SQRMReport1011 PDF

Hospital Authority
Quality And Risk Management

Annual Report
2010 - 2011
(Apr 10 - Mar 11)
ACKNOWLEDGEMENT
We would like to express our deepest appreciation to the support from all
frontline colleagues, hospital risk managers, clinicians, executives of hospitals,
and colleagues of cluster quality and risk management departments in
improving patient safety.
We would also like to thank them for their
contributions in the risk mitigation strategies and programmes.
Patient Safety and Risk Management Department

Quality and Safety Division
TABLE OF CONTENTS
Opening Message
Head Office Chapter
Hong Kong East Cluster Chapter

Hong Kong West Cluster Chapter
26

Kowloon Central Cluster Chapter
39

Kowloon East Cluster Chapter
59

Kowloon West Cluster Chapter
77

New Territories East Cluster Chapter
92

New Territories West Cluster Chapter
106

Opening Message
This is the third publication of Hospital Authority Quality and Risk Management
Annual Report, compiled by Patient Safety and Risk Management Department and
Quality and Standards Department, Hospital Authority. The purpose is to facilitate
sharing of good quality and safety practices across Hospital Authority.
With the advancement in healthcare service - new treatment options, new technology,
hospital operation is becoming even more complex. It is inevitable that adverse
events (from mishap, error) will occur. It is important to ensure that our healthcare
system is safe. With the increasing workload and demand on the public service, it is
also essential to ensure that our healthcare system is effective and efficient.
Over the past few years, the Division of Quality and Safety (Q&S), Hospital
Authority Head Office (HAHO) together with the clusters Quality and Safety team
has continued to strive for a safe, effective and efficient healthcare for our patients.
During the annual visit by HAHO Q&S Division to the different HA clusters, we have
observed a more structured approach to Q&S issues at the cluster and hospital level,
with the setting up of Q&S office and designated staff for Q&S. There were many
innovative Q&S programs being developed and implemented across the clusters.
These good Q&S practices should be shared among the clusters. We are also pleased
to see that the Q&S activities are being evaluated to ensure that the purpose of the
program is being achieved and led to further improvement, as part of the Continuous
Quality Improvement cycle.
A safe, effective and efficient healthcare system for our patient is also a better and
happier healthcare system for our staff to work. Keep up with the good work.
Dr. SF Lui, Consultant (Q&S), HAHO

for Q&S Division, HAHO
1. Structure & Initiatives
This report covers the quality and risk management initiatives implemented in Hospital
Authority Head Office (HAHO) from 1 April 2010 31 March 2011.
In the last year, both Quality
and Standards Department and Patient Safety and Risk Management Department have made
continuous effort in planning and steering strategies to ensure quality and patient safety in HA.
1.1 Hospital Accreditation
1.1.1 A Systematic Approach to Continuous Quality Improvement
Hospital accreditation program is recognized internationally as a CQI
tool to help hospitals and healthcare institutions to identify gaps and
opportunities for improvement.
Partnering with the Australian Council on
Healthcare Standards (ACHS), HA continued the Pilot Scheme of Hospital

Accreditation (Pilot Scheme) in 2010/11 with support and collaboration from the Government,
Private Hospitals Association (PHA) and the Department of Health (DH).
Five public hospitals
(namely, CMC, PYNEH, QMH, QEH and TMH) as well as three private hospitals (namely, the
Baptist Hospital, Hong Kong Sanatorium & Hospital and Union Hospital) completed their
Organisation Wide Survey from June to October 2010. They were all awarded 4-year full
accreditation status by ACHS.
1.1.2 Achievements
(a) Outstanding CQI Initiatives
Participating public hospitals had planned and implemented many CQI
initiatives with outstanding results. The surveyors had, during the Organization Wide Survey, duly
recognized their achievements, such as pressure ulcer management, care of dying and deceased,
incident, complaint and feedback management, external service provider management as well as
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safe practices and environment.

(b) Successful adaptation of local ACHS Accreditation Standards
The ACHS Evaluation and Quality Improvement Program (EQuIP) 4
Hong Kong Guide was developed. This Hong Kong version of EQuIP 4,
based on the local adaptation of the original ACHS EQuIP 4 Guide, received
recognition by both the ACHS and The International Society for Quality in
Health Care (ISQua). The Guide will ensure consistency in interpretation and
understanding of local guidelines between overseas and local surveyors.
(c) Building up a Hong Kong Surveyor System
As of March 2011, 33 local surveyor trainees had completed their
training and were appointed ACHS (HK) Surveyors. These local surveyors were given the same
recognition and status as the ACHS surveyors in Australia.
They are part of the Hong Kong
Surveyor System with involvement in future accreditation program and contributed to the long-term
vision of establishing a HK accreditation system.
(d) Enhancing Communication and Sharing
To support accreditation as a continuous improvement process, HA has developed and
launched an IT platform Continuous Quality Improvement Initiatives
System (CQIs) in December 2010.
This HA-wide database on quality
improvement projects was welcomed by hospital staff for learning and sharing,
planning of quality improvement programmes and streamlining documentation
for accreditation program.
The first issue of Quality Times, a periodic
publication on quality initiatives in HA, was launched in Feb 2010.
This
4-monthly publication is aimed at enhancing communication through sharing

of good practices as well as lessons learnt from local and overseas
experiences.
1.1.3 Common Gaps
The surveyors had identified some common gaps in pilot HA hospitals, such as sterilization
practices in operating theatre, document control, credentialing and defining scope of practice.
These gaps are being addressed at corporate level by setting up Task Force, Working Groups and
developing a Guideline on Disinfection and Sterilization of Reusable Medical Devices for
Operating Theatre.
1.1.4 Evaluation of Pilot Scheme
The Pilot Scheme has been evaluated both by the Steering Committee and the Nethersole
School of Nursing. The Chinese University of Hong Kong (CUHK) also conducted studies on
accreditation experience of the management and frontline staff of participating hospitals. The
evaluation findings will help to guide HA in the journey of hospital accreditation.
1.2 Access Management

In 2010/11, different working groups on access management had taken measures in addressing
the pressure areas in waiting time.
For specialist outpatient service, the electronic referral system
was extended to all 7 clusters to enhance quality of referrals, as well as facilitate feedback and
communication between referral sources and receiving ends.
The patterns of referrals were
surveyed to identify pressure areas to formulate referral templates to enhance structured referrals
and to develop specialty-specific programs.
For elective surgery waiting list / waiting time management, cataract, total joint replacement
and BPH surgery were identified as the pressure area.
Prioritization guidelines were developed to
triage patients with urgent clinical needs for surgery. Key performance indicators for selected
cancer types and elective surgeries were set with respective coordinating committees and monitored
in the Cluster Management Meetings quarterly.
Common platforms for sharing of information were developed in HA computer systems such
as Clinical Data Analysis and Reporting System (CDARS) and Management Information Portal
(MIPo) to facilitate various levels of staff ranging from clinicians to senior management on
real-time access of waiting time trend and information for service planning.
1.3 Clinical Measurement

A Working Group on Clinical Indicators (CI) was formed in October 2010 and laid out the
principles for a good Clinical Indicator: benchmarkable, longitudinally comparable, readily
retrievable and associate with Continuous Quality Improvement (CQI) programs.
Professional
advices from different coordinating committees, e.g. Anaesthesiology, Internal Medicine, Intensive
Care, Obstetrics & Gynaecology, Paediatrics, Radiology and Surgery were sought in the CI
development.
1.4 Unique Patient Identification (UPI)

The adoption of 2D barcode system technology in ensuring correct patient identification in
Blood and Non-blood Specimen Collection (phase 3 of UPI project) was further rolled-out to all
HA Hospitals in 2011 after the trial run in PWH, TMH, CMC, UCH, QEH.
Further application of
2D barcode has been introduced to Accident & Emergency Department (AED), NDH and PWH
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have piloted the technology in AED in 2010. The technology was also welcomed by Diagnostic
Radiography Department and was piloted in mobile radiography to reduce risk of in-patient
misidentification (phase 4 of UPI project).
It planned to roll-out its application to all HA hospitals
gradually.
1.5 Surgical Safety

Phase II of Surgical Safety Policy, Interventional Procedure Safety Policy, was effective on
1 October 2010 and fully implemented by 31 December 2010.
The phase III of Surgical Safety
Policy, Bedside Procedure Surgical Safety was effective since 1 March 2011.
It emphasized on
the development of a checklist for the bedside procedures Chest Tapping, drainage and
paracentesis and Insertion of intravascular catheter with the use of guide wire to improving
patient safety during bedside procedures.
1.6 Patient Safety Round

A Patient Safety Round Training was orgamized by Head Office in November 2010.
conducted by Dr. Allan Frankel of Pascal Metrics.
It was
The training comprised a one day forum and
on-site safety rounds at PMH, TMH, PMH, TWH and PYNEH. It had provided us with a new
perspective on the application of walkrounds and the leadership skills in engaging staff in clinical
units to improving patient safety.
1.7 Revamp of Advanced Incident Reporting System (AIRS)

With the recommendations from the user functional requirement study conducted by Hong
Kong Productivity Council (HKPC), the reporting methodology, system design and the screen
layout will be reviewed in the revamped version.
This new version would be simple, user-friendly
and easy for reporting and is named as AIRS 3.
The AIRS 3 has added a new feature of
reporting near miss to further promote the sharing and learning culture.
Prototypes testing were
conducted prior to pilot in clusters by November 2011.
1.8 Crew Resource Management (CRM)

