Medication Stockpiling (MS), in the Ministry of Health, Malaysia, resulted in the disposal of MYR 2 million worth of expired or spoilt medicines between 2014 and 2016. MS is an alarming issue that causes healthcare resources wastage and potentially harmful and toxic to patients. This study aimed to reduce MS in Hospital Selama, beginning with the medical wards within one year.
A situational analysis from the year 2013 to 2014 showed a 9.4% increase in MS. A four-month pre-intervention study from November 2014 to February 2015 revealed a 28% MS. The standard of the study was set based on the team members’ consensus. The aim was to reduce 50% of MS after four-month of intervention. The cause-effect analysis identified the main contributing factors of MS. The questionnaire was distributed to nurses in the wards and pharmacists to pinpoint the MS antecedent. The results indicated a lack of routine ward audit by the clinical pharmacists, over-indent by ward nurses and oversupply by the pharmacy unit. A flow-chart of the good care process comprises the steps of medications indent and supply was developed. It involved assigning the nightshift nurses for checking and indenting the wards’ medication stock, developing the ward stock indent (WSI) form, ensuring the pharmacy staff supply sufficient medication and enforcing a monthly ward audit by the clinical pharmacists and cross-audit by other pharmacists. Each indicator in the model of good care was then measured.
The post-intervention period successfully achieved a 3.5% MS; an 87.5% reduction (exceeded the target). Additionally, a cost reduction in the medication wastage from MYR 1,273.97 to MYR 654.44 was noted. The study successfully achieved less than 6% of MS from 2015 to 2018.
In conclusion, the study facilitated a successful collaboration among the hospital different units towards MS reduction.
The platelet concentrates (PCs) is used for the treatment and prevention of bleeding in patients with reduced platelet number or function. The prepared platelet concentrates (PCs) must meet the specified quality control (QC) test standards. PCs that do not meet QC standards will reduce the efficacy of patient care and increase the need of repeated PC transfusion. According to the standards, at least 75% PCs tested should contain more than 60 x 109 per platelet count units. Hence, the objective of this study was to increase the percentage of PCs that meet the platelet count standard to more or equal to 75%.
A cross sectional study was conducted from May 2015 to March 2016. Data were collected and analysed through monthly PCs QC test results. A retrospective QC data review in March and April 2015 showed only 30% PCs achieved the platelet count standard for QC tests. Intervention package was implemented to tackle the identified risk factors that lead to platelet count problems that do not meet the standards.
The post remedial results showed an increase to 90% of PCs that meet platelet count standards in January to February 2016. The study also found that the rate of platelet count increment in patients after PCs transfusion increased from 5 x 109 per ml to 9 x 109 per ml after the study. Additionally, the repeated PC transfusion rate decreased from 22% to 18%. Achievements were successfully maintained after the study which was 89% in March to April 2017. Continuous monitoring need to be carried out to ensure the achievement remains in compliance with the established standards. This quality improvement method has facilitated successful platelet transfusion to patient by improving the quality and performance of PCs. The improvement strategies of this study have the potential to be implemented at other blood collection centers in order to improve the quality of healthcare services.
Pregnant women with diabetes mellitus pose an increased risk of maternal and infant morbidity and mortality. In Perlis, for the year of 2016, only 3 (0.3%) out of 1,114 reproductive women with diabetes mellitus were using an intrauterine device (IUCD) as their main contraceptive measure. This project aims to improve the usage of IUCD to 10% among reproductive women with diabetes mellitus in nine health clinics of Perlis.
A retrospective contraception card review was undertaken to determine the baseline in providing IUCD services. Two sets of validated questionnaires were distributed to patients and healthcare providers in the pre and post-remedial period.
Customised training sessions were organised for both doctors and nurses’ group. A quick reference for IUCD was developed to guide the healthcare providers during counselling sessions. The Model of Good Care (MOGC) was integrated into the Maternal and Child Health State Plan of Action 2016 to ease the supervision of quality improvement.
