Developing patient safety system using WHO tool in hospitals in Oman

Developing patient safety system using WHO tool in hospitals in Oman Abstract Objective Oman is progressively implementing the Patient Safety Friendly Hospital Initiative (PSFHI), a tool formulated by the World Health Organization (WHO) to achieve optimal patient safety in hospitals. This paper describes its implementation in selected government and private hospitals in Oman and analyses the performance of four hospitals whose implementations of PSFHI were assessed by WHO. Design The PSFHI initiative was launched in 11 hospitals in Oman during 2016. The enrolled hospitals implemented a 1-year plan composed of several steps such as formation of steering committees, working groups, full orientation about the standards, training of staff, documents development and community involvement. One year later, four hospitals which were the earliest to join the initiative were subjected to WHO assessment. Setting Secondary level government and private hospitals. Intervention(s) The WHO-PSFHI standards. Main Outcome Measure Hospitals’ adherence to the standards. Results Three of the four hospitals (one government and two private) scored level two. One government hospital scored level three, earning it the distinction of being the first hospital in the Eastern Mediterranean Region to reach level three in the very first assessment. Conclusions Implementation of PSFHI in selected hospitals of Oman had successful outcomes in improving patient’s safety. patient safety, patient safety friendly hospital initiative, Oman, hospital care Introduction World Health Organization (WHO) estimates that in developed countries as many as 10% patients are harmed while receiving hospital care [1]. Hospital-acquired infections affect ~14% of admitted patients [1]. Furthermore, it is estimated that 310 million surgical operations are performed globally every year and surgical care is associated with considerable risk of complications. Half of the complications associated with surgical care are avoidable [1]. A recent worldwide study of 474 hospitals conducted by the International Surgical Outcome Study Group found that 16.8% surgical patients developed complications in the hospital. Compare this figure with the 1 in 1 0 00 000 chance of a traveler being harmed while in an aircraft [1, 2]. Such alarming statistics from the healthcare industry have greatly increased the awareness of these mostly avoidable consequences of hospitalization and the need for revamping all aspects of patient care systems. Medical errors also increase the direct and indirect economic costs of running a hospital. It is difficult to quantify the complex economic impact of poor quality and unsafe care due to the multiple overlapping variables such as loss of life or functionality, and inefficient and wasteful utilization of manpower and facilities [3], all of which eventually has to be borne by the society. Patient safety concept emerged in the Western world as recently as the 1990s. The initial motivators were pressures from accreditors such as the Joint Commission, media exposures, local and regional collaborations, and nongovernmental organizations such as the Institute for Healthcare Improvement [4]. This ultimately led to the emergence of a functional business case for improving patient safety, driven by public and governmental reporting systems [5], growing fines for serious cases of harm and emergence of ‘no pay for errors’ policies [6–8]. However, in spite of such movements, evidence showed that progress in eradicating medical errors still did not match the invested financial resources and efforts [9]. The major reason behind the underperformance was the absence of systematic assessment and monitoring [10]. WHO recognized the importance of patient safety and currently considers it as top priority in public healthcare [11]. Accordingly, WHO Regional Office in East Mediterranean launched a Patient Safety Program and supported the countries of the Eastern Mediterranean Region to implement the program through adopting and adapting the PSFHI to regional needs. This initiative was launched in 2007 to tackle the enormous problems of unsafe healthcare in the region [12]. This initiative involves the implementation of a set of patient safety standards in hospitals. Compliance with the standards ensures that patient safety is accorded the necessary priority and staff implement the best practice. The first version of the assessment manual was published in 2011, followed by version two in 2016 [13]. In 2016, Ministry of Health launched PSFHI and included it as an integral part of its strategic plan. Within this 1-year scheme, as many as 11 hospitals (8 government and 3 private) were short-listed to incorporate PSFHI in their respective work mechanism. In May 2017, the outcome of this initiative was scrutinized in four hospitals by WHO experts. These hospitals were selected based on their order of enrollment in PSFHI. Meanwhile, the consultant schedule permitted assessment of only these four hospitals. Methods This observational cohort study included four hospitals (two government and two private) which implemented the PSFHI for 1 year at the end of which they were assessed by WHO experts. The government hospitals provide secondary care services with more number of beds, while private hospitals provide primary and secondary care services (Table 1). One of the private hospitals was accredited by the Joint Commission International. Table 1 The four hospitals’ size and patient population for the year 2016 Sector  Hospital  Bed number  Average daily patient population  Private  I  50–100  Daily bed occupants: 17 Daily outpatient visits: 384 Daily emergency visits: 114  II  50–100  Daily bed occupants: 40 Daily outpatient visits: 600 Daily emergency visits: 150  Governmental  III  250  Daily bed occupants: 205 Daily outpatient visits: 652 Daily emergency visits: 161  IV  305  Daily bed occupants: 305 Daily outpatient visits: 650–700 Daily emergency visits: 190–220  Sector  Hospital  Bed number  Average daily patient population  Private  I  50–100  Daily bed occupants: 17 Daily outpatient visits: 384 Daily emergency visits: 114  II  50–100  Daily bed occupants: 40 Daily outpatient visits: 600 Daily emergency visits: 150  Governmental  III  250  Daily bed occupants: 205 Daily outpatient visits: 652 Daily emergency visits: 161  IV  305  Daily bed occupants: 305 Daily outpatient visits: 650–700 Daily emergency visits: 190–220  Table 1 The four hospitals’ size and patient population for the year 2016 Sector  Hospital  Bed number  Average daily patient population  Private  I  50–100  Daily bed occupants: 17 Daily outpatient visits: 384 Daily emergency visits: 114  II  50–100  Daily bed occupants: 40 Daily outpatient visits: 600 Daily emergency visits: 150  Governmental  III  250  Daily bed occupants: 205 Daily outpatient visits: 652 Daily emergency visits: 161  IV  305  Daily bed occupants: 305 Daily outpatient visits: 650–700 Daily emergency visits: 190–220  Sector  Hospital  Bed number  Average daily patient population  Private  I  50–100  Daily bed occupants: 17 Daily outpatient visits: 384 Daily emergency visits: 114  II  50–100  Daily bed occupants: 40 Daily outpatient visits: 600 Daily emergency visits: 150  Governmental  III  250  Daily bed occupants: 205 Daily outpatient visits: 652 Daily emergency visits: 161  IV  305  Daily bed occupants: 305 Daily outpatient visits: 650–700 Daily emergency visits: 190–220  The PSFHI manual provides the necessary tools for assessing hospitals. It is organized into two sections that include patient safety standards and hospital assessment tools [13]. Section 1 is composed of five domains that include ‘leadership and management’, ‘patient and public involvement’, ‘safe evidence-based clinical practices’, ‘safe environment’, and ‘lifelong learning’ (Table 2). These domains are divided into 24 subdomains with 139 standards that are categorized into critical [20 standards], core [89 standards] and developmental [30 standards]. Section 2 is composed of a set of tools to facilitate the assessment process. Table 2 Domains and standards of the PSFHIa Domains  Critical standards  Core standards  Developmental standards  Total  A. Leadership and management  7  19  6  32  B. Patient and public involvement  2  16  10  28  C. Safe evidence-based clinical practice  9  32  9  50  D. Safe environment  2  18  0  20  E. Lifelong learning  0  4  5  9  Total  20  89  30  139  Domains  Critical standards  Core standards  Developmental standards  Total  A. Leadership and management  7  19  6  32  B. Patient and public involvement  2  16  10  28  C. Safe evidence-based clinical practice  9  32  9  50  D. Safe environment  2  18  0  20  E. Lifelong learning  0  4  5  9  Total  20  89  30  139  aPSFHI: Patient Safety Friendly Hospital Initiative. Table 2 Domains and standards of the PSFHIa Domains  Critical standards  Core standards  Developmental standards  Total  A. Leadership and management  7  19  6  32  B. Patient and public involvement  2  16  10  28  C. Safe evidence-based clinical practice  9  32  9  50  D. Safe environment  2  18  0  20  E. Lifelong learning  0  4  5  9  Total  20  89  30  139  Domains  Critical standards  Core standards  Developmental standards  Total  A. Leadership and management  7  19  6  32  B. Patient and public involvement  2  16  10  28  C. Safe evidence-based clinical practice  9  32  9  50  D. Safe environment  2  18  0  20  E. Lifelong learning  0  4  5  9  Total  20  89  30  139  aPSFHI: Patient Safety Friendly Hospital Initiative. Compliance to critical standards is mandatory for a hospital to be eligible to be enrolled in the