CRM programme was first piloted in PYNEH in 2009 and received positive staff feedback.
The impact on patient safety culture was also reflected in the programme evaluation.
A Steering
Committee was formed under the Quality and Safety Division of HA to review and looked into the
future roll-out of CRM. A second phase of CRM in HA would be commenced in QEH & TMH in
2011/2012 and should focus on team-based training.
1.9 Continued efforts in phasing out reused Single Use Devices: Ensuring patient safety
Single use devices (SUD) are often reprocessed for reuse worldwide for various reasons.
In
this aspect, HA has established structures and processes to initiate a risk stratified approach to phase
out the reuse of SUD to ensure patient safety.
This includes:
An advisory group under the Central Committee on Quality & Safety;
Registration of SUD reused in HA;
Requirement for hospitals to develop a reprocessing protocol; and
Reporting of incidents relating to the reuse of SUD via HA's Advanced Incident
Reporting System (AIRS).
Since 2006, HA and has stopped reusing all high risk SUD, and planned to phase out the reuse
of moderately high risk SUD.
The challenge is to draw together the lessons learnt and to continue
implementing measures to reduce the reuse of SUD including the followings:

z
Ensuring registration data of SUD is accurate, complete and consistent;
Providing feedback to clusters to ensure consistency in the type of devices reused

amongst clusters;
Establishing guiding principles in the registration and funding of SUD;
Aligning the central priority list to phase out reuse of SUD with policy and funding; and
Exploring better options in improved procurement of SUD.
1.
Structure & Initiatives
1.1 Engaging Clinical Leaders

To foster the strategic direction of Building Clinical Leadership and Knowledge to Sustain
Quality and Safety Improvement, two more clinicians were appointed as Deputy Director (Q&S)
in April 2010, making a total of four in the team.
In order to widen the participation of doctors and nurses in quality and safety improvement,
new Department Q & S Coordinators were appointed with effect from 1 January 2011 for a
two-year term.

PYNEH was successfully awarded full accreditation for four years by the Australian Council
on Healthcare Standards (ACHS) in September 2010. As the first public hospital accredited under
the HA pilot scheme, PYNEH was commended by ACHS Survey Team in particular for its values
that allow and support staff to be innovative and creative in their clinical work practices for
continuous quality improvement and better outcomes for patients and clients entrusted to their care;
good teamwork with seamless interfacing between clinical and management teams; and a sound
management structure to facilitate the corporate and clinical governance operation of the Hospital.
In terms of quality and safety, the ACHS accorded the following five areas in PYNEH with
Extensive Achievement (EA):
1.2.1 Systems exist to ensure that the care of dying and deceased consumers / patients is managed
with dignity and comfort.
1.2.2 The incidence and impact of pressure ulcers are minimised through a pressure ulcer
prevention and management strategy.
1.2.3 The system for prescription, sample collection, storage and transportation and administration
of blood and blood components ensures safe and appropriate practice.
1.2.4 The Hospital ensures that the correct patient receives the correct procedure on the correct site.
1.2.5 Waste and environmental management supports safe practice and a safe environment.
1.3 Crew Resource Management (CRM)

A research in 1979 in the United States identified the majority of aviation accidents was due to
human factors: failures of interpersonal communications, decision making, and leadership.
CRM
training was developed to eliminate errors by making better use of the human resources on the flight
deck. CRM in aviation is being applied to healthcare in overseas organizations with similar
objectives.
PYNEH was commissioned by the Hospital Authority to plan and organize CRM training
program commencing 2009/10 as a pilot project.
By March 2011, over 1,400 doctors and nurses
have been trained to enhance risk awareness, communication and decision making in their clinical
teams.
A CRM Campaign entitled CRM-in-Action has been launched to reinforce the effective
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application of CRM tools in daily operations. The Campaign was kicked off in Dec 2010.
Top
management and all the Chiefs of Service have committed full support in promoting CRM towards
building a culture of patient safety.
Multiple channels and media are being used in the
promulgation, including a CRM Gallery, an intranet webpage as well as distribution of useful

workplace gadgets like iSBAR card and tourniquet.
1.4 Correct Patient Identification

Patient identification has been ranked the first of the Top 10 clinical risks in HKEC.
To
heighten staff awareness, HKEC has been organizing a series of educational & promotional
programs on Correct Patient Identification.
The Campaign promoted the use of at least two
personal core identifiers. Game booths were concurrently set up in all cluster hospitals during 1-3
March 2011. The total number of attendance was 2,297 and the correct rate in answering quiz at
booth games increased to over 90% this year. Compared with around 70% in 2009/10, this
demonstrates a significant improvement in staff awareness on correct patient identification.
11
1.5 Prevention of Patient Suicide

Following the successful implementation of the new guideline and checklist for Suicide Risk
Assessment in PYNEH, the same was rolled out to HKEC hospitals in 3Q 2010.
Training sessions
for medical, nursing and supporting staff were held across HKEC between April and May 2010.
HKEC achieved zero patient suicide in the year of 2010/11.
The multi-disciplinary model of staff engagement towards suicide prevention in HKEC was
presented in the HA Convention of 2010.
HKEC has been invited to share the experience in
various safety seminars after the HA Convention.
1.6 Surgical Safety

Implementation of a standardized surgical safety checklist has started to enhance team
communication and safety checking at various critical points before and after a surgery.
Compliance rate at PYNEH was 100% as revealed in an audit in March 2010.
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2.
Risk Prioritization
2.1 Identified clinical risks for 2010-2011

Identified clinical risks
1
Patient Identification
Communication
Surgical Safety
Medication
Fall
Pressure Ulcer
Suicide
Infection Control
Staff Competence
10 Blood Transfusion
2.2 Identified Non-clinical (operational) risk for 2010-2011

Identified non-clinical / operation risks (not in order of priority)
1
Fire Safety
Equipment Failure
Data Security and Confidentiality
Occupational Safety and Health
Security
Patient Transfer (external and internal)
Facility Defects
Medical Supplies Product Quality
Incorrect Payroll (due to new implementation of ERP(HCM) and new

procedures/practices)
2.3 Identified clinical risks (in order of priority) for 2011-2012

Identified clinical risks (in order of priority)
1
Communication
Medication Safety
13
Staff Competence
Clinical Handover and Communication
Surgical Safety
Infection Control
Fall
Pressure Ulcer
10 Suicide
2.4 Identified non-clinical / operational risks for 2011-2012 (not in order of priority)
Identified non-clinical / operation risk (not in order of priority)
1
Fire Safety
Equipment Failure
Data Security and Confidentiality
Security
Patient Transfer (external and internal)
Facility Defects
Medical Supplies Product Quality
14
3.
Risk Reduction and Quality Programs
3.1 Identified clinical risks for 2010/11

No.
Programme
(a)
Patient Identification Risk
Action Taken / Evaluation on Effectiveness
Correct Patient Identification

Campaign reinforcing the use of at
Total Attendance of 2,297.

Correct rate in answering quiz was over
90% (2009:70%)
Surveys have revealed that:

11 out of 12 dimensions of safety culture
(AHRQ) showed improvement.
least 2 personal core identifiers.

(b)
Communication
CRM-in-Action: Promulgation in the
use of tools introduced in Crew
Resource Management training in
improving patient safety in 4Q10.
(c)
Surgical Safety
Further Promulgation of Surgical
Safety.
(d)
Staff feel that the hospital is actively

improving patient safety
Participants agree CRM has positive
impact on patient safety culture
Majority of trainees had started practicing
CRM at work
Extension of HA policy on procedural

safety from operating theatres to
interventional suites.
Practising CRM tools e.g. briefing and

debriefing, SBAR and assertion in
Operating Theatres and Procedure Rooms.
Review of the 2008 version of Drug
Allergy List.
Review of drug allergy warning
mechanism and replacement of drug
Medication
Prevention of medication incidents
related to known drug allergy.
allergy warning sheet with a printed CMS

allergy record.
Number of medication incidents related to
known drug allergy was reduced to 3 in
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No.
Programme

the latter half of 2010/11. (Further
evaluation on the effectiveness is in
progress.)
Enhance learning and sharing of

medication incident.
Appointment of frontline staff as

Medication safety Ambassadors (ward) to
promote the learning and sharing.
Safety enhancement in handling high

risk medications
(e)
areas and with a warning.

Only one strength of midazolam is used in
each hospital.
Risk of Fall
Environmental screening against
patient falls.
Checklists for environmental safety to

prevent fall designed and available at
PYNEH Nursing Homepage for use of
ward staff in Patient Safety Round.
Alert Mobility System for safe

mobility of patients
System being developed as a pilot

program to facilitate both clinical and
non-clinical staff in managing mobility of
patients.
Forum From Fall Prevention to Safe

Mobilization of Fragile Patients to
Total Attendance of 293 staff.

Evaluation showed a satisfactory feedback
arouse staff awareness

(f)
No ward stock of muscle relaxants is kept

in general wards except in designated
of 4.82 average scores over 6.
Pressure Ulcer
Workshops on Prevention of Pressure
Ulcer
3 workshops conducted by a
multi-disciplinary team in April and May
2010
66 HKEC Pressure Ulcer Link Persons

were appointed
The Pressure Ulcer incidents decreased
from 0.40 per 1,000 in patient bed-days
(n=315) in 09/10 to 0.35 (n=276) in 10/11.