Of the 244 diabetic women who had undergone counselling, 44 (18%) agreed to use IUCD and 38 (16%) of them inserted the IUCD within two weeks. Our project was able to increase the usage of IUCD among diabetic women in nine Perlis health clinics from 3 (0.3%) to 38 (3.4%) within six months. There was a gap reduction in achievable but not achieved (ABNA) from 9.7% to 6.6%. [ABNA = Achievable benefit not achieved]
Low usage of IUCD among diabetic women is a challenging issue and patient refusal to use IUCD, lack of husband support and comfortable with the previous contraception method were among the main contributing factors. However, providing continuous awareness and new process of effort in promoting the usage of IUCD among diabetic women do improve the uptake of the approach
Wastage due to unnecessary laboratory test requests is a major problem in government hospitals because they have cost implications. Although screening of infectious marker tests such as Human Immunodeficiency Virus (HIV), Hepatitis B surface Antigen (HBsAg), Hepatitis B antibody (AHBS) and Hepatitis C Virus (HCV)) before testing have been put in place, inappropriate tests were still being carried out in the Serology laboratory, which resulted in wasted human resources and reagents, increased workload and increased maintenance costs. Based on the verification studies using the Laboratory Information System (LIS), we observed only 70% of the tests followed the ordering guidelines or test specifications. Thus, we aim to increase the standard to more than 95% of the infectious marker test requests which were appropriate according to a few guidelines.
A cross-sectional study was conducted for all infectious marker tests received at Serology Laboratory from January 2015 to June 2016 to verify the problem. A workplace audit and questionnaire survey on the staff were carried out to gain more information. Low level of knowledge, unavailability of standardised guidelines for quick and easy reference, lack of staff and inefficient work processes were among the main contributing factors. Empowering new staff to screen specimens, developing simple and informative screening guidelines, providing adequate trays and refrigerators for screening purposes and strengthening and developing a more effective process of care were the strategies taken during this study.
The appropriate tests carried out from July to September 2015, October to December 2015, January to March 2016 and April to June 2016 were 99%, 98.80%, 99.50%, 98.90% respectively. During the same period, 711, 411, 710 and 768 tests were rejected. We monitored the performance and managed to achieve 100% appropriate testing for the period of July 2016 to June 2018 and an estimation of MYR 73,437.50 cost saving was achieve
Pre-pregnancy care (PPC) is a set of interventions used to identify and reduce women’s risks during reproductive age, especially women with chronic illnesses to achieve a healthy pregnancy. It includes optimisation of care, advice on appropriate contraception, and lifestyle modification. Our project aims to increase the PPC registration percentage of women with diabetes and hypertension from 53% to 100%, hence increasing their chances of receiving appropriate PPC intervention.
Both the cards of diabetic and hypertensive clients were reviewed using the PPC assessment form where the percentages of registered clients, completeness of registration, and aspects of interventions were calculated. We developed a new standardised guideline with a refined registration process into our routine Non-Communicable Disease (NCD) Clinic. The new PPC guideline implementation was reassessed every three months for two cycles by our district PPC team.
Post-intervention, the percentages of diabetes and hypertension clients registered with PPC has increased to 79.2%. Furthermore, proper registration helped to increase the percentages of PPC intervention from 86.6% to 95.3%. The implementation analysis showed that the completeness of five registration components had increased significantly from 1.4% to 16.8%. All elements under optimisation of care showed a positive changed, from 65.1% to 85.6% for optimisation of treatment, 48% to 52.6% for contraception advice, and 30.2% to 44% for lifestyle modifications.
We conclude based on the findings of this study that a well-structured PPC guideline with a few modifications that enhanced the process efficiency was able to increase the PPC registration percentages of eligible women with diabetes and hypertension and in turn, increase their chances of getting appropriate intervention. Continuous assessment and periodic PPC courses for healthcare workers are essential to ensure the sustainability of the implementation.
Pap smear screening is proven to be an effective tool for the early detection of cervical cancer. Public Health Laboratory of the Ministry of Health Malaysia (MOH) reported that Pontian Health District achieved only 69.4% out of the 4,112 targeted Pap smear screening performed in 2014. Pontian District Health Office conducted a Quality Assurance (QA) project, aiming to increase the percentage of Pap smear screening uptake among women in Pontian district to 100%.
A cross-sectional study using questionnaires was conducted in January 2015 involving 256 women to measure their knowledge, attitude, and practice towards Pap smear screening. The results showed 93.8% of respondents have a good knowledge of Pap smear. However, only 72% agreed to do Pap smear screening while 28% refused to do the screening. The 72 women declined the Pap smear screening for various reasons, such as time constraint (27%) feeling shy (27%), perceived the procedure as painful (23%), afraid to know the result (19%) and perceived the screening as unimportant (4%). The results also revealed only 44% of the respondents received information about Pap smear screening from health staff.
