Kenya National Patient Safety Standards SurveyIFC-WHO Technical advice of SafeCare/ PharmAccess FoundationSupport from the Ministries of Health, Kenya.

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Overview: National Patient Safety Survey

Intended as a baseline survey to gauge state of patient safety standards in health facilities of all types in the country

Wide stakeholder participation on the study: • A collaboration between the World Bank Group’s Health in

Africa Initiative (HIA) and the World Health Organization (co-funders) • Technical advice of PharmAccess/ Safecare • Support of the Ministries of Health

SafeCare Essentials Checklist adapted as study tool

A total of 493 facilities in both private and public sectors sampled in 29 counties across the country• Public and private sector facilities comparable in terms of

facility size

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Key Messages

Patient safety remains an area for critical improvement within the wider issue of quality of care for both public and private sectors

Facilities want to know more & need training

Patients must be a central part of the picture

There is much scope for targeted interventions: information, guidelines and support

Action must be collaborative, taking into account support and enforcement, and both private and public sector facilities

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Overview

Why Patient Safety in Kenya?

Overview: National Patient Safety Survey and Methodology

Overview of Initial Findings from the Survey and Recommendations

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Why Patient Safety?•Resource-constrained health systems in the developing world present multiple challenges that require urgent attention:

Provider and service constraints Human resource capacity limitations

•What is patient safety? Process-based, Participatory, a Public Good

•Populations with critical health needs means that focusing attention on Preventive, Promotive, and Proactive action is key

• Risk mitigation and quality assurance of key areas• Coordinated leadership of staff and systematized management in facilities• Mitigation of health care associated infections and risks• Safe surgery and specialist services•Safe management of environmental risks• Patient-centered care

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The Private Sector and Quality of Care

•The need for effective collaboration with the private sector in SSA to meet unmet demand and improve effectiveness, access, and equity of care (IFC 2007).

•Concerns remain over the variability of quality in a diverse and under-regulated private sector with a variety of health care providers (Mills et al. 2002; Barnes et al. 2010).

FINDINGS OF THE BUSINESS OF HEALTH IN AFRICA REPORT The private sector already plays a significant role in delivering and

financing health care in Africa: it delivers 50 percent of health care and 60 percent of the financing coming from private sources.

Private providers (including for-profit and not-for-profit) serve all income levels and have broad geographic reach, not just the rich and elite in Africa.

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Patient Safety as a Regional Issue: Evidence from the Literature

The problem:Healthcare-associated infections:• WHO estimates that the risk of health care-associated infection in some developing

countries is as much as 20 times higher than in developed countries.Safe Surgery and safe specialist services:• Anesthesia-related mortality remains an issue with published mortality rates

between 1 : 150 and 1 : 3000• Mortality rates in major surgical procedures run between 5-10% due to surgical

complications

What can be done?• Evidence that relatively simple interventions may have marked effects• Effective interventions are often process-based• Documentation and systematization of risk-mitigation needs to be emphasized in facility management and care processes

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Process Based Changes are FeasibleExample : WHO’s ‘Safe Surgery Saves Lives’ Checklist

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Overview

Why Patient Safety in Kenya?

Overview: National Patient Safety Survey and Methodology

Overview of Initial Findings from the Survey and Recommendations

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Methodology: Sample design

8 Geographic clusters selected for sampling

Stratified Cluster sample in 29 counties

N. Eastern province was not included in the sampling frame due to security and logistical constraints with the study

Survey conducted by IPSOS using trained personnel with a nursing background

Mean SafeCare scores computed with SPSS

Geographic Cluster

Number of facilities surveyed

Coast 109

Coast South 56

Eastern C 47

Eastern S 61

Nairobi 40

Nyanza N 43

R Valley 93

Western 44

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Sampling: Overview of Facilities surveyed

urban peri-urban rural0

50

100

150

200

250

300

Location of facilities surveyed

• Roughly equal numbers of Public (247) and Private (246) Facilities surveyed, with a total of 493 facilities retained out of an original sample of 500•Greater number of rural facilities surveyed overall, with comparable numbers of urban and peri-urban facilities recorded.