(g)
Suicide
Elimination of environmental risks
16
Improvement works to high-risk locations
No.
Programme

in PYNEH.
y
Executive Walkaround conducted in

RHTSK and TWEH to identify potential
environmental risks.
Staff training on prevention of patient

suicide
Implementation of Suicide Prevention y

Program
Two rounds of training to medical,

nursing and supporting staff in Dec 2010
Zero case of patient suicide was recorded
in 2010/11.
Systematic review and assessment for
general patients in HKEC implemented in
3Q10.
(h)
Infection Control
Continuous audits and surveys to
monitor compliance of various
critical infection control measures
Compliance audit on various KPI to

ensure safe and effective patient care
practices showed improvement over
results in 2009/10.
Compliance on Isolation Precautions in
HKEC was 87.7% in the audit in 1Q10.
Overall compliance on hand hygiene
moment 1 ranged from 47.3% - 91.7% in
2Q10.
HA-wide prevalence survey on Hospital
Infection conducted in 3Q10 showed
improvement from 3.19% in 2007 to 2.79
in 2010.
Hand hygiene observation survey
conducted in 1Q11 showed overall
compliance slight improvement to 69%
compared with 67.3% in 2009.
Overall compliance on initiating physical
isolation to MRSA cases increased from
84.7% in 2008 to 93.3% in 2010.
Cluster-wide audit on Clinical Waste
Management completed in 3Q10. Overall
compliance was 98.6%.
17
No.
Programme
Use of needleless connector and

sterile cap in PYNEH in 1Q10
Survey showed utilization rate was 79%

and 98% for needleless connector and
sterile cap respectively.
Stringent control measures against

MRSA bacteraemia in Renal Unit
No Catheter Related Blood Stream

Infection (CRBSI) cases reported in renal
unit for 6 months from Aug 10 to Jan 11
Hand hygiene compliance had increased

from 61.8% in 4Q09 to above 80% in
1Q10 & 1Q11
Training to minimize blood culture

contamination in PYNEH & RHTSK.
(i)
Blood culture technique assessment

among phlebotomists conducted in 4Q10
2 sessions on post assessment refresher
trainings conducted in 4Q10 for all
phlebotomists
A lunch symposium targeted for doctors
held on 13 Jan 2011
The overall compliance was around 79%
Staff Competence
Setting up of a hospital credentialing
framework to guide, monitor and lead
improvement projects on
credentialing and introduction of new
A multi-disciplinary Hospital Committee

on Credentialing & Introduction of New
Interventions set up.
A new Policy on Credentialing &
Introduction of New Intervention

developed.
Clinical competency registers of medical,
interventions.
nursing and allied health staff in each

department drawn up and regularly
reviewed.
Structured process for annual verification
of medical registration by Human
Resources Department continued
Peer review meetings for continuous
sharing of lessons learned and
identification of opportunities for
improvement arranged
18
No.
Programme

y
Credentialing system for Minimal Access

Surgery (MAS) in Department of Surgery,
PYNEH, piloted.
(j)
1.
Blood Transfusion
Common platforms for staff to share
and communicate change of
procedures and practices in HKEC.

y
Cluster Transfusion Committee meets

twice annually among Blood Bank,
clinical department & nursing
representatives.
HKE Blood Bank staff meetings and
Quality Assurance meetings held
quarterly.
Incident shared, change of practice
adopted and ways to improve transfusion
service explored in these platforms.
Messages to frontline staff disseminated
through department representatives.
3.2 Identified non-clinical (operational) risks for 2010/11

No.
Programme
(a)
Fire Safety
1.
Improve the accessibility and
The fire safety training video shared to
staff in hospital website.

As at the end of June 2010, over 99% of
coverage of fire safety training.
PYNEH staff attended fire safety

training. 94% of PYNEH staff correctly
answered all 5 questions in the e-learning
fire safety module.
2.
Involving frontline participation in

fire safety promotion in departments.
Renewing appointment of 98 Fire Safety

Ambassadors in PYNEH
3.
Continuous quality improvement to

fire safety lectures.
95% of PYNEH staff attending Fire

Safety Lecture agreed that it enhanced
their knowledge on fire prevention,
evacuation and use of fire fighting
equipment.
19
No.
Programme
4.
Fire risk assessment.
Risk Assessment conducted at 24

PYNEH departments in 2010/11. Fire
risks were identified and subsequently
reduced by improvement actions.
(b)
Data security and confidentiality
1.
Enhanced control on security of data

in confidential waster paper.
(c)
1.
reviewed.
Tightened up physical
confidential waste paper.
security
of
100% staff of housekeeping contractor

completed mandatory awareness training
on data privacy within one week from the
date of reporting duties.
10 training sessions conducted for 500

supporting staff on handling of domestic
chemicals
Chemical safety training kits developed
& uploaded to cluster OSH website for
OSH Link Persons

Training on Safe Handling of
Chemicals
2.
Workflow in collection, storage and

disposal of confidential waste paper
Manual Handling Operation (MHO)
No related IOD incident reported.
MHO Risk Assessment tools developed
Risk Assessment and training
& implemented in Neuro-medical wards

of TWEH, Psycho-geriatric wards of
PYNEH, Geriatric wards of RHTSK and
y
(d)
Security
1.
Sharpening skills of Hospital Security

Staff.
SJH.
Relevant training conducted to minimize
MHO risk.
Completed analysis of core competence

and identification of training needs of
Hospital Security Guards.
Security response plans for occurrence of
crimes to supplement documented
20
No.
Programme

procedures for Security Guards
y
Basic life support training provided to all

Hospital Security Staff to equip them
respond to emergency situation when
necessary.
2.
Improve the physical security in

HKEC hospitals.
Minor capital works of $2M completed in

various hospitals.
3.3 Other Quality initiatives

3.3.1 Injury on Duty involving Medical Records Transfer
A Multi-disciplinary Work Group was formed to investigate the increasing trend of IOD cases
in the Transportation Team involving medical records transfer.
The following root causes were
identified:
(a)
Task Mismatch of workload and workforce causing overloading of trolleys
(b)
Tools Specially designed trolleys meant to move along narrow aisles in Records
Store turned out to be too tall and narrow to be safely moving around in the
hospital.
(c)
Facilities & Environment Hazards along the route of transfer, e.g. rough floor
surface, blind corners, bottleneck in some passageway
Improvement measures including workforce reinforcement, limiting trolley loads, removing

facilities hazards, recalling dangerous trolleys and etc were implemented in 2010.
As a result, zero
incident related to medical records transfer was recorded in 2010.

3.3.2 Heat Stress Reduction Program in Chai Wan Laundry
A series of improvement measures were implemented in Chai Wan Laundry as part of the Heat
Stress Reduction Program. They include:
(a) Upgrade of the ventilation system to increase the air flow rate from 9 to 18 air
changes per hour.
(b) Construction of electrical skylight and replacement with larger windows to increase
air circulation.
(c) Redistribution of equipment layout to remove obstruction to air flow.
(d) Replacing pressing process with tunnel finishing process so as to reduce heat
generation. Linen & uniform items with fabric that fits in the new finishing process
were introduced too.
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As a result, the measured heat index (WBGTi) ranged from 30.4 to 31.6 oC. That means the
risk of heat stroke to workers is low. Over 85% of staff were satisfied with the heat reduction.
3.3.3 Manual Handling Operation (MHO)
Manual handling operation (MHO) is a high risk in wards. Ceiling hoists have been installed
in 13 clinical wards as of May 2010.
They relieve MHO of the healthcare workers, thus
significantly reducing the risk of Injury-on-Duty (IOD).
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4.
Learning & Sharing Information
4.1 Prevention of Pressure Ulcer

A multidisciplinary working group was formed to develop preventive measures and
management guidelines on pressure ulcer in early 2010.
Train-the-trainers workshops - Multi-dimensional Pressure Prevention and Care were
conducted in 1Q-2Q10.
A total of 66 clinical staff has passed the assessment and become
qualified Pressure Ulcer Link Persons to facilitate knowledge transfer within their respective
departments.
4.2 Department OSH Link Persons
A total of 139 Department OSH Link Persons have been appointed in HKEC. The OSH
Committee has conducted regular meetings with OSH Link Persons to maintain a communication
for sharing of good practices to enhance staff safety and wellness.
A system has been established to provide mandatory OSH-related training to all staff on an
on-going basis so they are continuously refreshed on the basic knowledge and skills of OSH.
To equip staff knowledge on Management of Violence Aggression (MVA), basic trainings
were provided to all staff who work in high risk departments, namely Psychiatry, Security Service
and Community Nursing Service.
There has been a decreasing trend of workplace violence
incident, particularly in Department of Psychiatry.
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4.3 Community Engagement

The Fifth HKEC Symposium on Community Engagement Family The Key to a Healthy
Community was held on 15 May 2010 in collaboration with 14 NGOs/community partners.
400 participants attended.
Over
The Symposium promoted harmonious and healthy family relations
with the participation of community partners.
4.4 HKEC Clinical Audit Sharing Forum

The 1st HKEC Clinical Audit Sharing Forum was held on 21 March 2011 with a total
attendance of 184. Dr. Jonathan Boyce & Mr. Dick Waite, UK independent consultants, were
invited to share the Review of Clinical Audit across HA hospitals. Dr. Michael Cheung, Chairman
of Integrated Clinical Audit Committee from NDH, was also invited to share the local experience of
NDH & NTEC.
4.5 Quality & Safety Seminar

The 3rd HKEC Quality & Safety Seminar - Better Health for All: Mission, Passion and
Action was held on 6 March 2010 with a total attendance of 213. Mr Cheung Tak Hai, vice
chairman (external affairs) of Alliance for Patients Mutual Help Organizations and Dr Teresa Wang
were invited to deliver keynote speech on patient engagement in healthcare system.
There were 8
projects competing for the best project and oral presentation award while other 29 projects
competing for the best poster award.
4.6 Early Defibrillation

The Emergency Preparedness Committee has established key performance indicator (KPI) on
staffs response time to major incidents.
First-tier responders are expected to report duty to A&E
within 15 minutes upon receipt of notification from telephone operator through Short Message
Service (SMS) or pagers.
15 sets of automatic external defibrillators (AED) for emergency resuscitation had been
installed in public areas of HKEC hospitals.
In addition to provision of on-going training to staff on AED since 2009, Cardio-Pulmonary
Resuscitation auditing was conducted and monitored by the HKEC Resuscitation Committee.
4.7 Blood transfusion