Several strategies were identified to overcome the reasons; the expansion of Pap smear screening to the workplace and residences overcome time constraint issue, an innovative tool known as “Sisih Malu” to combat the shyness feeling of doing Pap smear screening, while “Celik Servik” demonstrates the procedure as simple and painless. Active promotion of Pap smear screening was also conducted by the clinics’ staff who emphasised on cervical cancer early detection, which is more treatable at an early stage. These improvement strategies were conducted from February until December 2015.
Post-intervention saw Pap smear screening in Pontian district increased to 4,936 (118.9%), exceeding the 4,152 target set for 2015 and increased 130.5% in 2016. Another survey among 99 women in January 2016 showed that a 100% willingness to undergo a Pap smear screening
Neonates in Special Care Nursery (SCN) are constantly exposed to routine procedures that are painful. Repetitive painful exposures in neonates are known to have long-term deleterious effects that may surpass adulthood. A quality improvement project was designed to reduce the pain experienced by neonates during routine minor procedures in SCN unit of Hospital Tuanku Fauziah (HTF), a tertiary state hospital in Perlis, Malaysia. The Neonatal Infant Pain Scale (NIPS) was used as a pain assessment tool in neonates throughout the study. Several factors contributing to neonatal painful experience during routine procedures were identified, including poor awareness on neonatal pain perception, poor procedural etiquette among paediatric house officers, and lack of non-pharmacological pain relief used during the procedures. Interventional measures included adjunctive use of non-nutritive sucking via orthodontic Avent® pacifier, use of adjustable swaddling blanket via SwaddleMe® size S, and introduction of a clinical training module for the house officers. There were 159 neonates recruited in the pre-intervention period and 163 neonates evaluated in the post-intervention period. Our study revealed a significant decrease in neonatal painful experience during routine procedures, from 49.7% to 17.8% (p
The Department of Oral & Maxillofacial Surgery at Hospital Sultanah Aminah, Johor Bahru started managing patients who lost their eyeballs with ocular prosthesis in 2013. Unfortunately, there was an increasing trend of failed ocular prosthesis from 2013-2015. The failure rate went from 28.6% in 2013 to 40% in 2014 and increased to 44.4% in 2015. Failed ocular prosthesis not only leads to dissatisfied patients but also an increase in cost due to redoing of prosthesis. The objective of this project was to reduce the incidence rate of failed ocular prosthesis. A failed case is when the prosthesis does not pass the issue stage and has to be redone from the beginning. The standard failure rate is 0%, as the average number of cases per year is only about 10 cases. We determined the contributing factors of failed ocular prosthesis by analysing retrospective data from patients’ dental and lab records. This was followed by a self-administered questionnaire on reasons for failed cases which was distributed among the dentists and lab technicians in our department. The contributing factors that were identified included insufficient knowledge or skill of dentist and lab technicians in the construction of the ocular prosthesis, as well as improper screening of new cases which was the main factor of all the failed cases. The strategies for change included improving the process of care by creating a checklist for proper screening of new patients, mentoring of new staff, and continuous training on construction of ocular prosthesis, Fabricated Iris Mould innovation technique and early referral for insertion of eye conformer. The interventions that were implemented reduced the failure rate to 20% in 2016 followed by 0% in 2017, 2018 and 2019. Ongoing efforts are being done to replicate this project in other Oral & Maxillofacial Surgery clinics in Johor.
Lukman Nul Hakim Md Khairi, Farah Syakirah Ahmad, Aimi Shazana Muhammad Anuar, Nurul Ain Wan Omar, Nurul Najmi Muhammad, Nurulhayati Abd. Jamal, et al.
Therapeutic drug monitoring (TDM) is a valuable clinical tool in optimisation of drug regimens. However, improper utilisation of TDM may lead to significant resource wastage and expose patients to avoidable trauma, toxicity, therapeutic failure and prolonged hospitalisation. This study aimed to reduce the percentage of inappropriate TDM sampling to our proposed standard of less than 20% within a four-month intervention period. A cross-sectional study was undertaken from January to December 2015 at the inpatient setting of Hospital Sultanah Nur Zahirah. Gentamicin and Vancomycin analytes were studied because these analytes accounted for 69.2% of total samples received in 2014. TDM Monitoring Form was used to collect sampling and dosage information to assess sampling appropriateness. A closed-ended self-administered questionnaire was distributed to a group of medical doctors to assess their knowledge on appropriate Gentamicin and Vancomycin TDM sampling method pre- and post-intervention. Prior to the intervention phase in October to December 2014, 79.4% of TDM were inappropriately sampled. The main contributing factors were inadequate knowledge among medical doctors, lack of sampling reminders for new TDM requests, and misunderstanding on sampling information for repeated TDM requests. 60-minute face-to-face educational sessions on TDM sampling method were conducted specifically for staff at the General Medical and Paediatric Departments, and two continuing medical education (CME) slots were held at the hospital level. Guidelines on TDM sampling was initiated and laminated copies were distributed to all wards. Implementation of TDM Alert System which consisted of digital reminders and physical stickers was also introduced. The interventions were able to reduce the inappropriate sampling percentage from 79.4% to 41.8% post-intervention, and to 19.1% in the recent monitoring phase of January until June 2019. Continuous close monitoring and sustainable implementation of the measures are vital as TDM sampling appropriateness may affect clinical interpretation of the results.