initiative. Meeting the core standards is not compulsory. However, the higher the overall score achieved, the higher the level hospital is ranked (Table 3). The developmental standards are those which enhance safe care of patients, and hospitals should attempt to comply with these according to their capabilities. To achieve level four of compliance, ≥80% of these standards are to be fulfilled. Table 3 Levels of compliance with patient safety standards Hospital-level  Critical standards (%)  Core standards  Developmental standards  Level 1  100  Any  Any  Level 2  100  60–89%  Any  Level 3  100  ≥90%  Any  Level 4  100  ≥90%  ≥80%  Hospital-level  Critical standards (%)  Core standards  Developmental standards  Level 1  100  Any  Any  Level 2  100  60–89%  Any  Level 3  100  ≥90%  Any  Level 4  100  ≥90%  ≥80%  Table 3 Levels of compliance with patient safety standards Hospital-level  Critical standards (%)  Core standards  Developmental standards  Level 1  100  Any  Any  Level 2  100  60–89%  Any  Level 3  100  ≥90%  Any  Level 4  100  ≥90%  ≥80%  Hospital-level  Critical standards (%)  Core standards  Developmental standards  Level 1  100  Any  Any  Level 2  100  60–89%  Any  Level 3  100  ≥90%  Any  Level 4  100  ≥90%  ≥80%  Implementation of this initiative was made with a 1-year plan divided into three phases. Phase 1, the pre-implementation phase, was of 2 months’ duration. The following steps were taken: Official launching of the initiative and public announcement in presence of key community figures and government officials. Dissemination of the initiative details through media and printed material. Formation of steering committee and four multidisciplinary working groups with clear description of terms of reference and line of reporting in order to ensure consistent and sustainable committee and groups work. Training of the committee and working groups’ members on the initiative standards and assessment tool. Gap analysis with proposed recommendations of improvement. Such analysis helped the hospital to prepare for the first assessment after 2–3 months. Phase 2 lasted 8 months and was composed of the following steps: Review of the gap analysis report and acting accordingly. Further training of members of the committee and working groups. Staff training on various quality and patient’s safety issues. Carrying out two assessments, 3 months apart. These assessments were based on four major review tools, as per WHO manual, that include document review, leaders and managers interviews, staff and patients and their relatives interview, and site visits to verify implementation of whatever policy. The assessment was carried out in 2 days for each hospital. Day 1 was dedicated for readying of hospital brief by the leadership, reviewing documents and interviewing leaders and managers using a standardized questionnaire. Day 2 was dedicated for interviewing staff and patients and their relatives from various units using standardized questionnaire, sites visits and debriefing the hospital leadership, and the committee and working groups. Phase 3 lasted 2 months and it consisted of the following steps: Follow-up of implementing recommendations from previous assessments. Carrying out the third assessment preparing hospital to the WHO assessment. Further, training of staff on various quality and patient’s safety issues. WHO assessment, which is conducted in 2–3 days. A coordinator from the Directorate General of Quality Assurance Center (DGQAC) was identified for each hospital to facilitate and follow-up implementation of the initiative standards. Furthermore, several meetings were held between the four hospitals that were aimed to share experiences. In addition, the DGQAC created an electronic tool that facilitated the assessment, analysis and reporting processes. The tool was adopted by WHO-EMRO and shared with member countries implementing PSFHI. Results The result of the WHO assessment was impressive for the four hospitals. These hospitals have met 100% of the critical standards (Table 4). One government hospital achieved level three, making it the first hospital in EMRO that scored such a level from the first assessment. The other three hospitals (one government and two private) achieved level two. Table 4 Results of hospitals assessment Domain  Critical standards N (%)  Core standards N (%)  Developmental standards N (%)  Total N (%)  Hospital I  A  7/7 (100)  15/18 1na (83)  2/6 (33)  24/31 (77)  B  2/2 (100)  12.5/16 (78)  1/10 (10)  15.5/28 (55)  C  9/9 (100)  27/32 (84)  5/9 (56)  41/50 (82)  D  2/2 (100)  12/17 1na (71)  -  14/19 (74)  E  -  1.5/4 (38)  1.5/5 (30)  3/9 (33)    20/20 (100)  68/87 (78)  9.5/30 (32)  97.5/137 (71)  Domain  Hospital II  A  7/7 (100)  15.5/18 1na (86)  4/6 (67)  26.5/31 (85)  B  2/2 (100)  12/16 (75)  2.5/10 (25)  16.5/28 (59)  C  9/9 (100)  28/32 (89)  5.5/9 (61)  43/50 (86)  D  2/2 (100)  10.5/17 1na (62)  -  12.5/19 (66)  E  -  1.5/4 (38)  2.5/5 (50)  4/9 (44)    20/20 (100)  67.5/87 (78)  14.5/30 (48)  102/137 (74)  Domain  Hospital III  A  7/7 (100)  16.5/18 1na (92)  3.5/6 (58)  27/31 (87)  B  2/2 (100)  10.5/16 (66)  5/10 (50)  17.5/28 (63)  C  9/9 (100)  29/32 (92)  2.5/9 (28)  40.5/50 (81)  D  2/2 (100)  16/17 1na (94)  -  18/19 (95)  E  -  1.5/4 (38)  3/5 (60)  4/9 (44)    20/20 (100)  73/87 (84)  14/30 (47)  107/137 (78)  Domain  Hospital IV  A  7/7 (100)  16.5/19 (87)  5/6 (83)  28.5/32 (89)  B  2/2 (100)  14.5/16 (91)  1/10 (10)  17.5/28 (63)  C  9/9 (100)  31.5/32 (98)  6/9 (67)  46.5/50 (93)  D  2/2 (100)  15/17 1na (88)  -  17/19 (89)  E  -  2.5/4 (63)  3/5 (60)  5.5/9 (61)    20/20 (100)  80/88 (90)  15/30 (50)  115/138 (83)  Domain  Critical standards N (%)  Core standards N (%)  Developmental standards N (%)  Total N (%)  Hospital I  A  7/7 (100)  15/18 1na (83)  2/6 (33)  24/31 (77)  B  2/2 (100)  12.5/16 (78)  1/10 (10)  15.5/28 (55)  C  9/9 (100)  27/32 (84)  5/9 (56)  41/50 (82)  D  2/2 (100)  12/17 1na (71)  -  14/19 (74)  E  -  1.5/4 (38)  1.5/5 (30)  3/9 (33)    20/20 (100)  68/87 (78)  9.5/30 (32)  97.5/137 (71)  Domain  Hospital II  A  7/7 (100)  15.5/18 1na (86)  4/6 (67)  26.5/31 (85)  B  2/2 (100)  12/16 (75)  2.5/10 (25)  16.5/28 (59)  C  9/9 (100)  28/32 (89)  5.5/9 (61)  43/50 (86)  D  2/2 (100)  10.5/17 1na (62)  -  12.5/19 (66)  E  -  1.5/4 (38)  2.5/5 (50)  4/9 (44)    20/20 (100)  67.5/87 (78)  14.5/30 (48)  102/137 (74)  Domain  Hospital III  A  7/7 (100)  16.5/18 1na (92)  3.5/6 (58)  27/31 (87)  B  2/2 (100)  10.5/16 (66)  5/10 (50)  17.5/28 (63)  C  9/9 (100)  29/32 (92)  2.5/9 (28)  40.5/50 (81)  D  2/2 (100)  16/17 1na (94)  -  18/19 (95)  E  -  1.5/4 (38)  3/5 (60)  4/9 (44)    20/20 (100)  73/87 (84)  14/30 (47)  107/137 (78)  Domain  Hospital IV  A  7/7 (100)  16.5/19 (87)  5/6 (83)  28.5/32 (89)  B  2/2 (100)  14.5/16 (91)  1/10 (10)  17.5/28 (63)  C  9/9 (100)  31.5/32 (98)  6/9 (67)  46.5/50 (93)  D  2/2 (100)  15/17 1na (88)  -  17/19 (89)  E  -  2.5/4 (63)  3/5 (60)  5.5/9 (61)    20/20 (100)  80/88 (90)  15/30 (50)  115/138 (83)  na, not applicable; -, no standard. A, B, C, D and E: please refer to Table 2. Table 4 Results of hospitals assessment Domain  Critical standards N (%)  Core standards N (%)  Developmental standards N (%)  Total N (%)  Hospital I  A  7/7 (100)  15/18 1na (83)  2/6 (33)  24/31 (77)  B  2/2 (100)  12.5/16 (78)  1/10 (10)  15.5/28 (55)  C  9/9 (100)  27/32 (84)  5/9 (56)  41/50 (82)  D  2/2 (100)  12/17 1na (71)  -  14/19 (74)  E  -  1.5/4 (38)  1.5/5 (30)  3/9 (33)    20/20 (100)  68/87 (78)  9.5/30 (32)  97.5/137 (71)  Domain  Hospital II  A  7/7 (100)  15.5/18 1na (86)  4/6 (67)  26.5/31 (85)  B  2/2 (100)  12/16 (75)  2.5/10 (25)  16.5/28 (59)  C  9/9 (100)  28/32 (89)  5.5/9 (61)  43/50 (86)  D  2/2 (100)  10.5/17 1na (62)  -  12.5/19 (66)  E  -  1.5/4 (38)  2.5/5 (50)  4/9 (44)    20/20 (100)  67.5/87 (78)  14.5/30 (48)  102/137 (74)  Domain  Hospital III  A  7/7 (100)  16.5/18 1na (92)  3.5/6 (58)  27/31 (87)  B  2/2 (100)  10.5/16 (66)  5/10 (50)  17.5/28 (63)  C  9/9 (100)  29/32 (92)  2.5/9 (28)  40.5/50 (81)  D  2/2 (100)  16/17 1na (94)  -  18/19 (95)  E  -  1.5/4 (38)  3/5 (60)  4/9 (44)    20/20 (100)  73/87 (84)  14/30 (47)  107/137 (78)  Domain  Hospital IV  A  7/7 (100)  16.5/19 (87)  5/6 (83)  28.5/32 (89)  B  2/2 (100)  14.5/16 (91)  1/10 (10)  17.5/28 (63)  C  9/9 (100)  31.5/32 (98)  6/9 (67)  46.5/50 (93)  D  2/2 (100)  15/17 1na (88)  -  17/19 (89)  E  -  2.5/4 (63)  3/5 (60)  5.5/9 (61)    20/20 (100)  80/88 (90)  15/30 (50)  115/138 (83)  Domain  Critical standards N (%)  Core standards N (%)  Developmental standards N (%)  Total N (%)  Hospital I  A  7/7 (100)  15/18 1na (83)  2/6 (33)  24/31 (77)  B  2/2 (100)  12.5/16 (78)  1/10 (10)  15.5/28 (55)  C  9/9 (100)  27/32 (84)  5/9 (56)  41/50 (82)  D  2/2 (100)  12/17 1na (71)  -  14/19 (74)  E  -  1.5/4 (38)  1.5/5 (30)  3/9 (33)    20/20 (100)  68/87 (78)  9.5/30 (32)  97.5/137 (71)  Domain  Hospital II  A  7/7 (100)  15.5/18 1na (86)  4/6 (67)  26.5/31 (85)  B  2/2 (100)  12/16 (75)  2.5/10 (25)  16.5/28 (59)  C  9/9 (100)  28/32 (89)  5.5/9 (61)  43/50 (86)  D  2/2 (100)  10.5/17 1na (62)  -  12.5/19 (66)  E  -  1.5/4 (38)  2.5/5 (50)  4/9 (44)    20/20 (100)  67.5/87 (78)  14.5/30 (48)  102/137 (74)  Domain  Hospital III  A  7/7 (100)  16.5/18 1na (92)  3.5/6 (58)  27/31 (87)  B  2/2 (100)  10.5/16 (66)  5/10 (50)  17.5/28 (63)  C  9/9 (100)  29/32 (92)  2.5/9 (28)  40.5/50 (81)  D  2/2 (100)  16/17 1na (94)  -  18/19 (95)  E  -  1.5/4 (38)  3/5 (60)  4/9 (44)    20/20 (100)  73/87 (84)  14/30 (47)  107/137 (78)  Domain  Hospital IV  A  7/7 (100)  16.5/19 (87)  5/6 (83)  28.5/32 (89)  B  2/2 (100)  14.5/16 (91)  1/10 (10)  17.5/28 (63)  C  9/9 (100)  31.5/32 (98)  6/9 (67)  46.5/50 (93)  D  2/2 (100)  15/17 1na (88)  -  17/19 (89)  E  -  2.5/4 (63)  3/5 (60)  5.5/9 (61)    20/20 (100)  80/88 (90)  15/30 (50)  115/138 (83)  na, not applicable; -, no standard. A, B, C, D and E: please refer to Table 2. Hospital (I) scored maximum for safe evidence-based clinical practices domain (82%) followed by leadership and management domain (77%); Table 4. This was followed by safe environment (74%), and patient and public involvement domains (55%). The lowest score was for lifelong learning domain (33%). The overall score of the hospital was 71%. As hospital met 100% of critical standards, 78% of core standards and 32% of developmental standards, it achieved level two. Hospital (II) recorded the highest score for safe evidence-based clinical practices domain (86%), followed by leadership and management domain (85%); Table 4. This was followed by safe environment (66%) and patient and public involvement domains (59%). The lowest score was recorded for lifelong learning domain (44%). The overall score of the hospital was 74%. As the hospital met 100% of critical standards, 78% of core standards and 48% of developmental standards, it achieved level two Hospital (III) accomplished the following scores; 95% for safe environment domain, followed by leadership and management domain (87%), safe evidence-based clinical practices domain (81%), and patient and public involvement domain (63%); Table 4. The lowest was recorded for lifelong learning measures (44%). The overall score of the hospital was 78%. As the hospital met 100% of critical standards, 84% of core standards and 47% of developmental standards, it achieved level two. Hospital (IV) scored 93% for the safe evidence-based clinical practices domain followed by leadership and management and safe environment domains (89% each); Table 4. Patient and public involvement domain scored 63% while lifelong learning measures scored 61%. As the hospital met 100% of critical standards, 90% of core standards, and 50% of developmental standards, it achieved level three. It is worth noting that low scores (≤50%) of some subdomains led to low overall score of the concerned domains. Interestingly, deep review of the scores suggests that this was due to low scores for developmental standards in the four hospitals (Table 5). For example, hospitals were lacking the system of communicating patient safety incidents to patients and their carers (subdomain B5). Similarly, hospitals were lacking sustainable systems that ensure continuous professional development on patients’ safety as well as monitoring of impact of such program (subdomain E1). Therefore, the hospitals were requested to create improvement action plan with specific timeframe based on the WHO consultants’ suggestions. Follow-up plan is prepared by the DGQAC. Table 5 Hospitals with ≤50% scores for the subdomains Domain  Subdomain  Hospital score (%)  I  II  III  IV  A  A.2. The hospital has a Patient Safety Program  50+  50+  25+  50+  A.3. The hospital uses data to improve safety performance  25+  50+  0+  50*  A.5. The hospital ensures staff safety for safer patients and availability of staff round the clock to deliver safe care      50+    A.6. Hospital has policies, guidelines, and standard operation procedure (SOP) for all departments and supporting services      0* 50+    B  B.1. Patient safety is incorporated into hospital’s patient and family rights statement  0+  50* 0+  0+  0+  B.2. The hospital builds health awareness for its patients and carers to empower them to share in making the right decisions regarding their care      50+  0+  B.3. The hospital ensures proper patient identification and verification at all stages of care  0+  0+  0+    B.4. The hospital involves community in different patient safety activities  17* 0+  50* 50+  0+  0+  B.5. The hospital communicates patient safety incidents to patients and their carers  50+  0+  0+  0+  B.6. The hospital encourages patients to speak up and acts upon the patient’s voice    0+  0+  0+  C  C.1. The hospital has an effective clinical system that assures inclusion of patient safety      50+    C.3. The hospital ensures safety of blood and blood products  50+    50+  0+  C.4. The hospital ensures safe injections, infusions, and immunization    50*  50*    C.5. The hospital has a safe medication system  0+  25+  50+    C.6. The hospital has completed medical records system  12.5+  50+      D  D.2. The hospital has a safe waste management system    33+  50*    E  E.1. The hospital has a staff professional development program with patient safety as a cutting theme  50* 50+  50+  50+  0+  E.2. The hospital verifies competency for all health professionals working in it or contracted      25+  50  E.3. The hospital conducts research in patient safety on ongoing basis  0* 50+  25+  0* 25+  50* 50+  Domain  Subdomain  Hospital score (%)  I  II  III  IV  A  A.2. The hospital has a Patient Safety Program  50+  50+  25+  50+  A.3. The hospital uses data to improve safety performance  25+  50+  0+  50*  A.5. The hospital ensures staff safety for safer patients and availability of staff round the clock to deliver safe care      50+    A.6. Hospital has policies, guidelines, and standard operation procedure (SOP) for all departments and supporting services      0* 50+    B  B.1. Patient safety is incorporated into hospital’s patient and family rights statement  0+  50* 0+  0+  0+  B.2. The hospital builds health awareness for its patients and carers to empower them to share in making the right decisions regarding their care      50+  0+  B.3. The hospital ensures proper patient identification and verification at all stages of care  0+  0+  0+    B.4. The hospital involves community in different patient safety activities  17* 0+  50* 50+  0+  0+  B.5. The hospital communicates patient safety incidents to patients and their carers  50+  0+  0+  0+  B.6. The hospital encourages patients to speak up and acts upon the patient’s voice    0+  0+  0+  C  C.1. The hospital has an effective clinical system that assures inclusion of patient safety      50+    C.3. The hospital ensures safety of blood and blood products  50+    50+  0+  C.4. The hospital ensures safe injections, infusions, and immunization    50*  50*    C.5. The hospital has a safe medication system  0+  25+  50+    C.6. The hospital has completed medical records system  12.5+  50+      D  D.2. The hospital has a safe waste management system    33+  50*    E  E.1. The hospital has a staff professional development program with patient safety as a cutting theme  50* 50+  50+  50+  0+  E.2. The hospital verifies competency for all health professionals working in it or contracted      25+  50  E.3. The hospital conducts research in patient safety on ongoing basis  0* 50+  25+  0* 25+  50* 50+  *Core standards. +Developmental standards. A, B, C, D and E: please refer to Table 2. Table 5 Hospitals with ≤50% scores for the subdomains Domain  Subdomain  Hospital score (%)  I  II  III  IV  A  A.2. The hospital has a Patient Safety Program  50+  50+  25+  50+  A.3. The hospital uses data to improve safety performance  25+  50+  0+  50*  A.5. The hospital ensures staff safety for safer patients and availability of staff round the clock to deliver safe care      50+    A.6. Hospital has policies, guidelines, and standard operation procedure (SOP) for all departments and supporting services      0* 50+    B  B.1. Patient safety is incorporated into hospital’s patient and family rights statement  0+  50* 0+  0+  0+  B.2. The hospital builds health awareness for its patients and carers to empower them to share in making the right decisions regarding their care      50+  0+  B.3. The hospital ensures proper patient identification and verification at all stages of care  0+  0+  0+    B.4. The hospital involves community in different patient safety activities  17* 0+  50* 50+  0+  0+  B.5. The hospital communicates patient safety incidents to patients and their carers  50+  0+  0+  0+  B.6. The hospital encourages patients to speak up and acts upon the patient’s voice    0+  0+  0+  C  C.1. The hospital has an effective clinical system that assures inclusion of patient safety      50+    C.3. The hospital ensures safety of blood and blood products  50+    50+  0+  C.4. The hospital ensures safe injections, infusions, and immunization    50*  50*    C.5. The hospital has a safe medication system  0+  25+  50+    C.6. The hospital has completed medical records system  12.5+  50+      D  D.2. The hospital has a safe waste management system    33+  50*    E  E.1. The hospital has a staff professional development program with patient safety as a cutting theme  50* 50+  50+  50+  0+  E.2. The hospital verifies competency for all health professionals working in it or contracted      25+  50  E.3. The hospital conducts research in patient safety on ongoing basis  0* 50+  25+  0* 25+  50* 50+  Domain  Subdomain  Hospital score (%)  I  II  III  IV  A  A.2. The hospital has a Patient Safety Program  50+  50+  25+  50+  A.3. The hospital uses data to improve safety performance  25+  50+  0+  50*  A.5. The hospital ensures staff safety for safer patients and availability of staff round the clock to deliver safe care      50+    A.6. Hospital has policies, guidelines, and standard operation procedure (SOP) for all departments and supporting services      0* 50+    B  B.1. Patient safety is incorporated into hospital’s patient and family rights statement  0+  50* 0+  0+  0+  B.2. The hospital builds health awareness for its patients and carers to empower them to share in making the right decisions regarding their care      50+  0+  B.3. The hospital ensures proper patient identification and verification at all stages of