A multi-disciplinary educational forum on Clinical Blood Transfusion Safety was held on 20
May 2010 with a total attendance of 351.
The objective is to strengthen the staff in their
24
knowledge and alertness in the critical points of blood transfusion.
4.8 Others
Corresponding to the top clinical risks identified and incidents taken place in 2010/11, the
following staff education and training were organized as well:
1.
An update on Care of Urinary Catheter
May 2010
2.
Seminar on updated nursing practice on naso-gastric tube

placement
September 2010
3.
Q&S Forum From fall prevention to safe mobilization of

fragile patients
March 2011
4.
Staff Forum on Radiation Safety
March 2011
5.
18 identical sessions of Basic Life Support Refresher Course

for nurses
Various dates in
2010/11
4.9 The Way Forward

The Quality and Safety Office of the HKEC will strengthen the fundamental qualities of the
staff as an on-going mission. To this end, clinical leadership, culture and communication are the
critical strategies we take. 4 clinical consultants will be appointed to manage public feedback;
continuous training programmes will be provided to sharpen the capability of the medical and
nursing Q&S coordinators in areas of feedback management. Operating units will sustain
CRM-in-Action as a means to translate the safety culture into day-to-day practice. Q&S Office
will continue to run Roadshows to support department Q&S coordinators in enhancing awareness in
quality and safety among the front-line and involving them in risk identification process.
25
Quality & Safety Department

Sr Advisor (Q&S)
Cluster coordinators
Information Security & Privacy
Medico-legal and Incident
Complaint & Open Disclosure
Patient Safety
PR & CA
Chairperson
Patient Safety
Subcommittee
CD (Q & S)
Accreditation
Q&S
26
Clinical Audit
OSH &E
Cluster Quality & Risk Management Subject Officers
Appreciation & Complaint

(Mr. Eric Law)
Blood Transfusion
(Dr. Clarence Lam)
Clinical Audit
(Dr. CK Chan/ Ms. Kate Choi)
Fire Safety
(Mr. Ricky Li)
Hospital Security
(Ms. Katherine Chan)
Infection control
(Dr. Vincent Cheng)
Information Security & Privacy

(Dr. K H Lau)
Information Technology Security

(Dr. Edmund Ip / Mr. Kelvin Law)
Medication Incident
(Mr. William Chui)
OSH & E
(Dr. Clarence Lam / Mr. TC Chan)
Patient Safety
(Dr. Teresa Li)
Procedural Safety
(Dr. SR Das)
Resuscitation
(Dr. W M Chan)
Sterilization & Disinfection

(Dr. V Cheng/ Ms Josepha Tai)
Subject Officers reporting to CQRMC

As of 1 July 2011 (arranged in alphabetical order)
1.1 New organizational Q&S structure

The new Q&S structure has incorporated the OSH and patient safety elements.
The
reporting framework of committees/ subject officers related to quality and safety has also been
revised to encompass more proactive risk identification and reporting system.
1.2 Cluster approach to Quality and Safety

A cluster approach to Quality and Safety including integrated walk rounds and preparation of
Accreditation has been implemented.
All quality and safety related committees and functions are
also revamped to be cluster based.

1.2.1 Accreditation
QMH underwent the Organization Wide Survey of Australian Council of Healthcare
Accreditation scheme in October 2010 and has achieved full accreditation status. Out of the 45
criteria assessed, QMH attained 1 outstanding achievement (OA) and 10 extensive achievement
27
(EA) levels. The preparation for Tung Wah Hospitals accreditation commenced in Jan 2011 to
enhance learning and sharing as Quality and Safety colleagues from all cluster hospitals were
invited to sit in all working group meetings.
1.2.2 Integrated walk rounds
Cluster integrated quality and safety rounds commenced in January 2010.
A core cluster
quality and safety team was formed in 2011 to conduct quality and safety rounds in transferring
knowledge on methodology to other colleagues within the cluster. In 2010/11, a total of 90
integrated quality and safety rounds were conducted in clinical and non clinical areas of Queen
Mary Hospital and starting from January 2011, the integrated rounds were promulgated to other
cluster hospitals with a total of 13 rounds in 1Q 2011 (Table 1).
Table 1
Integrated quality and safety rounds at HKWC

Year
QMH
TWH
GH
DKCH
FYKH
MMRC
2010
90
1Q 2011
1.3 Quality improvement initiatives

Through the various avenues of risk identification and gap analysis, quality improvement
projects were instituted with a monthly progress update that is uploaded onto HKWC Q&S website
accessible to all intranet users.
http://hkwc.home/QnS/Doc/HKWC%20Quality%20Initiatives%20Progress%20Report.doc
1.4 Hong Kong West Cluster Quality and Safety Annual Plan 2011/12
The HKWC quality and safety annual plan with strategies was developed based on a risk
identification framework.
1.4.1 Risk of medication incident occurrence due to over reliance on manual confirmation and
bypassing of pharmacists verification process.
Risk reduction strategies:
(a) Enhance medication delivery to reduce ward stock;
(b) Pilot 2D Barcode System for drug administration in private wards.
1.4.2 Risk of over-sedation and airway accidents due to inadequate expertise or supervision of
clinical staff in administering procedural sedation.
28
(a) Establish procedural sedation taskforce to define strategy ;

(b) Risk stratify procedural sedations conducted outside theatres;
(c) Recruit additional manpower for administering procedural sedation outside theatres;
(d) Provide education and training for relevant staff.
1.4.3 Hazard of patients in mixed gender wards being offended by those of opposite sex.
(a) Establish policy for segregation;
(b) Risk stratify patients that are unable to protect themselves into single gender ward;
(c) Enhance staff awareness and sensitivity;
(d) Educate patients and relatives.
1.4.4 Risk of patient safety hampered by bedside interventional procedures due to inadequacy or
non-compliance of patient identification procedures.
(a) Establish Committee for Surgical, Interventional & Procedural Safety to overlook
implementation of HAHO policy;
(b) Enforce use of standardized checklists for high risk procedures conducted over bedside;
(c) Conduct regular audits to ascertain compliance.
1.4.5 Hazard of failure to identify nutritional at risk patients.
(a) Apply nutritional assessment tool;
(b) Acquire necessary equipments for weighing patients;
(c) Educate staff the importance of nutritional screening;
(d) Conduct audits.
1.4.6 Infection control risk caused by substandard sterilization and disinfection.
(a) Establish Cluster sterilization and disinfection committee;
(b) Streamline Central Sterile Supply Department (CSSD) services;
(c) Eliminate satellite disinfection practices;
29
(d) Regulate and control flash sterilization;

(e) Explore on the long term plan of establishing Theatre Supply Service Unit (TSSU).
1.4.7 Lack of robust framework to regulate scope of practice of clinicians.
(a) Establish credentialing committee;
(b) Develop clinical privileging criteria for high risk high volume procedures;
(c) Conduct audits on control points in checking compliances.
1.4.8 Fragmented and inefficient care delivery model provided to patients.
(a) Enforce use of nursing care plan and discharge plan;
(b) Modernize care delivery model through introduction of clinical pathways.
1.4.9 Potential shortcomings in incident management leading to staff and client discontent.
(a) Revamp governance structure on incident management;
(b) Develop standing protocol for incident management.
30
Risk Prioritization
2.1 Identified clinical risk reduction strategies for 2010-2011 (as reported last year)
Identified clinical risk reduction strategies
1
Implement WHO second challenge for safe surgery
Enhance medication safety through reducing ward stock
Enhance correct patient identification of laboratory specimen using 2D

barcode system
Enhance nursing care quality with structured nursing care plan
Implement integrated quality and safety walk round
Incorporate integrated peri-operative nursing documentation into patients

medical record
Integrate clinical documentation for all clinical specialties
Improve in-patient dispensing system
Standardize instrument sterilization and tracking system through out all

areas in QMH
10
Streamline CSSD processes
2.2 Identified Non-clinical (operational) risk reduction strategies for 2010-2011

Identified operation risk reduction strategies (not necessary in order of
priority)
1
Enhance private patient billing
Institute PACS data storage and off-site backup
Enhance hospital security with regular staff update
Systematic monitoring of compliance with statutory requirement and

ordinance
5
6
Enhance fire safety through regular fire drill, training and mandatory paper
drill
Reinforce personal data security through training and paper drill
31

Identified clinical risks (in order of priority)
1
2
Risk of medication incident occurrence due to over reliance on manual

confirmation and bypassing of pharmacists verification process.
Hazard of inadequate supervision and monitoring of clinical staff in
administering procedural sedation.
Risk of Patient safety hampered by bedside interventional procedures
Risk of failure to identify nutritional at risk patients
Infection control risk caused by substandard sterilization and disinfection
Risk of substandard care due to lack of robust framework to regulate scope

of practice of clinicians
Risk of fragmented and inefficient care delivery model provided to patients
Potential shortcomings in incident management leading to staff and client

discontent
2.4 Identified Non-clinical (operational) risks for 2011-2012

Identified operation risks (not necessary in order of priority)
1
Hazard of patients in mixed gender wards being offended by those of

opposite sex
Risk of security or access lapse due to inadequate structure to oversee

access control and hospital security
Liability related to inconsistent time documented in medical record due to

unsynchronized clocks in different parts of the hospital
Risk of delayed treatment or getting lost in the hospital due to unclear and
uncoordinated signage within the cluster
Risk associated with access to and use of out-dated documents due to

inadequate document management system
Risk related to sudden mechanical failure due to outdated medical

equipment
32
3.1 Review of 2010 risk reduction programs
Quality initiatives
Action and progress
Implement WHO second challenge

for safe surgery
Implemented checklist for chest drain

insertion and tapping in ward settings for the
whole cluster in March 2011
Enhance medication safety through