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The majority of institutions sampled were smaller health facilities (KEPH 2, with less than 10 staff)

single <10 11 to 20 21 to 50 51 to 100 >100number of staff

0

50

100

150

200

250

300

350

400

Number of staff/ facility

2 3

4 5

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Sampling: Facility Size

Facility Level

Level of Care

1 Community

2 Dispensary/ Clinic

3 Health centre incl. maternity & nursing home

4 Sub-district & District hospitals

5 Provincial & General hospitals

6 National referral hospitals

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Complementary approaches: The SafeCare Essentials and The Kenya Quality Model for Health (KQMH)

SAFECARE ESSENTIALS TOOL KENYA QUALITY MODEL FOR HEALTHComplementary systems that have the goal of continuous quality improvement,

linked to systems and benchmarks

An international risk based approach to identifying high risk areas in a health facility, specifically tailored to resource-constrained settings over five areas

Checklist specifies issues that need to be adressed to achieve compliance with a broad quality platform of twelve dimensions, categorized by level of facility

Rapidly identify high risk areas in a facility through a systems based documentation approach to evidence of procedures and processes in place

Longer term engagement with quality issues that enables identification of elements which address quality dimensions harmonized with KEPH quality standards for each level of care

Relates directly to patient safety Incorporates multiple approaches, including the SafeCare and Kaizen management for quality improvement on a broader platform

Gives an overall score that allows for informed decision-making on the risk categorization of the facility

Self assessment helps facilities prepare for further quality improvement activities

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Survey Study Instrument: SafeCare Essentials Checklist

• The Essentials may be used as a rapid screening tool, as a self-evaluation strategy for facilities wanting to embark upon a quality improvement journey, but also as a basis for Governments to help develop an inspectorate system for public and private facilities.

• The Essentials Checklist uses 5 main areas of risk and 41 sub-categories to determine the achievement level of individual facilities in each area:

1.0 LEADERSHIP PROCESS & ACCOUNTABILITY 2.0 COMPETENT AND CAPABLE WORKFORCE 3.0 SAFE ENVIRONMENT FOR STAFF & PATIENTS 4.0 CLINICAL CARE OF PATIENTS 5.0 IMPROVEMENT OF QUALITY & SAFETY

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Survey Instrument: SafeCare Essentials Toolkit (PharmAccess Foundation) adapted for use