care  0+  0+  0+    B.4. The hospital involves community in different patient safety activities  17* 0+  50* 50+  0+  0+  B.5. The hospital communicates patient safety incidents to patients and their carers  50+  0+  0+  0+  B.6. The hospital encourages patients to speak up and acts upon the patient’s voice    0+  0+  0+  C  C.1. The hospital has an effective clinical system that assures inclusion of patient safety      50+    C.3. The hospital ensures safety of blood and blood products  50+    50+  0+  C.4. The hospital ensures safe injections, infusions, and immunization    50*  50*    C.5. The hospital has a safe medication system  0+  25+  50+    C.6. The hospital has completed medical records system  12.5+  50+      D  D.2. The hospital has a safe waste management system    33+  50*    E  E.1. The hospital has a staff professional development program with patient safety as a cutting theme  50* 50+  50+  50+  0+  E.2. The hospital verifies competency for all health professionals working in it or contracted      25+  50  E.3. The hospital conducts research in patient safety on ongoing basis  0* 50+  25+  0* 25+  50* 50+  *Core standards. +Developmental standards. A, B, C, D and E: please refer to Table 2. It is of interest to mention that the studied hospitals compared with the unstudied ones, showed better quality management and patient safety system. For example, studied hospitals showed 100% adherence with regard to the critical standards compared with low scores for unstudied hospitals. Furthermore, studied hospitals scored 78% and above for core standards, while those unstudied scored below 50%. Similarly, studied hospitals scored 32% and above for developmental standards compared with lower scores for unstudied hospitals. Discussion There is concerted effort to heighten patient safety practice globally in consonant with WHO’s World Alliance for Patient Safety (WAPS) with the aim of improving patient safety through international collaboration [14]. In 2007, WHO’s Eastern Mediterranean Regional Office (WHO-EMRO) commenced Patient Safety Friendly Hospital Initiative (PSFHI) aiming the development of patient safety system in the Eastern Mediterranean region that includes Oman. In Oman, the Directorate General of Quality Assurance Centre (DGQAC) in its ninth 5-year strategic plan (2016–2020) for quality management and patients’ safety specifies five main outcomes. Development of patients’ safety system using international tools and standards is one of these outcomes. The initiative will be introduced into all government and private hospitals under the supervision of the Ministry of Health (MoH) of Oman by the end of 2018. Initially in 2016, a 1-year pilot program was launched in 11 hospitals, at the end of which four participating hospitals were assessed by WHO. The success of the pilot is evidenced by the significant improvements in various components of the quality management and patient safety system at these hospitals. Prior to the WHO assessment the concerned hospitals were given three assessments and issued recommendations on various components of quality management and patients’ safety systems. For example, hospitals worked on developing documents through reviewing and updating policies, guidelines and protocols. Training of staff was enhanced by introducing continuous educational sessions and refresher courses on fire safety, basic life support, advanced cardiac life and other key health and quality related matters. In addition, human resources were optimized by appointing key personnel such as senior patient safety officer, which boosted implementation of the initiative standards. Alcohol dispensers were fixed at key locations. Waste management follow-up system was created. Fire safety readiness was ensured by regular maintenance of fire extinguishers and hose reels. Furthermore, new systems were introduced such as rapid response team that helped in detecting patients in need of specific intervention at the right time thus preventing overloading of critical care units. Introduction of leadership walk rounds and assessment of safety culture perception among staff helped identify the areas of strength and areas that provided opportunities for improvement. Performance scores were subdivided to reflect the status of each constituent that made up overall patient safety. For example, hospital (I) was recommended to have clinical pharmacists who participated in medication orders and to develop a system to identify drug–drug and drug–food interactions, which was not implemented. This ultimately led to getting low scores for this domain. All four hospitals met 100% of critical standards, indicating their readiness and commitment on the essentials of patient safety. They also scored higher than previous reports on hospitals of other countries in the EMRO region. In Sidiqqi et al.’s 2012 report on seven EMRO states, the range of compliance to critical standards had varied from 8% in Yemen to 78% in Egypt [12]. In another study by Bahadori, an eye hospital in Iran met 77.78% of the critical standards [15]. The average rate from another hospital in Iran for the critical standards was 75 % [16]. Similarly, Bairami et al. showed in their study that three hospitals in Tehran met more than 70% of the critical standards [17]. Furthermore, the four hospitals in the present study recorded good scores for the core standards, which reflect the strong patient safety commitments of their leadership and staff. Moreover, one hospital has achieved level three from the first assessment, which is considered the first of such assessment of hospitals enrolled in such initiative in EMRO. Looking deeper at the scores of studied hospitals, ‘safe evidence-based clinical practices’ scored the highest among individual domains. This could be explained by the work Oman’s Ministry of Health has undertaken in the last few years to reinforce the importance of this concept, in addition to the need to adhere to national and international standards such as the infection prevention and control policies and guidelines [18]. ‘Leadership and management’ domain scored second highest. This suggests that a key factor for the good performance of the hospitals may be effective managerial and leadership commitment and support for making positive changes within the organization, ensuring safe patient care and thus successfully implementing the initiative. The importance of this key factor has been reflected by many studies at different industries including healthcare systems [19–28]. Furthermore, staff commitment, enthusiasm, and teamwork were another key success factors for such performance [28]. This was revealed throughout the 1-year work on various elements of the initiative standards and during WHO consultants’ assessment. Interestingly, domain E scored low in all hospitals. One explanation could be due to the fact that, compared with the other four domains, none of the domain E standards is critical while many are developmental. Furthermore, it is noticeable that scores for such standards across the four hospitals were low that ultimately affected the final score of the subdomains. Nonetheless, hospitals are requested to make an action plan to implement developmental standards, thus improve scoring level in the next visit. For example, hospitals are required to; regularly develop reports on different patient safety activities and disseminates them externally, create credentialing system, establish a structured medical error open disclosure system, establish a system of proactive patient safety-related risk management and promote ongoing training for all staff to ensure safe patient care. Hospitals are also recommended to; conduct patient safety research including WHO cross-sectional studies to assess magnitude and nature of adverse events. Regular follow-up of implementing these recommendations will be made by the DGQAC through regular assessment and reports submission. Conclusion In conclusion, as per WHO assessment conducted in May 2017, four Omani hospitals were scrutinized using WHO Patient Safety Friendly Hospital Initiative standards. The exercises suggest that patient safety system in hospitals is adequate for being patient safety friendly hospitals. This activity helped in spreading culture of standards among institutions and facilitated establishing a structure for implementing a national accreditation system in the future. Based on the successful experience these hospitals underwent, each hospital is planning to achieve level four in the next assessment by strengthening its patient safety system through various strategies such as patients and staff empowerment and engagement. Furthermore, these hospitals have the potentials to achieve 100% of the core and developmental standards based on the strong will and commitment of leadership and staff. Acknowledgements The authors express their appreciation to leaders and staff of the four hospitals which participated in the initiative and supported the team during the WHO assessment process. The authors also thank the members of the Directorate General of Quality Assurance Center, particularly Attika Al-Lawati, Farah Al-Baloshi, Nada Al-Rahmah, Parveen Al-Lawati and Yusra Al-Wahaibi, for their important contributions. References 1 World Health Organization. 10 facts on patient safety by WHO . Geneva: WHO, 2010. http://www.who.int/features/factfiles/patient_safety/en/. Accessed 19 July 2017. 2 David G, Gunnarsson CL, Waters HC et al.  . Economic measurement of medical errors using a hospital claims database. Value Health  2013; 16: 305– 10. Google Scholar CrossRef Search ADS PubMed  3 Andel C, Davidow SL, Hollander M et al.  . The economics of health care quality and medical errors. J Health Care Finance  2012; 39: 39– 50. Google Scholar PubMed  4 Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood)  2010; 29: 165– 73. 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For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal for Quality in Health Care Oxford University Press