reducing ward stock
Ward stock of Department of Surgery,

Psychiatry and Paediatric in QMH reduced by
57%
Enhance correct patient

y
identification of laboratory specimen
Implemented 2D barcode for patient

identification of laboratory specimens in
using 2D barcode system
2011 at QMH
For roll out to cluster hospitals in
2011/2012
Enhance nursing care quality with

structured nursing care plan
Implement integrated quality and

safety walk round
Nursing care plan developed after

consensus
Implemented care plan by phases to
whole hospital in September 2010
Continued integrated walk-round for all
clinical and allied health areas of QMH in
preparation for accreditation a total of
90 walk rounds conducted with follow-up
improvement measures
Expand cluster based integrated
walk-round starting in January 2011
Incorporate integrated peri-operative

nursing documentation into patients
Implemented integrated peri-operative nursing

documentation that is filed into patients
medical record
medical record for all patients undergoing

surgical procedure in the OTS
Integrate clinical documentation for

all clinical specialties
Instituted integrated management and progress

sheet for all disciplines in enhancing seamless
care record
Improve in-patient dispensing

system
33
Employed 4 supporting staff for

improving efficiency of dispensing
turn-around-time
Pending employment of dispensers to
Quality initiatives
Action and progress

further enhance efficiency
10
Standardize instrument sterilization

and tracking system through out all
Eliminated satellite sterilization at ward

level
areas in QMH
Implemented instrument tracking system

in all OTS
Streamline CSSD processes
Replaced utensils supply by disposable items

to cater for increased demand for centralized
sterilization
3.2 Accreditation
Queen Mary Hospital one of the hospitals that joined the pilot accreditation scheme
underwent the OWS in October 2010.
With the concerted effort by all colleagues of Queen Mary
Hospital, the hospital attained 10 Extensive Achievement (EA) and 1 Outstanding Achievement
(OA) out of the 45 criteria and achieved full accreditation.
Clinical
Support
Corporate
Assessment
Appropriateness
Quality improvement
Strategic planning
Care plan
Effectiveness
Risk management
Governance & delegation
Consent
Medication safety
Incident management
Credentialing
Care evaluation
Infection control
Work force planning
External service provider
Discharge/ transfer
Pressure ulcer
Recruitment & selection
Safety management
Ongoing care
Falls
Learning & development
Buildings management
Death and dying
Blood transfusion
Employee support
Waste management
Health record
Correct site surgery
Health record management
Emergency management
Access to information
Community participation
Data & information
Security management
Access & admission
Rights & responsibilities
Information technology
Health promotion
Research
Note Extensive Achievement

Outstanding Achievement
34
35
4.1 Staff training

Highlights of Staff Education Activities: Topics:
1
Blood Transfusion related

Transfusion safety & annual report
OTBTS & summary of incidents
Transfusion for nurses (GH)
Safety in blood transfusion for care related workers/workman/drivers
Medication related
Annual Medication Safety Forum
Sessions
Fire Safety Talk

Queen Mary Hospital
20
Grantham Hospital
18
Tung Wah Hospital
11
Fung Yiu King Hospital
10
Duchess of Kent Childrens Hospital
MacLehose Medical Rehabilitation Centre
Infection Control Training

Queen Mary Hospital
11
Tung Wah Hospital
14
Grantham Hospital
Protecting Patient Data Privacy and Security

HKWC
13
Quality and Safety and Accreditation

6
Briefing and preparation for hospital accreditation (QMH, GH &
18
TWH)
Preparation for hospital accreditation for nursing supervisors (TWH)
Patient safety forum
Open disclosure
Quality & risk management (TWH)
36
4.2 Quality & Safety Publications
4.2.1 HKWC Quality of Care Report is an initiative to

publicize the commendable effort and invaluable
contributions of various units and departments in the
pursuit of service excellence and continuous quality
improvement.
4.2.2 QMH Newsletter
37
4.2.3 Quality Reminder
4.2.4 Accreditation Newsletter
38
This report covers the period from 1st April 2010 to 31st March 2011.
In the past year, Kowloon
Central Cluster has achieved gratifying outcomes in many aspects.
Structure
The cluster has further strengthened its structure. With the introduction of the position of Senior
Hospital Manager Q&S (Education & Development), KCC consolidated the pillars for supporting the
Quality & Safety Structure namely Risk Management, Quality & Standards, Patient Services and
Education & Development.
As mentioned in last years report, KCC established a Quality and Safety Office manned by full
time as well as part-time staff.
Management Committee.
The office is an executive arm of the Cluster Quality and Risk
The role of the Quality and Safety Office is to derive, drive, support and
monitor cluster priority risk areas, risk reduction programs and improvement efforts on a cluster level.
This was consolidated by the expansion of the cluster office supporting staff numbers.
At the hospital level, immense effort was placed in QEH to drive the hospital accreditation
process. Reinforcement of the structure of the Quality& Standards Team saw the hospital through the
journey.
39
Process
1.1 Years of Safety
KCC has continued its effort in enhancing patient safety. This was the third of its years of
safety the Year of Quality.
This year, we rewarded by the outcomes in 2 major projects.
We achieved excellent results in
the APBEST award and we also achieved full accredited status by the ACHS.
Detail of these will be
depicted later in this report.

1.1.1 New Risk Register
Every year, a cluster-wide / organization-wide risk identification exercise will be done starting
with the compilation and then collection of departmental risk registers. The Cluster Quality & Safety
Office will compile the Cluster Top Ten Priority Risk Areas using these risk registers and the
incident/complaints data of the previous year. This was done using the traditional way of using risk
matrices, etc.
This is a particularly difficult job for the clinicians as they find this tedious and the tools
unfriendly.
As different clinical departments might use the same words to describe different risks or different
vocabularies to describe the same risk, it adds on to the complexity of developing an organization-wide
risk register and thus affects the accuracy and usefulness of the Cluster Top Ten Priority Risk Areas
which are supposed to benefit these clinical departments.
Eventually, the Top Ten Risk Areas
predominantly reflected the incidents that occurred the previous year.

In 2010, we developed a new risk register using the World Health Organization Conceptual
Framework for the International Classification for Patient Safety 2009 (V1.1) as the backbone.
We
used the taxonomy to build an easy-to-use Excel file with multiple pull down menus and
self-explanatory guides.
The results were encouraging. The percentage of returned risk registers at deadline and the
completeness of the risk registers rose significantly.
As the clinical departments now use the same
glossary of terms, the data can be confidently pulled together and specific risks common to different
departments can be identified.
Thus, cluster-wide risk identification is now truly current.
Hopefully,
the Top Ten Priority Risk Areas can reflect the needs of the clinical departments and the work of the
subgroups designated to look after these Ten Risks will be able to assist the departments in mitigating
the most current problems.
Furthermore, the risk identification exercise can now with ease accommodate multiple inputs
namely Patient Safety Walk-around, technological risks identified by IT departments but not at the
frontline clinical areas, incident data, near-miss events data, complaints data.
All these contributed to
the complexity of highlighting or prioritizing risks. Using the World Health Organization Conceptual
40
Framework for the International Classification for Patient Safety, we can convert these risks into
meaningful data and further ourselves into the work of risk mitigation.
As this data collection exercise is novice, it has yet to show its true power or weakness.
longer term monitoring of its usefulness will be required. We were glad that a paper reporting the use
of this risk register tool was accepted by the 28th International Conference of The International Society
for Quality in Health Care (ISQUA) to be held in September 2011.
1.1.2 WISER Movement
Since the formation of the WISER taskforce in Oct 2009, WISER has come to represent
possibilities in KCC.
While Lean describes a thinking paradigm and a set of tools, WISER is
looking at the broader scope of engaging staff for innovation and for service improvement.
The
cluster has now 6 Blackbelts and almost 100 Greenbelts trained in Lean Six Sigma. The KCC Q&S
Office is the executive arm of this movement.
With the dedicated efforts of the Blackbelts and Greenbelts (all operating at their own time!),
KCC has been running regular Awareness training for all levels of staff.
also welcomed by the staff.
In-depth tools training are
This was exemplified by the regular over-subscription to the WISER
Tools Training Series (1 lunch session per week for 3 consecutive weeks).
We have also completed a website of WISER. If someone wanted a crash course of Lean
Management without the need to read through bulky textbooks or going to classes, this is the best place
to go. On the website, we also shared with everyone who have access to the intranet, information
regarding completed and on-going projects, timetable of our training programs as well as the training
materials. We have no intention (and we dont think we can) to monopolize the material, we thus put
everything on the web for everyone to freely download and read. We are also now testing a mobile
website to be used on mobile phones for quick reference to basic Lean concepts and simple tools (e.g.
Take time calculator).
Numerous projects sprouted from different departments.
We have projects ranging from the
management of formula milk stocks in wards to the improvement in the prostate biopsy specimen
handling. These projects were all problems identified by frontline colleagues and end-users. As all
projects need facilitation from either Black / Green belts, we have assured the quality of the results.
The fact that these projects need to report their progress to the WISER taskforce ensured that they
obtained the required management support (as the taskforce is well represented by all aspects of senior
management).
The WISER Sharing forum was a bimonthly event where a few of the completed projects were
invited to share their success stories to the rest of the cluster. The CCE was present on all occasions
and gave immense support to the staff, usually frontline, and commended them on their effort and
41
celebrated with them their successes.

