1.3. Establish QM system within healthcare system•In MOH: Establish Healthcare Services Quality Council•
In DOH: appoint staff to take charge of QM activities. QM Council isrecommended; Develop and approve provincial action program for QM
in healthcare•In hospitals: establish Hospital QM Council to run activities. Establish
QM department/unit, QM network and appoint full-time staff to takecharge of QM.
1.



3.5. Create quality rewards for healthcare institutions;3.6. Implement national QI programs in: nursing care, clinicalnutrition, infection control, rational drug use, voluntary
incident reporting system.
3.7. Develop and implement some clinical accreditation
programs in some specialties, common diseases and chronic
diseases.
3.8. Develop a pilot project for healthcare technology
evaluation.

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Session 7 | Updates from the Ministry of Health

TENTATIVE ACTIVITIES

Session 1

Reaching objective 4. To enhance awareness of QM
in healthcare, gradually developing quality culturein healthcare institutions
4.1. Develop and implement communication projects to raiseawareness of healthcare quality for healthcare managers,
hospital leaders, healthcare institutions and practitioners;
4.2. Develop and implement communication projects to raiseawareness of healthcare quality, rights and responsibilities
in healthcare services for patients and community.

19

Session 2

Nurses Technical procedures for nurses, midwives andtechnicians are standardized
 When patients are admitted to hospital, nurses
check patients’ condition, assess nursing careneeds and monitor
 Nurses support patients to use drugs following
indications to ensure safety and effectiveness.
 Nurses assess patients’ pain level and provide
them palliative care

Session 3

TENTATIVE ACTIVITIES
4.3. Introduce and disseminate quality initiatives. Make plansand organize study visits to healthcare institutions that are
successful in QM in the country.
4.4. Organize regular workshops and forums on hospital QM
to share information, models and QI initiatives of some
hospitals to others.
4.5. Vote for and award annual hospital quality prize.

Discussion

Laboratory
1.Checking with clinical examination andpathology
2.Ensuring pre-test quality
3.Ensuring quality during test period
4.Ensuring post-test quality

20

Session 4

DRAFT LIST OF NEW ADDITIONAL
CRITERIA IN 2016

Session 5

Scientific research and training
 Implementing training tasks
Towards patients
 Patients benefit from charity programs and social
work
 Directing healthcare activities to other levels
Towards healthcare workers
 Surveying healthcare workers’ satisfaction.
21

17

7.

18

Annex

Ensuring safety in blood preservation and bloodtransfusion in hospital.
 Ensuring safety in clinical blood transfusion.
 Applying surgical safety checklist
 Ensuring correct patient identification
 Ensuring safety in information exchange between
healthcare workers and patients
 Managing and utilizing medical equipment safely andeffectively
 Safe radiation during diagnosis and treatment
22Developing diagnosis and treatment guidelines
Applying diagnosis and treatment guidelines
8.
Monitoring compliance to diagnosis and treatment
guidelines
9.
Developing and computerizing treatment protocols
to improve clinical quality
10. Developing, evaluating and improving clinicalquality indicators
11. Conducting clinical accreditation and QI
6.

Session 7

Patient safety

Session 6

Clinical quality
1.Developing general disease patterns of hospital and clinicaldepartments.
2.Monitoring and evaluating clinical quality based on disease
patterns.
3.Following the technical list by hospital level.
4.Studying and applying new techniques and methods.
5.Applying and developing technical procedures for healthcare
services and monitoring qualityPatient satisfaction

Preventive medicine andcommunicable diseases

An important criterion to evaluate the hospital’s
prestige and services quality.
 A measure reflecting the outcomes of public andprivate healthcare institutions.


Ensuring safe immunization
 Ensured capacity for receiving, diagnosing and treating
communicable diseases
 Facilities are good enough for treatment of common
communicable diseases
 Developing and applying diagnosis and treatment guidelines forcommon communicable diseases in hospital.
 Reporting and monitoring communicable diseases following
current regulations.
 Organizing outpatient examination for HIV/AIDS and treatment
by technical level
Final goal of hospitals
PATIENT SATISFACTION

23

Healthcare workers' satisfaction
Obstetrics
Human resource: THE MOST IMPORTANT
RESOURCE
Evaluating staff’s satisfaction is a significant factor
that can help improve the hospital’s healthcare
services quality.
increasing patient satisfaction

Developing systems for reporting and collecting
data of 5 obstetric complications, including thoseleading to maternal mortality.
 Utilizing prophylactic antibiotics in obstetric andgynecologic operations and procedures
 Controlling appropriate rates of Caesarian section
 Capacity of pregnancy management system Capacity to care for newborns and prematurebabies24

