PROCESS OF CARE (POC)

MODEL OF GOOD CARE

(MOGC)
DR ISABELLA CHIA
UNIT KUALITI PENJAGAAN PERUBATAN

PROCESS OF CARE
Sequential

steps of activities
whilst providing a particular
healthcare services.

The

steps is adopted from the

professionally accepted standard
or norm , SOP, guidelines,
circulars, CPG, etc

PROCESS OF CARE
Data
Flow

Analysis tools Flow chart

chart a graphic
representation of how a process
works, showing the step by step
sequence of processes and
subprocess that include
events,reactions or decisions

WHY NEED PROCESS OF CARE

To

identify the actual path a

process follows
To improve or increase efficiency
To generate hypotheses about
causes
To stimulate communication among
participants
To establish a common
understanding about the process

WHEN TO USE A FLOW CHART

During problem identification, data analysis,
solution planning
Clarify how things are currently working
Clarify how the process can be improved
Assist in finding the key elements of a
process(critical step)
Identify appropriate team members who can
provide inputs or resources
Establish important areas for monitoring process

ADVANTAGES OF A FLOWCHART
Describe

the actual process

A basis for designing and improving
processes
Involve the people who have
information about the processes
On cover potential problems and
bottlenecks
Identify problems and opportunities
for improvement

PROCESS OF CARE
For

QA, the flowchart should contain

specific activity ( refer to a particular
process of care/management ) in the
area of concern for
improvement

It

must cover all steps of care that we

are interested into.

Flow

of care can be used to guide the

development of Model of Good Care

FLOW CHART SYMBOLS

First & last step

Decision point

Processing step

PROCESS OF CARE

I can proceed
with the QA
study

yes

Listen to Dr
Isabella s
lecture
Understand
all what
she said?

no
I must ask
question
afterward

yes
Still not
understand
?

no
Start the
QAP study

MANAGING HYPOTHERMIC PRETERM BABIES

IN LABOUR ROOM , HOSPITAL TAIPING
Preparation for premature
baby deliveries

Baby delivered
Anticipate Management of prematurity
Yes

Transfer to SCN
Treatment

Hypothermia

No

End

CARTA ALIRAN ASAL PENGENDALIAN KES

IBU BERSALIN DI PBBR, HTAA
Pendaftaran masuk di PAC

Saringan di buat oleh

Jururawat y/m mengikut
checklist

Risiko Tinggi

Risko Rendah

Bermasaalah

Dimasukkan ke
Dewan
Bersalin

Pemeriksaan ibu
dan janin di Pusat
Bersalin

Tidak
bermasaalah

Bersalin di PBBR

DISCAJ

Penjagaan ibu
dan bayi di
postnatal

FLOW CHART ON PROCESS OF OBTAINING URGENT PLATELET COUNT FOR

DENGUE CASES
REQUEST PLATELET COUNT Ix
BY DOCTOR
DR FILL UP FORM (URGENT SPECIMEN)
S/N CALL FOR MLT
FORM CHECKED BY NURSE
NO
COMPLETE ?
YES
S/N LABEL & TAKE BLOOD CALL
UP MLT & A/K
A/K DESPATCH BLOOD
SPECIMEN TO LAB
SPECIMEN RECEIVED BY MLT
& CHECKED BY MLT
NO
COMPLETE ?
YES

OUR P.O.C ??
Too straight forward
Incorrect symbols?
Appropriateness?

MENGURANGKAN % KEMASUKAN SEMULA PESAKIT MALNUTRISI DI KALANGAN

KANAK-KANAK ORANG ASLI DALAM PROGRAM RE-FEEDING
DISCAJ DARI
WAD KANAK-KANAK

PKD MOBILE TEAM

(PROGRAM KZM)