1.1.3 Building Safety Culture
Like brand-building in private corporations, culture building with regards to Quality and Safety
need to be persistent. The Q&S Website provides updated information, references, standards, good
articles and risk alerts for sharing. The objective is to increase staff alertness on quality and safety.
We have further enhanced our Electronic Patient Safety alert (EPS) by forming a
multi-disciplinary editorial board. The editorial board comprised of doctors and nurses from different
specialties and the serve to constantly supply the EPS with interesting stories as well as reviewing the
contents of these alerts. Each issue of the EPS was sent to all KCC electronically via email on a
bi-weekly basis.
KCC Quality and Safety Forums were also held bimonthly (intercalating with WISER Sharing
Forum).
Each Q&S Forum has a theme to follow.
In the past year, we ran forums focusing on
Incident Management and demystifying the process of Root Cause Analysis.
We have invited Dr Ares
Leung to give us a talk and the lecture theatre was packed with staff eager to learn.
forums with in-house staff.
We also ran
We developed the RCA series. This started small using data
from the SE/SUE Forum held by HA Head Office colleagues.
This generated a significant group of
followers and we discovered that they are interested in the mysteries and secrecies behind RCA
processes. We thus went ahead to explain to them the process of RCA (using freely available materials
from World Health Organisation). This, again, generated significant interests and we were requested
to further on in this series.
42
2. Risk Prioritization
The KCC Q&RM Committee had identified 10 priority risk areas (Table 2 & 3). Risk reduction
strategies and action plans were formulated and implemented accordingly.
2.1 Table 2: Identified Risk Areas for 2010/11

Identified Risk Areas for 2010/11
1
Medication Safety
Safe Surgery (Operation Theatre and Procedural Suites)
Sedation protocol
Document Control
Patient falls
Pressure Ulcer
Infection Control
Data Security
10 Investigation findings alert safety
2.2 Table 3: Identified Risk Areas for 2011/12

Identified Risk Areas for 2011/12
1
Medication Reconciliation & Administration
Medication Dispensing
Procedural Safety (surgical, interventional and bedside procedure safety)
Safe Handling of Abnormal Investigation Report
Fire Safety
Staff Injury
43
Workplace Violence
Data Security
10 Transfer of Critically Ill
44
3. Risk Reduction and Quality Programs

3.1 Progress on Risk Reduction Programs
1
Medication Safety
13/04/2010
A Failure Mode Effects Analysis (FMEA) was completed in

mid-March 2010 with recommendations made. A final report is
being prepared and will be submitted to KCC Medication Safety
Committee in mid-April as well as NQRM committee.
08/06/2010
A medication Reconciliation Workgroup led by Dr Kenneth Tsang

had been formed.
Members include pharmacist, doctors and
nurses. The Workgroup is responsible to liaise with the Head

Office Medication Safety Committee.
07/12/2010
A workgroup meeting was held on 10.9.10.
It was proposed to
standardize the drug allergy practice in KCC.

x
In a review at the recent KCC Q&RM Committee Meeting, it was

endorsed that executive power should be vested in the Medication
Safety Committee, accordingly the TOR of which would be
revised.
15/02/2011
RIE on Medication Reconciliation is in progress.
RIE on Medication Reconciliation in Med/QEH is in progress

with a pilot to be conducted shortly. Another RIE on the same
topic will be conducted in O&T/QEH.
11/04/2011
The Medication Safety Committee formed two taskforces: 1)

dilution table and 2) MAR standardization and time scheduling.
Respective meeting will be held in April 2011.
Known Drug Allergy Promulgation of good practice on known

drug allergy management would be made via CMS screen saver.
Safe Surgery
13/04/2010
The Safe Surgery Audit conducted in all operation theatres in

QEH and HKEH in March includes the three phases of safety
check: the pre-anaesthetic (sign-in), Time-Out process, and the
post-operative safety check (sign-out).
The Workgroup is also streamlining the process using Lean Six

Sigma methods.
All surgical specialties had participated in the
45
x
x
exercise and a new workflow is being drafted.

Safe Surgery policy with the use of a checklist will be rolled out
to all cardiac cases requiring intervention.
A checklist is being
drawn up by the Cardiac team with references from other HA

hospitals.
08/06/2010
Head Office Q&S audit on Safe Surgery Policy was completed in

March 2010.
The Workgroup is revising the workflow of the 3 steps of Safe

Surgery Policy to streamline patient journey throughout
pre-admission to completion of surgery.
A new Workgroup led by Dr YF Chow and Dr Donald Tang with

Dr Kenneth Tsang serving as facilitator will be formed to steer the
implementation of Phase 2 of Safe Surgery policy (all
Interventional Suites).
Cardiac Catheterisation Laboratory (B7) has already adopted and

fully complies with the Safe Surgery Policy.
07/12/2010
An integrated checklist form for Surgical Safety Process has been

endorsed. A pilot scheme will be conducted.
KCC Workgroup on Intervention Procedure Safety Policy was

formed and co-chaired by Dr Donald Tang, Dr KT Chan and Dr
CH Kwok.
15/02/2011
This policy will be fully implemented by 3.1.11.
The pilot of the integrated checklist form for surgical safety

process in QEH O&T and Surgery Department is in progress.
The interventional procedure safety policy has been fully

implemented.
11/04/2011
An audit will be conducted shortly.
The pilot of the integrated checklist form for surgical safety

process is still in progress.
The HA Safety Policy on Bedside Procedures became effective on

1 March 2011 and should be fully implemented by the end of 31
August 2011. It applies but is not limited to 1) Chest tapping,
drainage & paracentesis and 2) Insertion of intravascular catheter
with the use of guide wire. A meeting will be held to discuss this
issue.
Sedation Safety
46
13/04/2010
Policies of clinical departments are being reviewed for the

purpose of preparing a standardized protocol.
08/06/2010
Draft of departmental sedation checklists was near completion.
10/08/2011
A draft KCC guidelines for procedural sedation had been

developed and discussed.
It could be implemented in principle if
user departments manpower requirement could be met.

4
Document Control
08/06/2010
Target to comply with the standards of Australian Council on

Healthcare Standards (ACHS) in July.
Patient Fall
07/12/2010
A3 size Sweet Reminders has been designed and the patient

education pamphlet has been revised. They will be distributed to
clinical areas in KCC when ready.
13/04/2010
Due to the unexpected delay in the delivery of UPI co-ordinated

by HAHO, the implementation date of UPI system in HKEH
would be deferred to end of May.
08/06/2010
HKEH will implement the 2D barcode system for labeling of all

in-patient specimens on 28.6.10.
Related training is scheduled
for 21.6.10.
x
To provide better quality wristbands for patients, a new wristband

design has been developed.
System Scanning Ltd will continue
to be the supplier for the adult and paediatric patient wristbands.

All existing wristband printers will require tuning to suit the new
design.
The proposed date of live run for KH, HKEH is August
2010; QEH October 2010 and HKBH February 2011.
47
10/08/2010
A number of incidents regarding unlabelled blood culture

specimen had been reported.
The causes of these incidents were
still undetermined. A RCA workgroup had been formed to find

out the possible reasons.
x
A number of mislabeling incidents had been reported recently.

Most of them were due to the use of the traditional 1D barcode
system (bypassing the new 2D barcode system).
Measures will
be made to restrict the use of GCRS (1D barcode) machines.

x
The UPI Phase III Training was provided for HKE staff and QEH
housemen on 21.6.10 and 25.6.2010 respectively.
As the new UPI devices had not yet been programmed for KCCs
specific setting, the UPI implementation in HKE had been
postponed until further notice from HAHO.
A new design had been developed to improve the quality of

patient wristband.
The proposed dates of implementation of the
new design were as follows:
07/12/2010
KH: 3rd week of August 2010
HKE: 3rd week of August 2010
QEH: 1st week of October 2010
HKBH: 5th week of January 2011
A new design has been developed to improve the quality of

patient wristband. HKE and KH had commenced using the new
wristbands since 18.8.10.
QEH and HKBH will start in January
2011.
x
UPI devices have been upgraded to mitigate misidentification.
RIE on unlabelled blood culture is in progress.
Adoption of 2D barcode technology in portable X-ray is under

discussion.
15/02/2011
A new design has been developed to improve the quality of

patient wristband. QEH had commenced using the new wristbands
since 6.1.11. HKBH will start in May 2011.
According to HAHO, the new UPI sets will be available in 1Q

2011. UPI Phase III could be rolled out to HKE and KH when the
new UPI sets are ready.
48
11/04/2011
A survey is being conducted in QEH, KH and HKE to collect

feedback on the new patient wristband.
The pilot of UPI for portable X-ray will be conducted soon. Target
date for implementation is 3Q 2011.
Pressure Ulcers
x
Coordination between Geriatrics and Nursing units were

organized.
x
8
Pressure ulcer charts were reviewed and implemented
Infection Control
08/06/2010
A hand hygiene ceremony was held on 5.5.10.
A scheduled Education talk to Infection Control Link Nurse

(ICLN) focusing on preventive measure to reduce NSI will be
conducted on 10.6.10.
A programme to reduce Needle Stick Injuries (NSI) after use of

needle before disposal will be implemented in July 2010.
A Cluster Environmental Hygiene Committee has recently been

set up.
A protocol on the appropriate dilution of Hypochlorite has been

developed.
A protocol and checklist on Infection Control Risk Assessment for

Construction and Renovation work has been developed.
Data Security
08/06/2010
An information security and Privacy compliance check-list was

distributed to all department and operational units in KCC in May
2010.
All departments are requested to complete the audit and
return their return in 3Q10.

x
The Clinical Management System / Electronic Patient Record

(CMS/ePR) access audit (non-green zone, staff, private patient)
was completed in May 2010.
66 cases were audited. A total of
18 queries were raised with involvement of 12 staff.
Only one
case was required further follow up.

x
The HA Guidelines on Information Security and Privacy Incident

Management relating to lost / misplaced personal records / data
was issued to all KCC Senior Managers and Units Heads on
49
17.4.10.
x
The updated guideline for handling of unclaimed USB and other

data containing electronic devices found within the hospital
compound was issued to all KCC Senior Manager on 13.5.10.
The new e-learning course in English and Chinese on protecting

patient privacy and data security was developed and available
online.
Staff were reminded to participate in the course before
17.5.10.
07/12/2010
Most units / departments have conducted the Information Security

and Privacy Compliance Check as at 12.10.10. A report will be
compiled accordingly.
The Endpoint Encryption for Removable Media (EERM) was

implemented at open workstations in QEH in August 2010.
It
will be implemented in other KCC hospitals in 4Q 2010.

z
The 'Patient Selection Panel' (PSP) function has been enhanced on

29.9.10. The HKID & DOB of patient would be masked from the
initial screen of the patient name search function in the PSP.
Corporate Information Security and Privacy Office (CISPO),

HAHO has issued and distributed Information Security and
Privacy Training Kit for General Staff (including a video clip of 8
mins and a quiz) to HRs of all clusters on 5.11.10 for action.
15/02/2011
An Executive Walk Round for Privacy Compliance was held on

13.12.10. Members involved CCE and colleagues from HA IT,
KCC IT & Q&S.
The report revealed that the compliance in
KCC was satisfactory.