Lukman Nul Hakim Md Khairi, Farah Syakirah Ahmad, Nur Liyana Mohd Fozi, Aimi Shazana Muhammad Anuar, Wan Najiah W. Mokhtar @ W. Moxtor, Maznuraini Zainuddin
Bedside dispensing (BD) is one of the clinical services offered by the Pharmacy Department to patients prior to their hospital discharge. Increment in number of BD may improve the patients’ discharge process, patients’ satisfaction and their medication knowledge. This project aimed at increasing the percentage of BD in adult medical wards of Hospital Sultanah Nur Zahirah (HSNZ). The proposed standard of BD percentage was at least 30% within four months of intervention. The project was conducted from November 2016 to December 2019. The monthly report of pharmacy BD record was analysed to assess the achievement of BD. A pre-interventional retrospective BD data review of discharge prescriptions received throughout 2016 showed that only 8.1% of discharge prescriptions were dispensed at the bedside. A closed-ended questionnaire to evaluate knowledge, experience and perceived contributing factors to the low percentage of BD was distributed to nurses, inpatient pharmacists and ward pharmacists. The main contributing factors identified included time constraint, poor understanding of BD workflow, inadequate staff awareness and lack of cooperation among healthcare providers. Institutional BD workflow was implemented involving the introduction of discharge prescriptions pick-up points at medical wards, and a scheduled timing for prescriptions collection and dispensing during office hours. Three face-to-face educational sessions on overview of BD and its latest workflow were given to staff nurses, inpatient pharmacists at discharge pharmacy unit and ward pharmacists. In 2017, the percentage of BD increased from 8.1% to 28.0% after the implementation of interventions, and subsequently to 60.0% in the latest maintenance phase of January until December 2019. The sustainable implementation of this BD program could be shared and implemented at other facilities with inpatient discharge services to improve healthcare delivery.
Preschool children are one of the major target groups of the Oral Health Program, Ministry of Health Malaysia. However, caries prevalence of preschool children due to unmet treatment needs remains high. Thus, it is imperative for preschool children to receive dental treatment to maintain or restore function and aesthetics, prevent premature tooth loss and improve their quality of life. We aimed to increase the percentage of preschool children receiving dental treatment at kindergartens from 9.8% to 30% in a year. A cross-sectional study was conducted in January 2015 to March 2015 to identify factors contributing to low percentage of preschool children receiving dental treatment using a structured questionnaire modified and adapted from literatures. Ten kindergartens in Machang District were randomly selected, and a total of 200 preschool children, 180 parents and 13 dental therapists in Machang District were recruited for this study. Remedial measures were implemented in April 2015 until September 2015, followed by a post-remedial evaluation in October 2015 to December 2019. The factors contributing to low percentage included inconvenient visit schedule, lack of monitoring system, preschool children at kindergartens refusing dental treatment, and lack of oral health knowledge and awareness among parents. A series of interventions were introduced including improvement of care process, systematic planned visits, and formation of a dedicated team for kindergartens. Oral Health Education and seminars were given to parents. Supportive environment and innovations were created, including colorful attire, cartoon accessories and Benzo Kids’ eye-wear tools. The Benzo Kids functioned as a smart phone holder for a child to watch their favourite video during treatment to divert the child’s attention and reduce anxiety. The percentage of preschool children receiving dental treatment at kindergartens increased from 9.8% (2014) to 55.9% (2019), which exceeded the initial target of 30%. This study has had a significant impact on the number of deciduous teeth with dental caries of these preschool children when they progress to primary one. The HMIS data showed a decreasing trend of dental caries per 100 children from 80(2013) to 58(2019).