Developing patient safety system using WHO tool in hospitals in Oman

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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Abstract

Abstract Objective Oman is progressively implementing the Patient Safety Friendly Hospital Initiative (PSFHI), a tool formulated by the World Health Organization (WHO) to achieve optimal patient safety in hospitals. This paper describes its implementation in selected government and private hospitals in Oman and analyses the performance of four hospitals whose implementations of PSFHI were assessed by WHO. Design The PSFHI initiative was launched in 11 hospitals in Oman during 2016. The enrolled hospitals implemented a 1-year plan composed of several steps such as formation of steering committees, working groups, full orientation about the standards, training of staff, documents development and community involvement. One year later, four hospitals which were the earliest to join the initiative were subjected to WHO assessment. Setting Secondary level government and private hospitals. Intervention(s) The WHO-PSFHI standards. Main Outcome Measure Hospitals’ adherence to the standards. Results Three of the four hospitals (one government and two private) scored level two. One government hospital scored level three, earning it the distinction of being the first hospital in the Eastern Mediterranean Region to reach level three in the very first assessment. Conclusions Implementation of PSFHI in selected hospitals of Oman had successful outcomes in improving patient’s safety. patient safety, patient safety friendly hospital initiative, Oman, hospital care Introduction World Health Organization (WHO) estimates that in developed countries as many as 10% patients are harmed while receiving hospital care [1]. Hospital-acquired infections affect ~14% of admitted patients [1]. Furthermore, it is estimated that 310 million surgical operations are performed globally every year and surgical care is associated with considerable risk of complications. Half of the complications associated with surgical care are avoidable [1]. A recent worldwide study of 474 hospitals conducted by the International Surgical Outcome Study Group found that 16.8% surgical patients developed complications in the hospital. Compare this figure with the 1 in 1 0 00 000 chance of a traveler being harmed while in an aircraft [1, 2]. Such alarming statistics from the healthcare industry have greatly increased the awareness of these mostly avoidable consequences of hospitalization and the need for revamping all aspects of patient care systems. Medical errors also increase the direct and indirect economic costs of running a hospital. It is difficult to quantify the complex economic impact of poor quality and unsafe care due to the multiple overlapping variables such as loss of life or functionality, and inefficient and wasteful utilization of manpower and facilities [3], all of which eventually has to be borne by the society. Patient safety concept emerged in the Western world as recently as the 1990s. The initial motivators were pressures from accreditors such as the Joint Commission, media exposures, local and regional collaborations, and nongovernmental organizations such as the Institute for Healthcare Improvement [4]. This ultimately led to the emergence of a functional business case for improving patient safety, driven by public and governmental reporting systems [5], growing fines for serious cases of harm and emergence of ‘no pay for errors’ policies [6–8]. However, in spite of such movements, evidence showed that progress in eradicating medical errors still did not match the invested financial resources and efforts [9]. The major reason behind the underperformance was the absence of systematic assessment and monitoring [10]. WHO recognized the importance of patient safety and currently considers it as top priority in public healthcare [11]. Accordingly, WHO Regional Office in East Mediterranean launched a Patient Safety Program and supported the countries of the Eastern Mediterranean Region to implement the program through adopting and adapting the PSFHI to regional needs. This initiative was launched in 2007 to tackle the enormous problems of unsafe healthcare in the region [12]. This initiative involves the implementation of a set of patient safety standards in hospitals. Compliance with the standards ensures that patient safety is accorded the necessary priority and staff implement the best practice. The first version of the assessment manual was published in 2011, followed by version two in 2016 [13]. In 2016, Ministry of Health launched PSFHI and included it as an integral part of its strategic plan. Within this 1-year scheme, as many as 11 hospitals (8 government and 3 private) were short-listed to incorporate PSFHI in their respective work mechanism. In May 2017, the outcome of this initiative was scrutinized in four hospitals by WHO experts. These hospitals were selected based on their order of enrollment in PSFHI. Meanwhile, the consultant schedule permitted assessment of only these four hospitals. Methods This observational cohort study included four hospitals (two government and two private) which implemented the PSFHI for 1 year at the end of which they were assessed by WHO experts. The government hospitals provide secondary care services with more number of beds, while private hospitals provide primary and secondary care services (Table 1). One of the private hospitals was accredited by the Joint Commission International. Table 1 The four hospitals’ size and patient population for the year 2016 Sector  Hospital  Bed number  Average daily patient population  Private  I  50–100  Daily bed occupants: 17 Daily outpatient visits: 384 Daily emergency visits: 114  II  50–100  Daily bed occupants: 40 Daily outpatient visits: 600 Daily emergency visits: 150  Governmental  III  250  Daily bed occupants: 205 Daily outpatient visits: 652 Daily emergency visits: 161  IV  305  Daily bed occupants: 305 Daily outpatient visits: 650–700 Daily emergency visits: 190–220  Sector  Hospital  Bed number  Average daily patient population  Private  I  50–100  Daily bed occupants: 17 Daily outpatient visits: 384 Daily emergency visits: 114  II  50–100  Daily bed occupants: 40 Daily outpatient visits: 600 Daily emergency visits: 150  Governmental  III  250  Daily bed occupants: 205 Daily outpatient visits: 652 Daily emergency visits: 161  IV  305  Daily bed occupants: 305 Daily outpatient visits: 650–700 Daily emergency visits: 190–220  Table 1 The four hospitals’ size and patient population for the year 2016 Sector  Hospital  Bed number  Average daily patient population  Private  I  50–100  Daily bed occupants: 17 Daily outpatient visits: 384 Daily emergency visits: 114  II  50–100  Daily bed occupants: 40 Daily outpatient visits: 600 Daily emergency visits: 150  Governmental  III  250  Daily bed occupants: 205 Daily outpatient visits: 652 Daily emergency visits: 161  IV  305  Daily bed occupants: 305 Daily outpatient visits: 650–700 Daily emergency visits: 190–220  Sector  Hospital  Bed number  Average daily patient population  Private  I  50–100  Daily bed occupants: 17 Daily outpatient visits: 384 Daily emergency visits: 114  II  50–100  Daily bed occupants: 40 Daily outpatient visits: 600 Daily emergency visits: 150  Governmental  III  250  Daily bed occupants: 205 Daily outpatient visits: 652 Daily emergency visits: 161  IV  305  Daily bed occupants: 305 Daily outpatient visits: 650–700 Daily emergency visits: 190–220  The PSFHI manual provides the necessary tools for assessing hospitals. It is organized into two sections that include patient safety standards and hospital assessment tools [13]. Section 1 is composed of five domains that include ‘leadership and management’, ‘patient and public involvement’, ‘safe evidence-based clinical practices’, ‘safe environment’, and ‘lifelong learning’ (Table 2). These domains are divided into 24 subdomains with 139 standards that are categorized into critical [20 standards], core [89 standards] and developmental [30 standards]. Section 2 is composed of a set of tools to facilitate the assessment process. Table 2 Domains and standards of the PSFHIa Domains  Critical standards  Core standards  Developmental standards  Total  A. Leadership and management  7  19  6  32  B. Patient and public involvement  2  16  10  28  C. Safe evidence-based clinical practice  9  32  9  50  D. Safe environment  2  18  0  20  E. Lifelong learning  0  4  5  9  Total  20  89  30  139  Domains  Critical standards  Core standards  Developmental standards  Total  A. Leadership and management  7  19  6  32  B. Patient and public involvement  2  16  10  28  C. Safe evidence-based clinical practice  9  32  9  50  D. Safe environment  2  18  0  20  E. Lifelong learning  0  4  5  9  Total  20  89  30  139  aPSFHI: Patient Safety Friendly Hospital Initiative. Table 2 Domains and standards of the PSFHIa Domains  Critical standards  Core standards  Developmental standards  Total  A. Leadership and management  7  19  6  32  B. Patient and public involvement  2  16  10  28  C. Safe evidence-based clinical practice  9  32  9  50  D. Safe environment  2  18  0  20  E. Lifelong learning  0  4  5  9  Total  20  89  30  139  Domains  Critical standards  Core standards  Developmental standards  Total  A. Leadership and management  