1.0 Leadership Process & Accountability

2.0 Competent & Capable Workforce

3.0 Safe Environment for Staff and Patients

4.0 Clinical Care of Patients

5.0 Improvement of Quality & Safety

1.1 Leadership responsibilities and accountabilities identified

2.1 Personnel files and job descriptions for all staff

3.1 Regular inspection of buildings

4.1 Correct patient identification

5.1 There is an adverse event reporting system that includes analysis of the data or events

1.2 Leadership for quality and safety

2.2 Review of credentials of physicians

3.2 Control of hazardous materials

4.2 Informed consent 5.2 High-risk processes and high-risk patients are monitored

1.3 Collaborative management 2.3 Review of credentials of nurses and other health care professionals

3.3 Fire safety program 4.3 Medical and nursing assessments for all patients

5.3 Patient satisfaction is monitored

1.4 Oversight of contracts 2.4 Staff orientation to their jobs

3.4 Biomedical equipment safety

4.4 Laboratory services are available and reliable

5.4 There is a complaint process

1.5 Compliance with laws and regulations

2.5 Training in resuscitative techniques

3.5 Stable water and electricity sources

4.5 Diagnostic imaging services are available, safe, and reliable

5.5 Clinical guidelines and pathways are available and used

1.6 Commitment to patient and family rights

2.6 Staff education on infection prevention and control

3.6 Reduction of healthcare associated infections (hand hygiene)

4.6 Anesthesia and sedation are used appropriately

5.6 Staff know how to improve processes and quality improvement information is shared with staff

1.7 Policies and procedures for care of high risk patients

2.7 Communication among those caring for the patient

3.7 Barrier techniques are used (gloves, masks, etc..)

4.7 Surgical services are appropriate to patient needs

5.7 Clinical outcomes are monitored

3.8 Proper disposal of sharps and needles

4.8 Medication use is safely managed

3.9 Proper disposal of infectious waste

4.9 Patients are educated to participate in their care

3.10 Appropriate sterilization and cleaning procedures are used

4.10 Care that is planned and provided is written down in a patient record

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SafeCare Essentials: Scoring Guide

•The SafeCare Essentials Checklist is scored on a graded ‘Levels of Effort’ from 0-3, representing progressive achievement in risk reduction over the five areas identified in the Checklist:

Level 0: The desired activity is absent, or there is mostly ad hoc activity related to risk reduction

Level 1: The structure of more uniform risk-reduction activity begins to emerge

Level 2: The processes are in place for consistent and effective risk-reduction activities

Level 3: There are data to confirm successful risk-reduction strategies and continue improvement

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Questionnaire methodology: Determining Scoring

Simple questions form the basis of objective scores given: A total of about 250 simple “Yes/No” questions were defined by the research team and should ensure replicability of scoring method.Emphasizing documentation: In many cases, safety-related activities of health facilities had to be documented in order to be considered as “existing”.

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Overview

Why Patient Safety in Kenya?

Overview: National Patient Safety Survey and Methodology

Overview of Initial Findings from the Survey and Recommendations

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Results: Key messages

Low scores overall: most mean scores were less than 1 on the SafeCare scoring scale

Larger facilities tended to perform better in most subcategories

Smaller facilities exhibited varying levels of performance, with scores frequently below 0.5

Statistically significant differences in performance between public and private sectors in several areas

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Results Summary: Overall areas of strength and weakness

Particular weakness was demonstrated in these areas (mean scored performance on risk areas <0.5):

Risk area Mean scoreLeadership and management:Leadership for quality and safety (1.2)Compliance with laws and regulations (1.5)Oversight of contracts (1.4)

1.170.851.32

Patient records:Medical and nursing assessments for all patients (4.3)Care that is planned & provided is written down in a patient record (4.10)

1.041.48

Patient-centered care:Informed consent (4.2)Patient education to participate in their own care (4.9) Commitment to patient and family rights (1.6)

0.450.160.33

Staff management:Staff orientation to their jobs (2.4) 0.16

Specialized services:Safety of specialized services in anesthesia (4.6)Documented procedures for care of high risk patients (1.7)Safe medication management (4.8)

0.280.320.30

Safe environment: Control of hazardous materials (3.2)Stable infrastructure and services (3.5)

0.050.39

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Better performance in average scores for two subcategories:‘Leadership for Quality and Safety’ & ‘Oversight of Contracts’

Leadership Process & Accountability

1 Leadership Process and Accountability Private

1.1 Leadership responsibilities and accountabilities 0.15

1.2 Leadership for Quality and Safety 1.22

1.3 Collaborative management 0.20

1.4 Oversight of contracts 1.25

1.5 Compliance with laws and regulations 0.92

1.6 Commitment to patient and family rights 0.33

1.7 Policies and procedures for care of high risk patients 0.31

1.7 Policies and procedures for care of high risk patients

1.6 Commitment to patient and family rights

1.5 Compliance with laws and regulations

1.4 Oversight of contracts

1.3 Collaborative management

1.2 Leadership for Quality and Safety

1.1 Leadership responsibilities and accountabilities

0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2

Overall

Private

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Competent & Capable Workforce

Overall average scores were below 1, with particular areas of weakness in subcategories relating to staff management and orientation to their jobs

2.1 Personnel files and job descriptions for all staff *

2.2 Review of credentials of physicians

2.3 Review of credentials of nurses and other health care professionals

2.4 Staff orientation to their jobs*

2.5 Training in resuscitative techniques*

2.6 Staff education on infection prevention and control

2.7 Communication among those caring for the patient

0 0.2 0.4 0.6 0.8 1

OverallPrivate

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Safe Environment for Staff and Patients