ESTABLISHMENT OF PATIENT FEEDBACK SYSTEMORIENTATION FOR SURVEYINGPATIENT SATISFACTION
Patient and healthcare worker satisfaction surveys becomeroutine work.
 Applying IT to survey
 Do not print out forms, fill them directly with tablets andsmartphones (Iphone, Ipad, Android) Saving thousands of tons of paper and working days for
inputting data and analyzing results.
 Hospitals access the website WWW.KCB.VN and input
information online (AVAILABLE ON KCB.VN)


1. Patient satisfaction form
2. Abnormal incidents rapid reporting form
 3. Opinion box to receive patients’ feedback,including 2 forms:- Thank-you form- Complaint form



25

HOSPITALS SURVEY SATISFACTION OF PATIENTSAND HEALTHCARE WORKERS

Survey toolset was issued with Decision number
1334/QD-BYT dated 6 November 2015
 Hospitals survey by themselves and the evaluationteam conducts an independent survey andcompares with hospital’s results when evaluating
hospital quality


THANK YOU VERY MUCH AND WISH ALL
PARTICIPANTS HAVE EXCITING ANDFRUITFUL DISCUSSIONS!
Dr.Luong.kcb@gmail.com

26

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 130

Annex

Session 1

Forum Outline

Session 2

Vietnam Forum on Quality
Management and Patient Safety 201619-21 January 2016

1.

Sharing experiences of plans and progresses of small changes in quality management andpatient safety (QM/PS) among hospitals in Vietnam;

2.

Enhancing communication among people interested in QM/PS.

Hospital Tour

Session 5

Program:1.

Session 4

Objectives:

Discussion

Program for International Promotion of Japan’s Healthcare Technologies and Services
Strengthening Healthcare Staff’s Capability of Quality Management in Healthcare in
Viet Nam

Session 3

Ex-participants of the training course on
Quality Management and Patient Safety in Japan in 2015
Bach Mai Hospital
Ninh Binh Provincial General Hospital

Place: Ninh Binh Provincial General Hospital
Date: 19th January 2016
Forum: Presentations and discussion
Place: Bach Mai Hospital

Session 6

2.

Date: 20th - 21st January 2016•

Presenters are graduates from the training courses on QM/PS organized at National Center for
Global Health and Medicine (NCGM), Japan•

Session 7

Participants:

Observers are people who are interested in planning and action to create small changes in hospitals
in Vietnam.

Annex

The Forum was funded by the Program for International Promotion of Japan’s Healthcare Technologies andServices, FY2015, and implemented by NCGM and Japan’s Ministry of Health, Labor and Welfare.

Program
Program 20/01/2016
08:00 - 08:30

Reception

08:30 - 08:35

Opening speech

08:35 - 08:50

Objectives of the forum

Session 1

Learning culture in hospital
Challenges in shifting from punishment culture to learning culture to improve

08:50 - 09:30

patient safety
Dr. Le Viet Nho,
Vice Director, Head of Quality Management Department, Quang Nam Central General Hospital

Session 2

Establishing incident reporting system in hospital
Establishment of medical incident management system in Bach Mai Hospital

09:35 - 10:15

Dr. Nguyen Thi Huong Giang,
Head of Quality Management Department, Bach Mai Hospital

10:15 - 10:30

Tea breakDeveloping incident reporting system in Ha Nam Provincial General Hospital

10:30 - 11:10

Dr. Phan Anh Phong,Vice Director, Ha Nam Provincial General Hospital

11:15 - 11:55

Discussion

12:00 - 13:30

Lunch

Session 3

Improving compliance to timing standard
Improving compliance to standard emergency response time from 55% to 85% in

13:30 - 14:10

December 2016
Dr. Pham Viet Thai,
Head of Quality Management Department, Ninh Thuan Provincial General Hospital

14:10 - 15:30

Tea breakDiscussion
Eight core values in quality management in Japan
14:30 - 15:10

Dr. Shinsuke Murai,
National Center for Global Health and Medicine, Japan

15:10 - 16:00

Discussion

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Annex

Program 21/01/2016
Improving service quality in OPD
Plan to improve management and medical safety in dispensing drugs to patients in
08:50 - 09:10

Session 1

Session 4

Outpatient Department
Dr. Tran Quang Hien,

Session 5

5S

Session 2

Director, An Giang Hospital of Obstetrics, Gynecology and Pediatrics

5S implementation in two departments in Ninh Binh Provincial General Hospital(Nephro-urological Surgery and Endocrinology Departments)
Dr. Vu Thuy Giang,
Head of Quality Management Department, Ninh Binh Provincial General Hospital
09:55 - 10:10

Tea breakSession 3

09:15 - 9:55

5S implementation in Ha Dong General Hospital
Dr. Nguyen Thi Huong Lien,
Head of Quality Management, Dong General Hospital
Project for 5S implementation in Thai Binh Provincial General Hospital
10:55 - 11:35