7  19  6  32  B. Patient and public involvement  2  16  10  28  C. Safe evidence-based clinical practice  9  32  9  50  D. Safe environment  2  18  0  20  E. Lifelong learning  0  4  5  9  Total  20  89  30  139  aPSFHI: Patient Safety Friendly Hospital Initiative. Compliance to critical standards is mandatory for a hospital to be eligible to be enrolled in the initiative. Meeting the core standards is not compulsory. However, the higher the overall score achieved, the higher the level hospital is ranked (Table 3). The developmental standards are those which enhance safe care of patients, and hospitals should attempt to comply with these according to their capabilities. To achieve level four of compliance, ≥80% of these standards are to be fulfilled. Table 3 Levels of compliance with patient safety standards Hospital-level  Critical standards (%)  Core standards  Developmental standards  Level 1  100  Any  Any  Level 2  100  60–89%  Any  Level 3  100  ≥90%  Any  Level 4  100  ≥90%  ≥80%  Hospital-level  Critical standards (%)  Core standards  Developmental standards  Level 1  100  Any  Any  Level 2  100  60–89%  Any  Level 3  100  ≥90%  Any  Level 4  100  ≥90%  ≥80%  Table 3 Levels of compliance with patient safety standards Hospital-level  Critical standards (%)  Core standards  Developmental standards  Level 1  100  Any  Any  Level 2  100  60–89%  Any  Level 3  100  ≥90%  Any  Level 4  100  ≥90%  ≥80%  Hospital-level  Critical standards (%)  Core standards  Developmental standards  Level 1  100  Any  Any  Level 2  100  60–89%  Any  Level 3  100  ≥90%  Any  Level 4  100  ≥90%  ≥80%  Implementation of this initiative was made with a 1-year plan divided into three phases. Phase 1, the pre-implementation phase, was of 2 months’ duration. The following steps were taken: Official launching of the initiative and public announcement in presence of key community figures and government officials. Dissemination of the initiative details through media and printed material. Formation of steering committee and four multidisciplinary working groups with clear description of terms of reference and line of reporting in order to ensure consistent and sustainable committee and groups work. Training of the committee and working groups’ members on the initiative standards and assessment tool. Gap analysis with proposed recommendations of improvement. Such analysis helped the hospital to prepare for the first assessment after 2–3 months. Phase 2 lasted 8 months and was composed of the following steps: Review of the gap analysis report and acting accordingly. Further training of members of the committee and working groups. Staff training on various quality and patient’s safety issues. Carrying out two assessments, 3 months apart. These assessments were based on four major review tools, as per WHO manual, that include document review, leaders and managers interviews, staff and patients and their relatives interview, and site visits to verify implementation of whatever policy. The assessment was carried out in 2 days for each hospital. Day 1 was dedicated for readying of hospital brief by the leadership, reviewing documents and interviewing leaders and managers using a standardized questionnaire. Day 2 was dedicated for interviewing staff and patients and their relatives from various units using standardized questionnaire, sites visits and debriefing the hospital leadership, and the committee and working groups. Phase 3 lasted 2 months and it consisted of the following steps: Follow-up of implementing recommendations from previous assessments. Carrying out the third assessment preparing hospital to the WHO assessment. Further, training of staff on various quality and patient’s safety issues. WHO assessment, which is conducted in 2–3 days. A coordinator from the Directorate General of Quality Assurance Center (DGQAC) was identified for each hospital to facilitate and follow-up implementation of the initiative standards. Furthermore, several meetings were held between the four hospitals that were aimed to share experiences. In addition, the DGQAC created an electronic tool that facilitated the assessment, analysis and reporting processes. The tool was adopted by WHO-EMRO and shared with member countries implementing PSFHI. Results The result of the WHO assessment was impressive for the four hospitals. These hospitals have met 100% of the critical standards (Table 4). One government hospital achieved level three, making it the first hospital in EMRO that scored such a level from the first assessment. The other three hospitals (one government and two private) achieved level two. Table 4 Results of hospitals assessment Domain  Critical standards N (%)  Core standards N (%)  Developmental standards N (%)  Total N (%)  Hospital I  A  7/7 (100)  15/18 1na (83)  2/6 (33)  24/31 (77)  B  2/2 (100)  12.5/16 (78)  1/10 (10)  15.5/28 (55)  C  9/9 (100)  27/32 (84)  5/9 (56)  41/50 (82)  D  2/2 (100)  12/17 1na (71)  -  14/19 (74)  E  -  1.5/4 (38)  1.5/5 (30)  3/9 (33)    20/20 (100)  68/87 (78)  9.5/30 (32)  97.5/137 (71)  Domain  Hospital II  A  7/7 (100)  15.5/18 1na (86)  4/6 (67)  26.5/31 (85)  B  2/2 (100)  12/16 (75)  2.5/10 (25)  16.5/28 (59)  C  9/9 (100)  28/32 (89)  5.5/9 (61)  43/50 (86)  D  2/2 (100)  10.5/17 1na (62)  -  12.5/19 (66)  E  -  1.5/4 (38)  2.5/5 (50)  4/9 (44)    20/20 (100)  67.5/87 (78)  14.5/30 (48)  102/137 (74)  Domain  Hospital III  A  7/7 (100)  16.5/18 1na (92)  3.5/6 (58)  27/31 (87)  B  2/2 (100)  10.5/16 (66)  5/10 (50)  17.5/28 (63)  C  9/9 (100)  29/32 (92)  2.5/9 (28)  40.5/50 (81)  D  2/2 (100)  16/17 1na (94)  -  18/19 (95)  E  -  1.5/4 (38)  3/5 (60)  4/9 (44)    20/20 (100)  73/87 (84)  14/30 (47)  107/137 (78)  Domain  Hospital IV  A  7/7 (100)  16.5/19 (87)  5/6 (83)  28.5/32 (89)  B  2/2 (100)  14.5/16 (91)  1/10 (10)  17.5/28 (63)  C  9/9 (100)  31.5/32 (98)  6/9 (67)  46.5/50 (93)  D  2/2 (100)  15/17 1na (88)  -  17/19 (89)  E  -  2.5/4 (63)  3/5 (60)  5.5/9 (61)    20/20 (100)  80/88 (90)  15/30 (50)  115/138 (83)  Domain  Critical standards N (%)  Core standards N (%)  Developmental standards N (%)  Total N (%)  Hospital I  A  7/7 (100)  15/18 1na (83)  2/6 (33)  24/31 (77)  B  2/2 (100)  12.5/16 (78)  1/10 (10)  15.5/28 (55)  C  9/9 (100)  27/32 (84)  5/9 (56)  41/50 (82)  D  2/2 (100)  12/17 1na (71)  -  14/19 (74)  E  -  1.5/4 (38)  1.5/5 (30)  3/9 (33)    20/20 (100)  68/87 (78)  9.5/30 (32)  97.5/137 (71)  Domain  Hospital II  A  7/7 (100)  15.5/18 1na (86)  4/6 (67)  26.5/31 (85)  B  2/2 (100)  12/16 (75)  2.5/10 (25)  16.5/28 (59)  C  9/9 (100)  28/32 (89)  5.5/9 (61)  43/50 (86)  D  2/2 (100)  10.5/17 1na (62)  -  12.5/19 (66)  E  -  1.5/4 (38)  2.5/5 (50)  4/9 (44)    20/20 (100)  67.5/87 (78)  14.5/30 (48)  102/137 (74)  Domain  Hospital III  A  7/7 (100)  16.5/18 1na (92)  3.5/6 (58)  27/31 (87)  B  2/2 (100)  10.5/16 (66)  5/10 (50)  17.5/28 (63)  C  9/9 (100)  29/32 (92)  2.5/9 (28)  40.5/50 (81)  D  2/2 (100)  16/17 1na (94)  -  18/19 (95)  E  -  1.5/4 (38)  3/5 (60)  4/9 (44)    20/20 (100)  73/87 (84)  14/30 (47)  107/137 (78)  Domain  Hospital IV  A  7/7 (100)  16.5/19 (87)  5/6 (83)  28.5/32 (89)  B  2/2 (100)  14.5/16 (91)  1/10 (10)  17.5/28 (63)  C  9/9 (100)  31.5/32 (98)  6/9 (67)  46.5/50 (93)  D  2/2 (100)  15/17 1na (88)  -  17/19 (89)  E  -  2.5/4 (63)  3/5 (60)  5.5/9 (61)    20/20 (100)  80/88 (90)  15/30 (50)  115/138 (83)  na, not applicable; -, no standard. A, B, C, D and E: please refer to Table 2. Table 4 Results of hospitals assessment Domain  Critical standards N (%)  Core standards N (%)  Developmental standards N (%)  Total N (%)  Hospital I  A  7/7 (100)  15/18 1na (83)  2/6 (33)  24/31 (77)  B  2/2 (100)  12.5/16 (78)  1/10 (10)  15.5/28 (55)  C  9/9 (100)  27/32 (84)  5/9 (56)  41/50 (82)  D  2/2 (100)  12/17 1na (71)  -  14/19 (74)  E  -  1.5/4 (38)  1.5/5 (30)  3/9 (33)    20/20 (100)  68/87 (78)  9.5/30 (32)  97.5/137 (71)  Domain  Hospital II  A  7/7 (100)  15.5/18 1na (86)  4/6 (67)  26.5/31 (85)  B  2/2 (100)  12/16 (75)  2.5/10 (25)  16.5/28 (59)  C  9/9 (100)  28/32 (89)  5.5/9 (61)  43/50 (86)  D  2/2 (100)  10.5/17 1na (62)  -  12.5/19 (66)  E  -  1.5/4 (38)  2.5/5 (50)  4/9 (44)    20/20 (100)  67.5/87 (78)  14.5/30 (48)  102/137 (74)  Domain  Hospital III  A  7/7 (100)  16.5/18 1na (92)  3.5/6 (58)  27/31 (87)  B  2/2 (100)  10.5/16 (66)  5/10 (50)  17.5/28 (63)  C  9/9 (100)  29/32 (92)  2.5/9 (28)  40.5/50 (81)  D  2/2 (100)  16/17 1na (94)  -  18/19 (95)  E  -  1.5/4 (38)  3/5 (60)  4/9 (44)    20/20 (100)  73/87 (84)  14/30 (47)  107/137 (78)  Domain  Hospital IV  A  7/7 (100)  16.5/19 (87)  5/6 (83)  28.5/32 (89)  B  2/2 (100)  14.5/16 (91)  1/10 (10)  17.5/28 (63)  C  9/9 (100)  31.5/32 (98)  6/9 (67)  46.5/50 (93)  D  2/2 (100)  15/17 1na (88)  -  17/19 (89)  E  -  2.5/4 (63)  3/5 (60)  5.5/9 (61)    20/20 (100)  80/88 (90)  15/30 (50)  115/138 (83)  Domain  Critical standards N (%)  Core standards N (%)  Developmental standards N (%)  Total N (%)  Hospital I  A  7/7 (100)  15/18 1na (83)  2/6 (33)  24/31 (77)  B  2/2 (100)  12.5/16 (78)  1/10 (10)  15.5/28 (55)  C  9/9 (100)  27/32 (84)  5/9 (56)  41/50 (82)  D  2/2 (100)  12/17 1na (71)  -  14/19 (74)  E  -  1.5/4 (38)  1.5/5 (30)  3/9 (33)    20/20 (100)  68/87 (78)  9.5/30 (32)  97.5/137 (71)  Domain  Hospital II  A  7/7 (100)  15.5/18 1na (86)  4/6 (67)  26.5/31 (85)  B  2/2 (100)  12/16 (75)  2.5/10 (25)  16.5/28 (59)  C  9/9 (100)  28/32 (89)  5.5/9 (61)  43/50 (86)  D  2/2 (100)  10.5/17 1na (62)  -  12.5/19 (66)  E  -  1.5/4 (38)  2.5/5 (50)  4/9 (44)    20/20 (100)  67.5/87 (78)  14.5/30 (48)  102/137 (74)  Domain  Hospital III  A  7/7 (100)  16.5/18 1na (92)  3.5/6 (58)  27/31 (87)  B  2/2 (100)  10.5/16 (66)  5/10 (50)  17.5/28 (63)  