10
Safe Handling of Abnormal Investigation Reports

07/12/2010
Workgroup meeting would be held bi-monthly.
Individual
department workflow would be brought into focus.

15/02/2011
The workflow on investigation findings in A&E was reviewed.

Recommendations were made to them. Next unit to be reviewed is
Day Ward/QEH.
11/04/2011
The workflows on investigation findings in Day Wards of HKBH

and QEH were reviewed. Recommendations were made to them.
Next unit to be reviewed is ACC/QEH.
50
Others 11/04/2011 Informed Consent

z
The Informed Consent SOP has been revised and adopted.
Departments are reviewing their information pamphlets to

facilitate patient/carer understanding.
The QEH Audit on Informed Consent in 2010 has been

completed. The finding reviewed that all operations / procedures
were performed as consented. Several recommendations have
been made for improvement.
3.2 APBEST AWARDS

APBEST Implementation in QEH
The Asia Pacific Business Excellence STandard (APBEST) Award programme has been
commenced in January 2009.
Under the guidance of an external consultant, seven hospital
departments (Central Nursing Division, Administrative Services, Human Resource, Accident &
Emergency, Anesthesiology & Operating Theatre Services, Pathology, Surgery) embarked on a one-year
journey of learning, self-assessment, and planning using European Quality Award (EQA) criteria to
identify strengths and areas for improvement.
The evidence of achievements was summarized in the
Award Submission Document for the scrutiny of the Board of Examiners (comprising 5 international
experts on quality management), and a site verification visit was conducted by 3 international
examiners on 13th August 2010.
Onsite Verification Visit for APBEST 2010

on 13th August 2010
51
APBEST
Examiners
and
Department
Representatives on 13th August 2010
According to the EQA scoring framework, QEH was given a score of 774 out of the total 1000
which is unprecedentedly high as compared with the Spanish hospitals where the EQA is very popular.
Through examining the submission documents and during the visit and interview with staff and patients,
the examiners were deeply impressed by the dedication of hospital team and the quality of service.
The achievements were reflected in the examiners conversations with patients who unanimously
expressed great appreciation to staff members and the services received.
As a result, QEH topped all
the other commercial or non-commercial competitors in the Asia Pacific region, and received the Grand
Award and four other corporate and individual awards under the ABPEST:
z
Queen Elizabeth Hospital:
APBEST Grand Award Winner of the Year
BEST Hospital in Asia-Pacific and overall winner
Dr. HUNG Chi-Tim, Hospital Chief Executive:
Dr. CHOW Yu-Fat, COS (A&OTS):
APBEST Strategist of the Year.
APBEST Customer Services Driver of the Year
Dr HO Hiu-Fai, COS (A&E):
APBEST Operations Driver of the Year
The outstanding results in the APBEST Award symbolized an international recognition of the
QEH Hospital quality management.
Traveling the APBEST journey, staff members have also gained
invaluable insight and impetus for the ongoing quality movements, notably the ACHS Hospital
Accreditation Pilot Scheme.
52
Project Presentation by Dr. T C Wu, Associate

Consultant (Med) QEH
Dr. C T Hung receiving the BEST

Hospital in Asia-PacificAward
Group
Photograph
with
Organizer and other APBEST

candidates
3.3 ACHS Hospital Accreditation

3.3.1 Organization Wide Survey 2010 in QEH
The Australian Council on Healthcare Standards (ACHS) Organization Wide Survey (OWS) was
completed in QEH on 19-23.7.10.
Full accreditation was granted by the Australian Council on

53
Healthcare Standards (ACHS) and three areas were rated with Extensive Achievements which include:
(a) Systems for ongoing care of the consumer / patient are coordinated and effective
(b) Healthcare incidents, complaints and feedback are managed to ensure improvement
(c) External service providers are managed to maximize quality of care
The ACHS Hospital Accreditation Certificate Presentation Ceremony for QEH was completed on
14th March 2011 with an attendance of about 150. Representatives for medical and nursing staff, and
patient groups were invited to share experience on hospital accreditation and quality healthcare.
Experience sharing by Dr. M H Leung,

Associate Consultant (Med), QEH
Experience sharing by Ms S L Leung, Ward

Manager (Surg), QEH
Experience sharing by Mr. Tong Chow,

Chairman of Mutual Aid Association Ltd.
(Nasopharyngeal
Self-Help Group)
54
Carcinoma
Patient
Dr. C T Hung receiving the ACHS

Hospital Accreditation Certificate
Guests are Mr Brian Johnston, Chief
Executive ACHS & ACHSI; A / Prof Peter
Woodruff, President ACHS & ACHSI
Board; Mr John LEE, JP, Chairman HGC /
QEH;
and
Dr
LIU
Hing
Wing,
Director(Quality & Safety) HA
In response to the recommendations from the OWS in QEH and to prepare for phase II
implementation in cluster hospitals, cluster based working groups on specific EQuIP criteria have been
set up to streamline and strengthen practices on respective aspects which include: Assessment and care
planning; Discharge and ongoing care; Care of dying; Information to community; Access and admission;
Pressure ulcer; Patient falls; Consumer participation; Population health.
3.3.2 Self Assessment 2011 in QEH
Along the EQuIP hospital accreditation cycle, OWS is not the destination.
In fact, the
completion of the OWS denotes the commencement of another phase of this cyclical exercise in
continuous quality improvement.
It conveys expectations and new challenges to the organization
every year. QEH has been undergoing the Self Assessment 2011 and the scope of review covers all
criteria of the Clinical Function of EQuIP, all the mandatory criteria, and recommendations given in the
OWS 2010.
The Self Assessment report is being compiled via the CQI electronic system into which
departments are submitting improvement projects.
The report will be submitted to ACHS on 19th July
2011.
3.3.3 2nd Phase Implementation of Hospital Accreditation
The 2nd phase hospital accreditation involving 15 HA hospitals will be rolled out in 2011.
In
KCC, KH and BH will be participating the phase II program which will be commenced after mid-2011
and expected to be completed within 3-5 years.
55
3.4 Year Of Quality Strategic Planning

KCC has moved into the third and final year of the
rolling Years of Safety program.
In the previous two
years, we have been focusing specifically and rightly on

improving patient and staff safety, which are arguably the
most fundamental attributes of quality health care
delivery.
With the safety-conscious mindset firmly
engraved, colleagues of KCC are ready to engage

themselves upfront in the broader arena of quality in
healthcare.
Encircling this frame of mind, the
participants of the 2010 KCC Quality Strategic

Workshop set out to explore about healthcare quality
improvement in this one day workshop held on 4th December 2010.
The workshop was held at the Breakthrough Youth Village Shatin and a total of 76 colleagues had
participated.
During the workshop we have adopted the more comprehensive 9- dimension healthcare
quality model to start our journey. The categorization of quality dimensions is more than an academic
exercise it provides an understandable framework for the important achievable goals of quality, and
put our current improvement activities into perspectives, particularly in the perspectives of our
customers (patients, relatives, carers etc).
3.4.1 Nine-dimension healthcare quality model
During the workshop, a number of process and outcome indicators were identified which when
collected and reviewed along the courses of the improvement actions, will help to complete the
Plan-Do-Check-Act quality improvement cycle of Deming. In fact, the workshop had been designed
and conducted with the Deming model in mind, and going through the one-day program participants
have journeyed through a condensed PDCA cycle. It is foreseen that a number of the discussed
projects will come to fruition by the end of this year, and be presented in the year-end KCC Quality
Convention.
Butterfly Game eventually, we knew

that we were leading the move of each
other
56
Yes! We got it!
Victory!
We work as a TEAM!
57
4. Learning & Sharing Information

A full-time Senior Hospital Manager has been deployed in early January 2011 to coordinate,
enhance and sustain the staff education and development in initiatives relating to Q&S.
4.1 Project Learning

The year of 2009/2010 was both a consolidating and rewarding year for project learning in KCC.
Based on the Three Pillars model, we engaged and developed KCC staff through various WISER (We
Innovate, Services excel regularly) project learning initiatives:
(a) Project coaching
(b) Corporate awareness
(c) Sharing forums
4.1.1 Project Coaching
A total of 37 projects were registered. Based on the department burning issues, various levels of
front-line staff worked together, tried out the lean tools and accomplished remarkable business
outcomes like reduced waiting time for daily procedures.
Six A3 coaching sessions were conducted to develop staffs competency in completing and
documenting the WISER projects.
4.1.2 Corporate Awareness
To develop one common language of services innovation and enhancement, 43 WISER Awareness
workshops were conducted across all cluster hospitals.
A WISER Link was also established in
October 2010 to educate staff on lean tools and techniques through electronic means.
4.1.3 Sharing Forums
To further engage staff in their project accomplishments, they were invited to present their
completed WISER projects through structure sharing forums.
Three Come and Be WISER Forums were arranged with 8 projects shared by the front-line staff.
4.2 Recognition & Awards