Discussion

10:10 - 10:50

Dr. Tran Thi Quynh Anh,
Deputy Head of Quality Management Department, Thai Binh Provincial General Hospital
Lunch
5S

13:35 - 14:00

Ms. Megumi Ikarashi, Bureau of Medical International Cooperation,

Session 4

11:40 - 13:30

National Center for Global Health and Medicine, Japan
Improving quality in clinical departments
Reducing ventilator associated pneumonia by 5% and pressure ulcer by 10% in
14:00 - 14:40

ICU within three months
Dr. Tran Quang Dat,

Increasing the rate of proper use of prophylactic antibiotics in surgery after one
PDCA cycle

Session 6

Deputy Head of Quality Management Department, Quang Nam Central General Hospital

14:45 - 15:25

Session 5

Session 6

Dr. Ton Thanh Tra,
Head of Quality Management Department, Cho Ray HospitalTea breakSession 7

Updates from the Ministry of Health

Session 7

15:25 - 15:30

Applying Hospital Quality Standards to improve hospital quality and patient care
15:30 - 16:00

Dr. Duong Huy Luong,

16:00 - 16:25
16:25 - 16:30

Discussion

Annex

Medical Services Administration, Vietnam Ministry of Health

ClosingSteering Committee
1.

Hospital Tour (19 January 2016)
Ninh Binh Provincial General Hospital
Dr. Vu Thuy Giang, M.D., MSc.

2.

Presentations (20-21 January 2016)
Dr. Nguyen Thi Huong Giang, M.D., MSc.
Dr. Le Viet Nho, M.D., PhD.
Dr. Phan Anh Phong, M.D., MSc.
Dr. Pham Viet Thai, M.D.
Dr. Shinsuke Murai, DDS., PhD.
Dr. Tran Quang Hien, M.D., PhD.
Dr. Vu Thuy Giang, M.D., MSc.
Dr. Nguyen Thi Huong Lien, M.D., MSc., 2nd Degree Specialist
Dr. Tran Thi Quynh Anh, M.D., 1st Degree Specialist
Dr. Tran Quang Dat, M.D., 2nd Degree Specialist
Dr. Ton Thanh Tra, M.D., MSc.
Ms. Meguma Ikarashi
Dr. Duong Huy Luong, M.D., PhD.

3.

Contributors
Dr. Nguyen Thi Huong Giang, M.D., MSc., Head of Quality Management Department, Bach Mai Hospital
Dr. Do Van Thanh, M.D., PhD., Head of International Cooperation Department, Bach Mai Hospital

4.

Secretariat
NCGM – Bach Mai Hospital Medical Collaboration Center (MCC), Hanoi, Vietnam
Ms. Pham Thi Phuong Thuy, MPH.
Dr. Nguyen Thi Le Hang, M.D., PhD.
Ms. Le Thi Thu Phong

5.

Coordinator
National Center for Global Health and Medicine (NCGM)
Dr. Shinsuke Murai, Course Director, Strengthening Health Staff’s Capability of Quality Management and Patient
Safety in Healthcare Program
Ms. Megumi Ikarashi, Bureau of International Health Cooperation

6.

Funding
The present forum was funded of the Program for International Promotion of Japan’s Healthcare Technology andServices, FY2015 and conducted by National Center for Global Health and Medicine (NCGM) and Ministry of Health,
Labor and Welfare, JapanPractices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Annex