C  9/9 (100)  29/32 (92)  2.5/9 (28)  40.5/50 (81)  D  2/2 (100)  16/17 1na (94)  -  18/19 (95)  E  -  1.5/4 (38)  3/5 (60)  4/9 (44)    20/20 (100)  73/87 (84)  14/30 (47)  107/137 (78)  Domain  Hospital IV  A  7/7 (100)  16.5/19 (87)  5/6 (83)  28.5/32 (89)  B  2/2 (100)  14.5/16 (91)  1/10 (10)  17.5/28 (63)  C  9/9 (100)  31.5/32 (98)  6/9 (67)  46.5/50 (93)  D  2/2 (100)  15/17 1na (88)  -  17/19 (89)  E  -  2.5/4 (63)  3/5 (60)  5.5/9 (61)    20/20 (100)  80/88 (90)  15/30 (50)  115/138 (83)  na, not applicable; -, no standard. A, B, C, D and E: please refer to Table 2. Hospital (I) scored maximum for safe evidence-based clinical practices domain (82%) followed by leadership and management domain (77%); Table 4. This was followed by safe environment (74%), and patient and public involvement domains (55%). The lowest score was for lifelong learning domain (33%). The overall score of the hospital was 71%. As hospital met 100% of critical standards, 78% of core standards and 32% of developmental standards, it achieved level two. Hospital (II) recorded the highest score for safe evidence-based clinical practices domain (86%), followed by leadership and management domain (85%); Table 4. This was followed by safe environment (66%) and patient and public involvement domains (59%). The lowest score was recorded for lifelong learning domain (44%). The overall score of the hospital was 74%. As the hospital met 100% of critical standards, 78% of core standards and 48% of developmental standards, it achieved level two Hospital (III) accomplished the following scores; 95% for safe environment domain, followed by leadership and management domain (87%), safe evidence-based clinical practices domain (81%), and patient and public involvement domain (63%); Table 4. The lowest was recorded for lifelong learning measures (44%). The overall score of the hospital was 78%. As the hospital met 100% of critical standards, 84% of core standards and 47% of developmental standards, it achieved level two. Hospital (IV) scored 93% for the safe evidence-based clinical practices domain followed by leadership and management and safe environment domains (89% each); Table 4. Patient and public involvement domain scored 63% while lifelong learning measures scored 61%. As the hospital met 100% of critical standards, 90% of core standards, and 50% of developmental standards, it achieved level three. It is worth noting that low scores (≤50%) of some subdomains led to low overall score of the concerned domains. Interestingly, deep review of the scores suggests that this was due to low scores for developmental standards in the four hospitals (Table 5). For example, hospitals were lacking the system of communicating patient safety incidents to patients and their carers (subdomain B5). Similarly, hospitals were lacking sustainable systems that ensure continuous professional development on patients’ safety as well as monitoring of impact of such program (subdomain E1). Therefore, the hospitals were requested to create improvement action plan with specific timeframe based on the WHO consultants’ suggestions. Follow-up plan is prepared by the DGQAC. Table 5 Hospitals with ≤50% scores for the subdomains Domain  Subdomain  Hospital score (%)  I  II  III  IV  A  A.2. The hospital has a Patient Safety Program  50+  50+  25+  50+  A.3. The hospital uses data to improve safety performance  25+  50+  0+  50*  A.5. The hospital ensures staff safety for safer patients and availability of staff round the clock to deliver safe care      50+    A.6. Hospital has policies, guidelines, and standard operation procedure (SOP) for all departments and supporting services      0* 50+    B  B.1. Patient safety is incorporated into hospital’s patient and family rights statement  0+  50* 0+  0+  0+  B.2. The hospital builds health awareness for its patients and carers to empower them to share in making the right decisions regarding their care      50+  0+  B.3. The hospital ensures proper patient identification and verification at all stages of care  0+  0+  0+    B.4. The hospital involves community in different patient safety activities  17* 0+  50* 50+  0+  0+  B.5. The hospital communicates patient safety incidents to patients and their carers  50+  0+  0+  0+  B.6. The hospital encourages patients to speak up and acts upon the patient’s voice    0+  0+  0+  C  C.1. The hospital has an effective clinical system that assures inclusion of patient safety      50+    C.3. The hospital ensures safety of blood and blood products  50+    50+  0+  C.4. The hospital ensures safe injections, infusions, and immunization    50*  50*    C.5. The hospital has a safe medication system  0+  25+  50+    C.6. The hospital has completed medical records system  12.5+  50+      D  D.2. The hospital has a safe waste management system    33+  50*    E  E.1. The hospital has a staff professional development program with patient safety as a cutting theme  50* 50+  50+  50+  0+  E.2. The hospital verifies competency for all health professionals working in it or contracted      25+  50  E.3. The hospital conducts research in patient safety on ongoing basis  0* 50+  25+  0* 25+  50* 50+  Domain  Subdomain  Hospital score (%)  I  II  III  IV  A  A.2. The hospital has a Patient Safety Program  50+  50+  25+  50+  A.3. The hospital uses data to improve safety performance  25+  50+  0+  50*  A.5. The hospital ensures staff safety for safer patients and availability of staff round the clock to deliver safe care      50+    A.6. Hospital has policies, guidelines, and standard operation procedure (SOP) for all departments and supporting services      0* 50+    B  B.1. Patient safety is incorporated into hospital’s patient and family rights statement  0+  50* 0+  0+  0+  B.2. The hospital builds health awareness for its patients and carers to empower them to share in making the right decisions regarding their care      50+  0+  B.3. The hospital ensures proper patient identification and verification at all stages of care  0+  0+  0+    B.4. The hospital involves community in different patient safety activities  17* 0+  50* 50+  0+  0+  B.5. The hospital communicates patient safety incidents to patients and their carers  50+  0+  0+  0+  B.6. The hospital encourages patients to speak up and acts upon the patient’s voice    0+  0+  0+  C  C.1. The hospital has an effective clinical system that assures inclusion of patient safety      50+    C.3. The hospital ensures safety of blood and blood products  50+    50+  0+  C.4. The hospital ensures safe injections, infusions, and immunization    50*  50*    C.5. The hospital has a safe medication system  0+  25+  50+    C.6. The hospital has completed medical records system  12.5+  50+      D  D.2. The hospital has a safe waste management system    33+  50*    E  E.1. The hospital has a staff professional development program with patient safety as a cutting theme  50* 50+  50+  50+  0+  E.2. The hospital verifies competency for all health professionals working in it or contracted      25+  50  E.3. The hospital conducts research in patient safety on ongoing basis  0* 50+  25+  0* 25+  50* 50+  *Core standards. +Developmental standards. A, B, C, D and E: please refer to Table 2. Table 5 Hospitals with ≤50% scores for the subdomains Domain  Subdomain  Hospital score (%)  I  II  III  IV  A  A.2. The hospital has a Patient Safety Program  50+  50+  25+  50+  A.3. The hospital uses data to improve safety performance  25+  50+  0+  50*  A.5. The hospital ensures staff safety for safer patients and availability of staff round the clock to deliver safe care      50+    A.6. Hospital has policies, guidelines, and standard operation procedure (SOP) for all departments and supporting services      0* 50+    B  B.1. Patient safety is incorporated into hospital’s patient and family rights statement  0+  50* 0+  0+  0+  B.2. The hospital builds health awareness for its patients and carers to empower them to share in making the right decisions regarding their care      50+  0+  B.3. The hospital ensures proper patient identification and verification at all stages of care  0+  0+  0+    B.4. The hospital involves community in different patient safety activities  17* 0+  50* 50+  0+  0+  B.5. The hospital communicates patient safety incidents to patients and their carers  50+  0+  0+  0+  B.6. The hospital encourages patients to speak up and acts upon the patient’s voice    0+  0+  0+  C  C.1. The hospital has an effective clinical system that assures inclusion of patient safety      50+    C.3. The hospital ensures safety of blood and blood products  50+    50+  0+  C.4. The hospital ensures safe injections, infusions, and immunization    50*  50*    C.5. The hospital has a safe medication system  0+  25+  50+    C.6. The hospital has completed medical records system  12.5+  50+      D  D.2. The hospital has a safe waste management system    33+  50*    E  E.1. The hospital has a staff professional development program with patient safety as a cutting theme  50* 50+  50+  50+  0+  E.2. The hospital verifies competency for all health professionals working in it or contracted      25+  50  E.3. The hospital conducts research in patient safety on ongoing basis  0* 50+  25+  0* 25+  50* 50+  Domain  Subdomain  Hospital score (%)  I  II  III  IV  A  A.2. The hospital has a Patient Safety Program  50+  50+  25+  50+  A.3. The hospital uses data to improve safety performance  25+  50+  0+  50*  A.5. The hospital ensures staff safety for safer patients and availability of staff round the clock to deliver safe care      50+    A.6. Hospital has policies, guidelines, and standard operation procedure (SOP) for all departments and supporting services      