In a risk area of weakness for both sectors, statistically significant differences favoring the private sector were confirmed in the following

Private

3.3 Fire safety program 0.57

3.5 Stable water and electricity sources 0.68

3.7 Barrier techniques are used 0.19

3.10 Appropriate sterilization and cleaning procedures are used 0.68

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Clinical Care of Patients

Patients do not appear to be receiving sufficient information from providers

4.10 Care that is planned and provided is written down in a patient record

4.9 Patients are educated to participate in their care

4.8 Medication use is safely managed

4.7 Surgical services are appropriate to patient needs

4.6 Anesthesia and sedation are used appropriately

4.5 Diagnostic imaging services are available, safe, and reliable

4.4 Laboratory services are available and reliable

4.3 Medical and nursing assessments for all patients

4.2 Informed consent

4.1 Correct patient identification

0 0.5 1 1.5 2

Overall

Private

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Focus on 4.2: Informed Consent

Informed consent was a general area of weakness in performance

4.2 Informed consent. (Facilities where surgical procedures are carried out) Facility Type

Score PrivateNo informed consent documentation is available 0 94Can you show me a document about the process for patient information and consent for surgical or other high-risk procedures? 1 37

1. Can you show me an informed consent form for surgical procedures?2. Can you show me an informed consent form for anesthesia?3. Can you show me an informed consent form for the use of blood and

blood products, if applicable to your facility 2 21

Can you show me your most recent evaluation report of the patient information and consent process? 3 7

Total Facilities 159

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Improvement of Quality and Safety

All the facilities scored low in this category, however statistically significant differences observed in the areas of monitoring of patient satisfaction which was better in the private sector.

Private score

Patient satisfaction is monitored

0.32

5.7 Clinical outcomes are monitored

5.6 Staff know how to improve processes & quality improvement information is shared

5.5 Clinical guidelines and pathways are available and used

5.4 There is a complaint process

5.3 Patient satisfaction is monitored

5.1 There is an adverse event reporting system that includes analysis of the data or events

0 0.5 1

Overall

Private

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Key messages from the analysis of the Survey

Facilities & regulators: Main Challenges

Patient care: Key gaps

Facilities want more Information and Support on patient safety

Greater awareness of patient rights and patient safety standards on the part of facility users is critical

Regulators must provide targeted Oversight, Guidance and Enforcement focused on areas of weakness

Informed consent and participatory care planning

Infrastructure: basic services and environmental safety are key

Patient centered care needs to be emphasized

Safety of specialized services is an area of further attention

Private and Public sectors must work together to understand patient preferences and needs

Smaller facilities with more limited capacities need further support

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Recommendations for Next steps

Recommendation ActionsDocumentation Encourage facilities to document their patient safety processes to

create greater systematization of careImplementation Further the implementation of central quality models (Kenya Quality

Model for Health) at all facility levels for longer-term actionInformation Make information on patient safety available to facilities of all levels &

provide support and guidance on self-assessment and planning for quality improvement

Interventions Better strategies for improving compliance are needed, including incentives and enforcement through targeted inspections

Priority Setting Since there are vast opportunities for improvement across all risk areas, priorities have to be set by decision-makers

Support All facilities need supportive supervision. Smaller facilities need particular support with regard to patient safety in all areas

Sensitization Provide comprehensive information to patients through different media on their rights and basic patient safety standards

Training Include comprehensive training on patient safety within health education curricula and Continuous Professional Development

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Concluding Messages

•Focus on designing effective interventions: The findings of the National Patient Safety Standards Survey can help in the process of setting priorities, as well as the subsequent design of interventions.

•A repeat survey will show which interventions have been most effective.

Thank you.

For more information, please visit www.wbginvestmentclimate.org/healthwww.who.int

www.safe-care.org