Quality management for hospitals in Viet Nam

Monitoring correct documentation

A success story from GIZ’s health programme in Viet Nam

One of the worst hospitals I had ever seen

About three years ago when I started to work for the GIZ-supported health programme “Strengthening Provincial Health Systems”, I began writing a project diary. I visited all project hospitals for the first time, wrote down my observations and ranked the hospitals according to their cleanliness, range of services, staff, patient friendliness etc.

Tay Bac Hospital in Nghe An province, a 260 bed district hospital, ranked as one of the worst project hospitals I had ever seen. It was dirty, particularly in its operating theatre, and there were hardly any patients – a clear sign that the population did not have much trust in the hospital’s services. At the time the director explained to me that the hospital would soon be reconstructed in a better place and that it would then be upgraded and serve a larger area.

For the time being, however, most patients preferred to go to the provincial hospital even though it was over hundred kilometers away. Those who could not afford the transport, including many mothers and children, suffered from the lack of services. And many newborns, whose parents wanted good medical care for them, died on the long way to the provincial capital.

Just recently I undertook another field visit to Tay Bac hospital and was struck by how much it has changed. Although the hospital is still in the same old building, it has become a very different place.

Introducing quality management

It all began when our programme introduced the hospital to quality management as a way to identify urgent problems and to develop feasible methods to solve them.

And there were many urgent problems in Tay Bac Hospital: The staff worried about the right use of equipment, about the professionalism of their work and about their behaviour towards patients, to name but a few. Yet given the high rate of incidents in the hospital, the safety of their patients was the health workers greatest concern: Small and medium incidents, such as confusing oral medicines, false injections or doing x-rays of the wrong patients occurred almost monthly. More severe incidents with fatal consequences were likely to happen every three years.

When we jointly discussed these incidents and looked for their root causes, it turned out that hardly any standard operatiing procedures (SOP) were in place and that the existing ones were not followed accurately. So where should we start?

During one of the trainings on different methods of accreditation, GIZ had introduced the Joint Commission International (JCI) Essentials of Health Care Quality and Patient Safety tool. This methodology does not automatically lead to accreditation, but helps hospitals to implement basic standards and strategies for continuous improvement in all departments of the facility. Only if these standards are firmly established and the hospital staff has applied them successfully for a longer period of time, can it start considering accreditation.

The JCI International Essential of Health Care Quality and Patient Safety

The JCI International Essential of Health Care Quality and Patient Safety is a specific quality standard for the health sector that does not require additional financial resources or infrastructural changes in the health facilities; it is for free. It provides systematic methods, assessment and self-assessment tools for hospitals as well as scientific evidence for hospitals’ quality ranking. Its improvement strategy is specific and clear: quality improvement must be a continuous process, there will always be something that can still be done better.

Tay Bac Hospital decided to work with this standard, selecting five areas that seemed particularly relevant for patient safety:

  • Leadership Process and Accountability
  • Competence and Capable Workforce
  • Safe Environment for Staff and Patients
  • Clinical Care and Safety of Patients
  • Quality of Services.

For each of these, ten criteria were identified that would address the risk practices the health staff wanted to reduce. Together, these 50 criteria formed a comprehensive guide for the improvements in patient safety that the hospital was aiming for.

Next, so-called “levels of effort” were defined for each criterion as a means for quickly assessing the status quo and eventually the risk reduction and quality improvement. The levels are set on a scale from level zero, at which the desired activity is absent, to level three, at which data confirm that successful risk reduction strategies are being implemented and contribute to continuous improvement.

Three years later, the hospital has become a different place

The hospital has been using this tool for more than a year now and looks very different when compared to three years ago.

The ratings of departments that had originally caused particular concern, like the operating theatre and the ICU, show that quality management processes are well under way and have led to substantial improvements in patient safety. A broad set of standard operating procedures has been approved and is being applied, including correct patient identification, patient surgery, specimen collection and laboratory services turnaround time, imaging services, blood store and delivery and hospital contracting.

The pictures of the ICU for Newborns and of the operating theatre show some of the results of the quality improvement measures:Correct monitoring of documentation

Correct monitoring documentation - © GIZ Viet Nam

Pre-operation hand-washing according to guidelines

Pre-operation hand-washing according to guidelines - © GIZ Viet Nam

Cleaning of the operating room according to guidelines

Cleaning of the operating room according to guidelines - © GIZ Viet Nam

A culture of quality improvement

And yet, what I have found most striking are the changes in the hospital staff’s thinking and in their attitude towards quality and safety. The Board of Directors management capacity has been strengthened through the quality standard, which has allowed them to set in motion and direct the hospital’s quality improvement strategy. The different quality sub-committees have begun to connect with each other, creating a network of quality improvement for the entire hospital. There is now a sense of solidarity among the health staff, based on a shared culture of quality improvement: the staff has not just improved their presentation and computer skills, but they have also become much better team workers.

The patients have come back

Meanwhile Tay Bac Hospital’s ICU had to be enlarged. The cleaner and safer environment of the newborn intensive care unit has attracted many young mothers to give birth here rather than making the long trip to a provincial hospital. Particularly women from the poorer ethnic minorities from the surrounding mountainous villages benefit from the improvements. It has become very rare for newborns to be referred to higher level facilities.

With GIZ support, cleaning standards for the operating theatre were set up, responsibilities were assigned for each procedure and are followed up by supportive supervision activities.   

The nurses and doctors are proud on the results of their joint efforts and feel encouraged to do even better. The hospital director has provided monetary incentives for all of them. During Tet, the lunar new year in Viet Nam, Dr. Ha, the hospital director expects to be able to reward more dedicated and hard-working colleagues for their good work.

Even though the continuous improvement is still ongoing, Tay Bac Hospital already serves as a good practice example for other hospitals.

Concerning my project diary: After three years, I had almost forgotten about the bad ranking I gave Tay Bac hospital at the beginning of my work here. Coming back from my last visit to it, I decided to open a new chapter on it.

Nurses being trained in Hygiene

Dr. Maria Dung-Pham

See also:

How to improve the Health System in Viet Nam

Preventing hospital-acquired infections: A major concern for many Vietnamese hospitals

BMZ glossary

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