MENDAPAT
BAKUL KZM

TIDAK MENDAPAT
BAKUL KZM

MENCAPAI TARGET MENCAPAI TARGET

Z SCORE < 2
Z SCORE < 2
YA
TEMUJANJI RUTIN
KLINIK PAKAR

TIDAK

TIDAK

READMISSION KE
WAD KANAK-KANAK

Discaj Dari
Wad Kanak-kanak

PKD Mobile Team

(Program KZM)
Tidak
Mendapat
Bakul KZM?
Ya
Mencapai Target
Z Score < 2
Tidak
Readmission Ke
Wad Kanak-kanak

Ya

Temujanji Rutin
Klinik Pakar

WHAT IS MOGC

MOGC is the process of care with a good

design
`GOOD is based on the specifications
considered optimum and achievable
`GOOD is defined by Criteria and Standards

Good
Structure

Structure

Process

Outcome

Good process will

produce good outcome

Good
Process

Good
outcome

 The

good steps can be adopted from

the professionally accepted
standard or norm , SOP, guidelines,
circulars, CPG, etc

It

may also be innovations thought

of, by the group

WHAT IS MOGC?

Extracted from critical steps in the process

of care
Each step will contribute to the final service
outcome
This chosen critical steps of care must be
accomplished within the set criteria and
standard
If not followed, it might cause a multiplying
effect of failure in the series of care
Finally, will end-up with an undesired product
or NOT A GOOD CARE

MULTIPLYING EFFECT OF FAILURE

Morbidity
Mortality
Defect at any
step will
contribute to the
failure of
subsequent steps
including the final
outcome

WHY WE NEED MOGC?

Due to variation in healthcare delivery
To follow the best practice available
Element of Evidence-Based Medicine
- Case management protocol
- CPG
- Standard Operating Procedures ( SOP)
- Checklists
- Clinical pathways
- HACCP : hazard analysis & critical
control point

MODEL OF GOOD CARE

NO

PROCESS

CRITERIA

1.
2.
3.

1.
2.

1.
2.
3.

1.

STANDARD

USAGE OF M.O.G.C

Quality assurance

A generic term encompassing any

systematic effort to ensure & improve
quality of health care services
Assessment of the actual quality of
care and correction of the observed
defect
The focus is on ensuring the provision
of best possible care for all clients

USAGE OF M.O.G.C
Assessment of the actual quality of care
- the extent to which actual care is in
conformity with preset criteria for
good care
- measurable difference what is
realized and what should be realized

USE OF M.O.G.C
As a model process
that is thought to be
good and achievable
Compare this model with the
real situation

CRITERIA

is the set of condition of essential element for

good care, thing that make care good for the
particular step of care
Example of essential element
i) things should do
- perform ECG and serum enzyme on those
suspected AMI
- Cross match blood before transfusion
- take consent from those for operation
- drug counselling before dispensing
polymedication

ii) Information should be obtained

- LMP of antenatal mother on booking
- Previous medical/surgical history of current
illness on admission
- Specific/related symptoms for certain c/o
- Possible complication of chronic patient on F/up
iii)Things to records;
- essential external signs on P/Ex of specific condition
- head chart / level of consciousness of MVA patients
with head injury
- plan of Rx / Mx after reviewing the patient
- partogram for mother in progress of labor

Standard setting in the MOGC

- is the minimum level of acceptable performance for the
respective step in the process of care ( referred to as
Optimum Achievable Standard (OAS )

-the value of a Criteria that marks the line between good

and poor
-widely / professionally accepted value
( evidence-based / best practice )
-preferably for the critical steps only
-consensusly agreed

SOURCE OF STANDARD
Own

situational analysis / study

Past experience / performance
National, internationally accepted Std.
Expert panel opinions
Concensus opinions among healthcare
providers.
CPG, evidence-based research
Textbook, scientific journals

MOGC : THE TEMPLATE

No

Procedure

Criteria

No

Before
Implementation of
Remedial Measures

Procedure

Criteria

Standard

Pre
Remedial
Measures

After
Implementation of
Remedial Measures

No

Standard

Procedure

Criteria

Standard

Pre
Remedial
Measures

Post
Remedial
Measures

REDUCING DELAY IN ADMINISTERING

FIRST DOSE OF IV ANTIBIOTIC TO
ICU PATIENTS

Doctor write prescription

Any problem?

yes

Clarify with doctor

No
Check drug availability in ward
Supply available in ward?

