The National University Hospital has been monitoring several hospital-wide Clinical Quality Indicators. These indicators are based on the Quality Indicator Projects (QIP) by the Maryland Hospital Association and its subsidiary, the Centre for Performance Sciences (CPS).
The QIP indicators were initiated in Maryland in 1985. As interest in the project spread outside the US, the International Quality Indicator Project (IQIP) was formed in 1997. It is a comparative analysis research project, with participants from various hospitals around the globe. It provides a clinical outcome-based approach to measuring and evaluating organisational performance.
The Ministry of Health's Healthcare Performance Group employs Clinical Quality Indicators to fulfill one of its key objectives of monitoring and assessing the clinical performance of hospital institutions so as to facilitate continuous quality improvement and benchmarking.
By adopting and tracking Clinical Quality Indicators, the results can be used to compare or benchmark information related to clinical care. Possible problems and/or opportunities for improvement are flagged out within the organisation. The data can help to highlight problem areas in clinical performance, inform or drive quality improvement activities, prompt reflections on clinical practice, ensure proper channeling of resources and identify important issues for further research. Valid and reliable data concerning desired and undesired results play an important role in a comprehensive monitoring and evaluation system.
Why Monitor Clinical Performance?
Clinical indicators serve to examine the trends in the standards of care in NUH beyond fulfilling regulatory requirements.
Clinical Performance Indicators
By participating in the IQIP, hospitals have a choice of monitoring a large number of clinical performance indicators. At present, NUH monitors 12 hospital-wide clinical quality indicators under the IQIP. NUH also monitors other performance indicators undertaken by various clinical audit committees:
Hand hygiene refers to the process of cleaning the hands by performing hand washing or through the use of alcohol-based hand rub solutions. In a healthcare setting, proper hand washing is the simplest way to reduce cross-transmission of microorganisms associated with infections which lead to increased length of stay, cost of care, and even mortality.
Despite this knowledge being imparted across all categories of healthcare staff, hand hygiene compliance rates have remained low. In multi-centre studies from 1981 to 1999, compliance to hand hygiene in ICUs has been observed to be less than 50%.1 In 2004, the WHO World Alliance for Patient Safety has initiated a global response in an effort to reduce healthcare-associated infections (HCAI), emphasizing the promotion of hand hygiene. Since then, various measurement tools and improvement efforts have been developed and implemented within and across countries.2
Measuring Hand Hygiene Compliance in NUH
Different institutions have their own ways of measuring hand hygiene compliance. They range from direct observation by trained observers, self-report by healthcare workers (HCWs), direct observation by patients, consumption of hygiene products and automated monitoring systems.3
The NUH audit process to measure hand hygiene compliance is very rigorous and it covers 33 wards 7 and ICUs. The NUH Infection Prevention Team, hospital management and clinical stakeholders have been working together to refine its hand hygiene programme since 2006. It includes training and assessment of healthcare staff at all levels of seniority on the proper techniques and timing of hand washing. In addition, it uses measurement tools such as direct observation, measurement of product use and conducting surveys. The ultimate aim is to decrease the number of healthcare associated infections, especially that of MRSA (Methicillin-resistant Staphylococcus aureus).
NUH Infection Prevention Team monitors staff hand hygiene compliance via covert observation. This means that the healthcare workers are not aware that they are being observed by an “undercover” auditor. This reduces bias because auditees tend to change their behaviour when they know that they are being audited (Hawthorne effect). Compliance is defined as the number of hand hygiene actions divided by the number of opportunities that require hand hygiene actions, multiplied by 100 and expressed as a percentage. NUH adopts the World Health Organisation’s guidelines on the “Five Moments of Hand Hygiene”4
- Before touching a patient
- Before clean/aseptic procedure
- After body fluid exposure risk
- After touching a patient
- After touching patient surroundings
Training of healthcare staff on hand hygiene is done during orientation for new staff. Posters on hand washing techniques are put up at strategic locations. Yearly Hand Hygiene campaigns, like observance of Hand Hygiene Week, and video and poster competitions, have increased staff awareness of its importance. Hand Hygiene Assessment for staff is held every two years.
The chart below shows the quarterly compliance rate from 2009 (Figure 1). These overall rates have been encouraging, as we have consistently achieved quarterly rates of >80% in 2017. We have over 2000 observations hospital wide per quarter, conducted by trained auditors.
Figure 1: Hand Hygiene Compliance in NUH
Source: NUH Infection Prevenetion
Information correct as at March 2018
1. Pittet, D, “Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach”, Emerging Infectious Diseases, Vol. 7, No. 2, March–April 2001
2. National Hand Hygiene: NHS Campaign Audit Report, 2007 http://www.documents.hps.scot.nhs.uk/hai/infection-control/national-hand-hygiene-campaign/audit-report.pdf, accessed on 20 May 2010
3. Measuring Hand Hygiene Adherence: Overcoming the Challenges http://www.jointcommission.org/NR/rdonlyres/68B9CB2F-789F-49DB-9E3F-2FB387666BCC/0/hh_monograph.pdf, accessed on 20 May 2010
4. “First Global Safety Challenge: Clean Care is Safer Care”, 2009, WHO Guidelines on Hand Hygiene in Health Care
Falls are one of the major patient safety concerns in hospitals as it results in injuries, prolonged hospital stay and increases healthcare utilisation and costs.
The occurrence of inpatient falls is one of the most commonly reported patient safety incidents. It can result in soft tissue injury, fractures and even death. The incident may also cause anxiety and depression to patients and may lead to decreased mobility due to fear of further falls1.