Session 1

List of participants(ɉSPH[PVU

Role

Speaker3

Nguyen Thi Huong Giang

Bach Mai Hospital

Speaker

4

Nguyen Thi Huong Lien

Ha Dong General Hospital

Speaker5

Pham Viet Thai

Ninh Thuan Provincial General Hospital

Speaker

6

Phan Anh Phong

Ha Nam Provincial General Hospital

Speaker7

Ton Thanh Tra

Cho Ray Hospital

Speaker8Tran Quang Dat

Quang Nam Central General Hospital

Speaker9Tran Quang Hien

An Giang Obstetrics – Pediatrics Hospital

Speaker10

Tran Quynh AnhThai Binh Provincial General Hospital

Speaker

11

Vu Thuy Giang

Ninh Binh Provincial General Hospital

Speaker

12

Pham Thi Thuy Dung

Cho Ray Hospital

Observer13

Dinh Thi Ngoc Yen

Cho Ray Hospital

Observer14

Nguyen Thi Thanh Cam

Quang Nam Central General Hospital

Observer15

Bui Thi Minh Hien

Quang Nam Central General Hospital

Observer16

Pham Thi Phuong Hanh

Ninh Binh Provincial General Hospital

Observer17

Nguyen Thi Tuoi

Ninh Binh Provincial General Hospital

Observer18

Nguyen Truc Quynh

Ha Dong General Hospital

Observer19

Pham Quoc Tuan

Duc Giang General Hospital

Observer20

Ho Thi Thu Hang

Vinh Long Provincial General Hospital

Observer21

Do Van Thanh

Bach Mai Hospital

Observer22

Nguyen Thi Ngoc Lan

Bach Mai Hospital

Observer23

Vu Hang Hanh

Bach Mai Hospital

Observer24

Nguyen Thi Nghe

Bach Mai Hospital

Observer25

Hoang Viet Anh

Bach Mai Hospital

Observer26

Nguyen Ngoc Phuoc

Bach Mai Hospital

Observer27

Nguyen Thi Anh

Bach Mai Hospital

Observer28

Nguyen Minh Chau

Bach Mai Hospital

Observer29

Dang Thi Hai Duyen

Ha Nam Provincial General Hospital

Observer30

Tran Ngoc Hoa

Ha Nam Provincial General Hospital

Observer31

Nguyen The Toan

Quy Hoa Central Leprosy-Dermatology Hospital

Observer32

Nguyen Dinh HungSaint Paul Hospital

Observer33

Uong Thanh Tung

Saint Paul Hospital

ObserverAnnex

Quang Nam Central General Hospital

Session 7

Le Viet Nho

Session 6

2

Session 5

Medical Services Administration, Ministry of Health (MOH) Speaker

Session 4

Duong Huy Luong

Discussion

1

Session 3

Name

Session 2

No.



No.



Name

(ɉSPH[PVU

Role

34

Nguyen Cong ThanhSaint Paul Hospital

Observer35

Ha Ba Chan

Bac Ninh Provincial General Hospital

Observer36

Nguyen Minh Quan

Thu Duc District Hospital

Observer37

Huynh My Thu

Thu Duc District Hospital

Observer38

Lu Quoc Hung

Hanh Phuc Hospital

Observer39

Pham Huu Thuong

Hanoi Lung Hospital

Observer40

Luong Ngoc Khue

MOH

Observer41

Cao Hung Thai

MOH

Observer42

Nguyen Trong Khoa

MOH

Observer43

Vuong Anh Duong

MOH

Observer44

Bui Quoc Vuong

MOH

Observer45

Hoang Thi Hoa Ly

MOH

Observer46

Dao Minh Nguyet

Thai Nguyen Central General Hospital

Observer47

Do Hong Phuong

UNICEF

Observer48

Pham Van Man

Dien Bien

Observer (JICA)

49

Luong Van Long

Dien Bien

Observer (JICA)

50

Hoang Van Hieu

Lao CaiObserver (JICA)

51

Nguyen Duc Diep

Lao CaiObserver (JICA)

52

Cao Ngoc Thang

Yen BaiObserver (JICA)

53

Bui Ngoc Quynh

Yen BaiObserver (JICA)

54

Ly Thi Huong Giang

Son LaObserver (JICA)

55

Sa Ngoc Hung

Son LaObserver (JICA)

56

Truong Quy Duong

Hoa Binh

Observer (JICA)

57

Vu Van Tu

Hoa Binh

Observer (JICA)

58

Do Thi Duong

Lai ChauObserver (JICA)

59

Kyoko TAKASHIMA

JICA

Observer60

Shinsuke MURAI

NCGM

:[Hќ

61

Megumi IKARASHI

NCGM

:[Hќ

62

Nguyen Thi Le Hang

MCC

:[Hќ

63

Pham Thi Phuong Thuy

MCC

:[Hќ

64

Le Thi Thu Phong

MCC

:[Hќ

65

Interpreter

Interpreter66

Mr. Chau

Photographer

Practices in Hospital Quality Management and Patient Safety in Vietnam: Challenges and Achievements Volune 1

Annex

Session 1

Session 2

Session 3

Discussion

Session 4

Session 5

Session 6

Session 7

Annex



Practices in Hospital Quality Management and Patient Safety
in Vietnam: Challenges and Achievements
Volume 1

Based on Proceedings and Discussions in the 1st Vietnam Forumon Quality Management and Patient Safety, Hanoi, Vietnam in January 19-21, 2016.
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 February in 2018.
;OLKVJ\TLU[^HZTHKLPU[OLYLZLHYJOVU =PZ\HSPaH[PVUVMWYVNYLZZVMLќVY[ZVUX\HSP[`HUKZHML[`PUOLHS[OJHYLPUKL]LSVWPUNJV\U[YPLZ
(T.Nakasa and S.Murai)" funded by The Grant for National Center for Global Health and Medicine (27 Shitei 2).