No

Get supply from pharmacy

yes
Check the requirement to take C & S specimen

Need to take C & S

specimen?

yes

Doctor take C & S specimen

No
Check the need to withold the administration
of drug eg. hemodialysis
yes
Should withold drug
administration?
No
SN prepare and administer
drug to patient

Withold administration until procedure

finish

MODEL OF GOOD CARE

NO

PROCESS

CRITERIA

STANDARD

PRE
REMEDIAL

Doctor write
prescription

-SS first antibiotic need to be

countersigned by specialist
before sent to pharmacy

100%

62.5%

Get antibiotic from

pharmacy

-If antibiotic not available in

ward, get supply from pharmacy

100%

72%

within 1 hour
3

Check the
requirement to take
C & S specimen

-Doctor need to take C & S

specimen from patient within 2
hours after prescription written.

100%

70%

Staff nurse prepare

and administer drug
to patient

-Administer drug within 4 hours

100%

83.3%

REDUCING % OF ENDOPHTHALMITIS AFTER

CATARACT SURGERY
Pt selected for cataract
surgery

Preop assessment: Blood-taking / ECG / A-scan

Review by Dr.

Fit for op

Yes

Admission

Daycare

high BP, high blood

sugar, ECG changes

Preop counselling
refer / op
deferred
Pt goes to
OT

Pt
optimized

Cataract surgery
performed
Pt returns to
ward
Admission
cases

Discharged next
day after 1st
dressing

No

Daycare
cases
Discharged
home same
day

Follow-up as schedule

No.

Procedure

Preoperative
assestment

Preoperative
counselling

Cataract
surgery

Postop Care

Criteria

Standard

1. Fasting blood sugar < 12 mmol/L

100%

2. No blepharitis or wound elsewhere

100%

1. Dedicated paramedic staff

95%

2. Written instructions in different languages

100%

1. Skin & conjunctival sac preparation with 5%

aqueous Povidone (beginning & end of op)

100%

2. Meticulous isolation of eyelashes with non-cloth

drape

100%

3. Strict supervision of learning surgeon

100%

1. Proper instillation of intensive eyedrops

100%

2. Reinforcement of postoperative eyecare (dos &

don'ts)

100%

No.

Procedure

Preoperative
assestment

Preoperative
counselling

Cataract
surgery

Postop Care

Standard

Preremedial
measures

1. Fasting blood sugar < 12 mmol/L

100%

88.9%

2. No blepharitis or wound elsewhere

100%

0%

1. Dedicated paramedic staff

95%

75%

2. Written instructions in different

languages

100%

50%

1. Skin & conjunctival sac preparation

with 5% aqueous Povidone
(beginning & end of surgery)

100%

7.7%

2. Meticulous isolation of eyelashes

with non-cloth drape

100%

38.5%

3. Strict supervision of learning

surgeon

100%

50%

1. Proper instillation of intensive

eyedrops

100%

80%

2. Reinforcement of postoperative
eyecare (dos & don'ts)

100%

75%

Criteria

No.

Procedure

Preop
assestment

Preop
counselling

Cataract
surgery

Postop Care

Standard

Preremedial
measures

Postremedial
measures

1. Fasting blood sugar < 12 mmol/L

100%

88.9%

100%

2. No blepharitis or wound elsewhere

100%

0%

95%

1. Dedicated paramedic staff

95%

75%

95%

2. Written instructions in different

languages

100%

50%

100%

1. Skin & conjunctival sac preparation

with 5% aqueous Povidone
(beginning & end of op)