In view of the above, falls prevention has been a healthcare challenge, requiring a multi-faceted approach.2 Identification of risk factors is a key to success in preventing falls. These risk factors may be intrinsic (physiologic) or extrinsic (environmental or other hazards).3 Intrinsic factors are those that pertain to the patient’s health status, effects of polypharmacy (taking more than 6 drugs at any given time), leading to confusion, altered toilet needs, dizziness and changes in gait. Extrinsic factors would include poor lighting, physical obstruction, slippery flooring, and inappropriate footwear. Distinguishing between intrinsic or extrinsic factors can facilitate identification of preventive strategies.
NUH monitors falls as one of the patient safety indicators. It is adopted from the hospital-wide indicators of the International Quality Indicator Project (IQIP) since 2002. An inpatient fall is defined as one that is recorded by staff in the hospital’s incident report database. These documented falls are expressed as number of inpatient falls per 1000 patient days.
A multidisciplinary hospital fall prevention team was established in 2015 to look into key areas of focus. Initiatives focusing on staff awareness on Patient Safety, critical thinking, effective communication and accountability; mandating a critical evaluation of safety precautions and application of falls prevention protocol as follows:
- Post fall review
- Patient and Family education
- Footwear advice
- Structured 2 hourly rounding and supervised toileting
- Medication review
- Staff awareness and education to increase nurses’ knowledge of fall prevention practices
Figure1. Falls Rate in NUH
Data source: Incident Reporting System
Figure 1 above shows the trend over the years. NUH exhibits a marked decrease in fall rates over the years from 1.92 per thousand patient days in 2002 to 0.81 per thousand patient days up to the third quarter in 2017.
This clinical outcome data monitoring has proved to be very useful for our hospital in the planning and implementation of interventional measures. Multi-disciplinary involvement from the medical, nursing, allied health and administration teams has contributed largely to the goal of reducing inpatient falls.
Periodic review of guidelines, nursing staff education on risk assessment tools using a validated falls assessment tool that has undergone rigorous research3, and visual identifiers such as green wrist tags, name boards or ‘green eye’ for patients at risk for falls, have considerably reduced our falls rate over time.
Information correct as at March 2018
1. MOH Clinical Practice Guidelines: “Prevention of Falls in Hospitals and Long Term Care Institutions”, 2005, Ministry of Health, Singapore
2. Koh SL, et al, 2009, “Impact of a fall prevention programme in acute hospital settings Singapore”, Singapore Med J, Vol 50, Issue 4, pp 425-432
3. Yip WK, Mordiffi SZ, Wong HC, Ang E. 2016. Development and Validation of a Simplified Falls Assessment Tool in an Acute Care Setting. Journal of nursing care quality. DOI: 10.1097/NCQ.0000000000000183
4. Acute Care Implementation Manual, October 2006 Revision, International Quality Indicator Project, Center for Performance Sciences: Maryland, USA
NUH measures ventilator-associated events (VAEs). These events involve any deterioration in respiratory status after a period of stability or improvement on the ventilator, evidence of infection or inflammation, and laboratory evidence of respiratory infection. 1
From March 2016, MOH required the reporting of these VAEs. There are three tiers to this classification, each having specific clinical and laboratory criteria to be met in order to be identified as such:
Tier 1: Ventilator-associated Condition (VAC) – A patient on mechanical ventilation more than 2 days and baseline period of stability or improvement, followed by sustained period of worsening oxygenation
Tier 2: Infection-related Ventilator-associated Complication (IVAC) - Objective changes in temperature and/or white blood cell (WBC) counts along with the use of new antibiotic treatment
Tier 3: Possible Ventilator-associated Pneumonia (PVAP), determined by positive results of microbiology
The table below shows the trend of PVAP in NUH.
(Mar to Dec)
(n = 3)
(n = 3)
(n = 3)
Table 1. Possible Ventilation-associated Pneumonia (rate per 1000 ventilator-days)
Data source: Infection Prevention
Ways of preventing VAP in patients include limiting exposure to resistant bacteria, discontinuing mechanical ventilation as soon as possible, and a variety of strategies to limit infection while the patient is intubated. Drug-resistant infections increase the risk of death and are often associated with prolonged hospital stay. Hence, infection control measures are mandated in NUH with strict adherence to proper hand washing, sterile techniques for invasive procedures and isolation of individuals with known resistant organisms. As proposed by the US-based Institute of Healthcare Improvement (IHI), NUH has also implemented the 'ventilator bundle' in intensive care units. This bundle refers to care processes which aim to reduce VAP, a key component of which is the elevation of the head of the bed at 30° - 45°.
Previous monitoring of VAP (using IQIP definition), showed an increased trend of its acquisition in the coronary care unit (CCU). Thus, an evidence based implementation project was conducted to identify the compliance level of nurses in using the VAP bundle2. This evidence-based project utilised a process cycle of audit, feedback and re-audit strategy. It was implemented in three phases which include evidence review and pre-audit; training and education on best practice and evaluation. The audit tool was derived from Joanna Briggs Institute (JBI); Practical Application of Clinical Evidence System (PACES).1 Pre-audit results demonstrated that there is 0% compliance on daily cessation of sedation and 3% compliance assessment of readiness to extubate. Post-audit demonstrated an increase of 88% and 90% respectively. Only 47% staffs were compliant in positioning patients in semi-recumbent position during the pre-audit. An increase of 50% compliance was shown in the post-audit. Overall, the results showed a reduction in VAP rate. This project has shown reduction of VAP rate in CCU and increase in compliance of nurses.
Information correct as at March 2018
1. Technical Manual for the Surveillance of National Infection Control Indicators, 1 April 2016
2. Nyeo HQ¹, Tho PC¹, Yap EF¹, Ting KC¹, Khoo SN¹, Reducing Ventilator Associated Pneumonia (VAP) rate in the Coronary Care Unit: An Evidence-based Implementation Project, National University Hospital, Singapore
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