0* 50+    B  B.1. Patient safety is incorporated into hospital’s patient and family rights statement  0+  50* 0+  0+  0+  B.2. The hospital builds health awareness for its patients and carers to empower them to share in making the right decisions regarding their care      50+  0+  B.3. The hospital ensures proper patient identification and verification at all stages of care  0+  0+  0+    B.4. The hospital involves community in different patient safety activities  17* 0+  50* 50+  0+  0+  B.5. The hospital communicates patient safety incidents to patients and their carers  50+  0+  0+  0+  B.6. The hospital encourages patients to speak up and acts upon the patient’s voice    0+  0+  0+  C  C.1. The hospital has an effective clinical system that assures inclusion of patient safety      50+    C.3. The hospital ensures safety of blood and blood products  50+    50+  0+  C.4. The hospital ensures safe injections, infusions, and immunization    50*  50*    C.5. The hospital has a safe medication system  0+  25+  50+    C.6. The hospital has completed medical records system  12.5+  50+      D  D.2. The hospital has a safe waste management system    33+  50*    E  E.1. The hospital has a staff professional development program with patient safety as a cutting theme  50* 50+  50+  50+  0+  E.2. The hospital verifies competency for all health professionals working in it or contracted      25+  50  E.3. The hospital conducts research in patient safety on ongoing basis  0* 50+  25+  0* 25+  50* 50+  *Core standards. +Developmental standards. A, B, C, D and E: please refer to Table 2. It is of interest to mention that the studied hospitals compared with the unstudied ones, showed better quality management and patient safety system. For example, studied hospitals showed 100% adherence with regard to the critical standards compared with low scores for unstudied hospitals. Furthermore, studied hospitals scored 78% and above for core standards, while those unstudied scored below 50%. Similarly, studied hospitals scored 32% and above for developmental standards compared with lower scores for unstudied hospitals. Discussion There is concerted effort to heighten patient safety practice globally in consonant with WHO’s World Alliance for Patient Safety (WAPS) with the aim of improving patient safety through international collaboration [14]. In 2007, WHO’s Eastern Mediterranean Regional Office (WHO-EMRO) commenced Patient Safety Friendly Hospital Initiative (PSFHI) aiming the development of patient safety system in the Eastern Mediterranean region that includes Oman. In Oman, the Directorate General of Quality Assurance Centre (DGQAC) in its ninth 5-year strategic plan (2016–2020) for quality management and patients’ safety specifies five main outcomes. Development of patients’ safety system using international tools and standards is one of these outcomes. The initiative will be introduced into all government and private hospitals under the supervision of the Ministry of Health (MoH) of Oman by the end of 2018. Initially in 2016, a 1-year pilot program was launched in 11 hospitals, at the end of which four participating hospitals were assessed by WHO. The success of the pilot is evidenced by the significant improvements in various components of the quality management and patient safety system at these hospitals. Prior to the WHO assessment the concerned hospitals were given three assessments and issued recommendations on various components of quality management and patients’ safety systems. For example, hospitals worked on developing documents through reviewing and updating policies, guidelines and protocols. Training of staff was enhanced by introducing continuous educational sessions and refresher courses on fire safety, basic life support, advanced cardiac life and other key health and quality related matters. In addition, human resources were optimized by appointing key personnel such as senior patient safety officer, which boosted implementation of the initiative standards. Alcohol dispensers were fixed at key locations. Waste management follow-up system was created. Fire safety readiness was ensured by regular maintenance of fire extinguishers and hose reels. Furthermore, new systems were introduced such as rapid response team that helped in detecting patients in need of specific intervention at the right time thus preventing overloading of critical care units. Introduction of leadership walk rounds and assessment of safety culture perception among staff helped identify the areas of strength and areas that provided opportunities for improvement. Performance scores were subdivided to reflect the status of each constituent that made up overall patient safety. For example, hospital (I) was recommended to have clinical pharmacists who participated in medication orders and to develop a system to identify drug–drug and drug–food interactions, which was not implemented. This ultimately led to getting low scores for this domain. All four hospitals met 100% of critical standards, indicating their readiness and commitment on the essentials of patient safety. They also scored higher than previous reports on hospitals of other countries in the EMRO region. In Sidiqqi et al.’s 2012 report on seven EMRO states, the range of compliance to critical standards had varied from 8% in Yemen to 78% in Egypt [12]. In another study by Bahadori, an eye hospital in Iran met 77.78% of the critical standards [15]. The average rate from another hospital in Iran for the critical standards was 75 % [16]. Similarly, Bairami et al. showed in their study that three hospitals in Tehran met more than 70% of the critical standards [17]. Furthermore, the four hospitals in the present study recorded good scores for the core standards, which reflect the strong patient safety commitments of their leadership and staff. Moreover, one hospital has achieved level three from the first assessment, which is considered the first of such assessment of hospitals enrolled in such initiative in EMRO. Looking deeper at the scores of studied hospitals, ‘safe evidence-based clinical practices’ scored the highest among individual domains. This could be explained by the work Oman’s Ministry of Health has undertaken in the last few years to reinforce the importance of this concept, in addition to the need to adhere to national and international standards such as the infection prevention and control policies and guidelines [18]. ‘Leadership and management’ domain scored second highest. This suggests that a key factor for the good performance of the hospitals may be effective managerial and leadership commitment and support for making positive changes within the organization, ensuring safe patient care and thus successfully implementing the initiative. The importance of this key factor has been reflected by many studies at different industries including healthcare systems [19–28]. Furthermore, staff commitment, enthusiasm, and teamwork were another key success factors for such performance [28]. This was revealed throughout the 1-year work on various elements of the initiative standards and during WHO consultants’ assessment. Interestingly, domain E scored low in all hospitals. One explanation could be due to the fact that, compared with the other four domains, none of the domain E standards is critical while many are developmental. Furthermore, it is noticeable that scores for such standards across the four hospitals were low that ultimately affected the final score of the subdomains. Nonetheless, hospitals are requested to make an action plan to implement developmental standards, thus improve scoring level in the next visit. For example, hospitals are required to; regularly develop reports on different patient safety activities and disseminates them externally, create credentialing system, establish a structured medical error open disclosure system, establish a system of proactive patient safety-related risk management and promote ongoing training for all staff to ensure safe patient care. Hospitals are also recommended to; conduct patient safety research including WHO cross-sectional studies to assess magnitude and nature of adverse events. Regular follow-up of implementing these recommendations will be made by the DGQAC through regular assessment and reports submission. Conclusion In conclusion, as per WHO assessment conducted in May 2017, four Omani hospitals were scrutinized using WHO Patient Safety Friendly Hospital Initiative standards. The exercises suggest that patient safety system in hospitals is adequate for being patient safety friendly hospitals. This activity helped in spreading culture of standards among institutions and facilitated establishing a structure for implementing a national accreditation system in the future. Based on the successful experience these hospitals underwent, each hospital is planning to achieve level four in the next assessment by strengthening its patient safety system through various strategies such as patients and staff empowerment and engagement. Furthermore, these hospitals have the potentials to achieve 100% of the core and developmental standards based on the strong will and commitment of leadership and staff. Acknowledgements The authors express their appreciation to leaders and staff of the four hospitals which participated in the initiative and supported the team during the WHO assessment process. 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For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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International Journal for Quality in Health CareOxford University Press

Published: Mar 24, 2018

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