100%

7.7%

100%

2. Isolation of eyelashes with noncloth drape

100%

38.5%

100%

3. Strict supervision of learning

surgeon

100%

50%

100%

1. Proper instillation of intensive

eyedrops

100%

80%

100%

2. Reinforcement of postoperative
eyecare (dos & don'ts)

100%

75%

100%

Criteria

TO REDUCE THE INCIDENCE OF VAP IN ICU HOSPITAL

TAIPING
START

Admission to
ICU

No
Assess for Intubation

Yes
Continue ventilation
Intubation &
Ventilation

Invasive
Procedures

A
41

A
Compliance
Audit

Assess for
VAP after 48
hours

No

Continue
Ventilation

Yes
Institute Treatment

Weaning

Extubation
42

MODEL OF GOOD CARE

No

Process

Criteria

Standard

Admission to ICU

Enforce compliance to patient area.11

(12-14 sq. meters)

100%

Assess for Intubation

Ensure adequate preparation, proper

technique.

100%

Intubation &
Ventilation

Daily VCB Compliance Audit

Perform Oral Hygiene every 4 hourly
Administer Metered Dose Inhaler PRN.
Measure Cuff Pressure once a shift.

80%
100%
100%
100%

Invasive Procedures

Practice Standard Precautions

Daily Audit

100%

Assess for VAP

Assess for VAP after 48 hours and daily.

100%

Institute Treatment

Administer appropriate antibiotics.

100%

Weaning

Sedation Vacation and daily assessment for

weaning from ventilator.

100%

Timely extubation

100%

Extubation

43

TO REDUCE DENTAL FEAR IN SCHOOL CHILDREN

IN PPD LMS
Introduction to the NEW Guidelines on Permanent Teeth Extraction in Schools

Day before Extraction

Name List Preparation
Tools and Materials Preparation
Student Preparation
On Extraction Day

Local Anesthesia ( Topical L.A.)

Extraction
Oral Analgesic Immediately
Post Extraction Instruction
Review

NEW !!!

MODEL OF GOOD CARE

No

Procedure

Criteria

Standard

Day before Extraction

1

Preparation of Name
List

Name list of students for extraction is prepared by referring to

LP8 card

100%

Preparation of
Materials and Tools

Preparation of materials and tools for extraction

100%

Preparation of
Students

1. Students informed of extraction one day earlier

2. Students advised to inform parents
3. Pre-extraction instructions given verbally, supplemented
with written ARAHAN SEBELUM HARI CABUTAN

100%

Day of Extraction
4

Local Anesthetic
(Topical L.A.)

1. Topical L.A. is applied onto mucosa at injection site

2. Local anesthetic injection given once topical L.A. works

100%

Tooth Extraction

1.
2.
3.
4.

100%

Oral Analgesic

Students given oral analgesic immediately after procedure (e.g.

2 tab Paracetamol 500mg)

100%

Post Extraction
Instructions

1. Post-extraction instructions given verbally, supplemented

with written NASIHAT SELEPAS CABUTAN GIGI
2. Sterile gauze pack and oral analgesic pack are given
3. Medical leave is given (if indicated)

100%

Review

Extraction socket is reviewed or sutures removed after 1 week

100%

Adequate numbness is ensured (check with Probe 9)

Tooth extraction is carried out with care
Bleeding arrested with gauze pressure
Haemostatic agent or suture placed (if indicated

Q
A
H
o
s
p
t
a

SHORTFALL IN
QUALITY

T
a

n
g

2
8

3
0

Assessment of quality of care :

Unable to achieve the set standard within the
stipulated period
SIQ would automatically trigger the
INVESTIGATION PROCESS &
REMEDIAL MEASURES

SIQ INVESTIGATION

Evaluate every steps in the process of care & to

determine whether the step was

appropriate, timely & adequate

check your MOGC

Provide the planning measures to prevent or
overcome similar shortfalls

IN SUMMARY
Model

of good care is about a `good

process design
`Good is defined by criteria and
standards
`Actual Care is compared to this
model
Helps is focussing and planning
remedial measures
MOGC is NOT STATIC

MOGC.

QUALITY IS NEVER AN
ACCIDENT
It is always the result of
intelligent & sincere
efforts to produce superior
work consistently

THANK YOU

Q
A
H
o
s
p
t
a

T
a

n
g

2
8

3
0

Any
question
?