Through the Three Pillars approach, KCC WISER Movement was accepted for poster display
in HA Convention 2011.
In addition, KCC WISER Movement was also related as one of the 6
finalists in the Hong Kong Management Association Award for Excellence in Training & Development
2011, which is one of the most prestigious awards in Hong Kong.
held on July 15, 2011.
58
The Final presentation would be
1.1
Quality & Safety Management Structure

On 1 Dec 2010, KEC had appointed a new Cluster Service Director (Quality & Safety), who
was also appointed as Service Director (Quality & Safety) of UCH since 3 Jan 2011.
1.2
Initiatives in KEC Quality and Safety

Under the new management, the division had undertaken process re-engineering both
internally and externally in driving for efficacy and effectiveness:

1.2.1 Strengthened the internal structure and process of the KEC Quality & Safety (Q&S)
Division
1.2.2 Streamlined various platforms of education and communication about Q&S
1.2.3 Improved effectiveness and efficiency of cluster Q&S committee meeting
1.2.4 Enhanced accountability of Q&S division to hospital and cluster management through
reporting
1.2.5 Incorporated ISPO as Q&S division member
1.2.6 Enhanced incident management at departmental level
1.2.7 Established executive partnership program to augment exposure of middle managers in Q&S
59
1.3
Promotion of Think Safe, Work Smart

To sustain the momentum gained from 2010, the KEC Quality Week 2011 was conducted
under the theme Think safe, Work smart. The main objective
was to fortify quality culture in our cluster through staff participation in the various quality-related
activities. The week was kicked off with the KEC Quality
Conference 2011 at which various speakers shared with the
audience their experience and expertise on areas related to risk
management and quality enhancement. The conference was
followed by workshops & visits under the pivot of workflow
improvement, and also the patient safety rounds. The quality
week had delivered an efficient platform for staff in consolidating and synergizing their efforts in
the quest for service betterment.
1.4
KEC Convention
To enable staff to refresh on the good quality endeavours
exemplified in the HA Convention, the KEC Convention was held in May

2010. Staff selected for oral presentation in the HA Convention and those
outstanding staff and team receiving the HA merit award shared their
good works on various patient safety and service enhancement areas.
1.5
Consolidation of CQI Concept

In order to revitalize the importance of CQI concept, there were regular Q&S forums
conducted by inviting colleagues of different streams to share their CQI programs. A UCH Forum
on HA CQI Initiatives was also held by inviting HA Q&S Division to coach departmental
coordinators on use of the HA CQI Initiatives System. The latest competition for the best CQI
program in KEC under the KEC Quality Week 2011 also marked the culmination of staff
engagement in quality culture building via the number of abstracts received. The thrust of driving
CQI in the cluster would be sustained as one of our major initiatives.
1.6
Preparation for Hospital Accreditation
1.6.1 KEC Cross Hospital Survey

In preparing for future accreditation exercise, KEC had organized the 4th
60
cross hospital survey among UCH, TKOH & HHH in Oct 2010. A total of 6 ACHS criteria were
selected as mock exercise for staff to go through the survey process. Summation sessions were held
at the end of each survey during which good practices and services gaps were shared. Follow up
actions on those identified gaps were undertaken to complete the loop in attainment of quality
improvement.
1.6.2 Seminars on Hospital Accreditation and Teaching Walkround

Capacity building and knowledge sharing were two essential pillars
in preparing for hospital accreditation. In Dec 2010, we had invited
representative of HKWC and NTWC to share their invaluable experience on
accreditation. In Feb 2011, representative of KCC and KWC were invited to
conduct seminar followed by teaching walkrounds. Staff all found these activities
both informative and educational.
1.7
Patient Safety Enhancement
1.7.1 Executive Patient Safety Walkround

To demonstrate top level commitment to patient safety as well as establishing direct line of
communication with frontline colleagues, regular patient safety walkround at hospital and cluster
levels were conducted. In Jan 2011, a cluster grand round comprising 4 teams led by invited experts
as team leader was organized. Relevant good practice and areas of recommendation were shared.
Follow up improvement actions were devised with progress monitored timely.
Walkrounds conducted in first half of 2010/11 (Apr to Sep 10)
Nature
No. of action
items
No. of items completed

within 2010/11
Percentage of
completion
Remarks
Cluster 6
100%
UCH
31
80%
Remaining items: In
39
progress with target

completion date defined
1.7.2 Promotion of Use of Correct Specimen Bottles

Following the introduction of new specimen labelling policy, a propaganda campaign was
organized through email communication, face-to-face training with interactive exercise, poster and
promotion. The main objective was for improving accuracy of labelling appropriate blood specimen
containers by staff, in particular the phlebotomists and interns. Through the conjoint efforts by
61
various departments, the number of inappropriate blood specimen container incidents also
experienced a significant drop by 66% before and after implementation of the policy.
1.7.3 Medication Safety - PIVAS (Pharmacy IntraVenous Admixture Service)

The program embraced the following features:
z
Enhancement of safe and effective use of medication for NICU & PICU patients thro
clinical pharmacy service & unit dose dispensing of high risk medications, commonly used
antibiotics etc
IT support on pharmacy web application of reconstitution worksheet,

unit dose preparation worksheet
Support with handheld device for drug administration checking and

discontinuation
Other features include: Alarm for due dose, PIVAS dashboard, dose time label (Label for
every 36 hours)
1.7.4 Infection Control

Key initiatives were in place pertaining to infection control areas:
Initiatives
Control of MRSA infection

Review existing practices in

individual units

Target on high risk areas

Develop rapid molecular detection
method
Performance
MRSA bacteremia for acute episodes (cases
per 1000 bed days)
KEC
HA
Develop mechanism for prompt

isolation, decolonization and patient
education
Mean
62
2008
2009
2010
0.1271
0.1243
0.1162
0.1718
0.1735
0.1503
Initiatives
Antibiotic Stewardship Program

Performance

Antibiograms & guidelines for

empirical therapy
Compliance (%) to recommended

indications of Big gun antibiotics
UCH
TKOH
Formulary restriction and

pre-authorisation
2008
94
70
2009
94
85
Staff education
2010
96
88

Antibiotic order forms

Audit and feedback
Utilisation of big gun antibiotics in

terms of DDD per 1 000 BDO
UCH
TKOH
HA
average
1.8
ICU
298.41
292.99
274.1
Medical
34.18
24.18
45.48
Surgery
21.91
10.1
35.41
Orthopedic
6.69
8.11
12.75
Process Re-engineering in Bed Booking System in KEC

To streamline patient transfer arrangement in the cluster, the Inter-hospital Patient Transfer
Working Group had developed an automated intranet-based bed-booking system. The system had
allayed cumbersome manual operation of the bed booking system and enhanced transparency of
booking status. The project also received a silver award from the Bright Suggestion Scheme as
recognition of its merit in bringing forth workflow improvement.
1.9
Occupational Safety and Health (OSH)

OSH team had organized and coordinated various CQI programs and training in development
of a safety management system. These included management of major nature of injuries, 5S,
manual handling operations, display screen equipment, work at height, trolleys operations and staff
wellness programs. There was also coordination of multi-departmental drills on workplace violence
& chemical spillage as well as regular OSH visits. Their endeavours had attained the following
achievement and recognition:
1.9.1 Number of IOD per 100 staff was decreased by 7.4% and IOD sick leave day was decreased
by 55% in 2010/11 (in comparison to same period of 2009/10).
1.9.2 Cluster OSH Coordinator / CGM(HR) had received a Bronze Award (Management Category)
in the 2nd OSH Best Employee 2010 organized by the Occupational Safety and Health
63
Council (OSHC).
1.9.3 3 OSH Improvement Projects had received Merit Award in various
recognition schemes organized by the OSHC.
1.9.4 1 submission from OSH team was accepted by HA Convention
for oral presentation and 3 were accepted for poster display.
1.10 Information Security and Privacy (ISP)

1.10.1
Privacy Walkround
The KEC Privacy Walkround with Corporate ISP team was successfully conducted in July
2010. The main objectives of the walk round was to ascertain compliance with PD(P)O and HA ISP
Policy by the frontlines and build up culture on data privacy and security. The walkround provided
staff a good opportunity to reflect and refresh on current system. A lot of good practice was also
acknowledged by the corporate team.
1.10.2
KEC e-Media Disposal Campaign
To uphold the data protection principle in handling of electronic personal information, KEC
ISP office had organized the campaign to clear and develop a process for proper handling of unused
electronic storage media. With the positive response and support from staff, KEC had sanitized over
7,000 pieces of electronic storage media. The Campaign had enriched staff knowledge on proper
handling of electronic storage media and fostered the information security culture in KEC.
1.11 Quality & Safety Bulletin

To nurture the quality and safety culture in the cluster, a monthly newsletter was published to
keep staff abreast of latest knowledge and operational tips related to quality and risk management
issues. The newsletter was formally renamed as KEC Quality & Safety Bulletin in Jan 2011. A
review was also conducted to refine its scope. The bulletin under the new format encompassed a
three-month cycle with the following themes:
1st Month
2nd Month
Sharing of quality & safety topics

by subject functional officers
Quality programs sharing by

cluster hospitals
3rd Month
Cluster SE/SUE sharing
+ / - Topical sharing
Accreditation tips
Translation of selected article from HA Risk Alert
64
2.1
Risk Prioritization
Identified clinical risks for 2010-2011 (as reported last year)

Identified clinical risk
2.2
Medication incident
Wrong site surgery
Retained foreign objects
Specimen mislabelling
Patient suicide
Inter-hospital transfer
Patient fall
Patient documentation
Resuscitation
10
Transfusion
Identified Non-clinical (operational) risk for 2010-2011 (as reported last year)
Type
Identified operation risk

(not necessary in order of priority)
Compliance / IT
Information security
OSH / Security
Workplace violence
Compliance
Mortuary
Corporate /
Compliance
Compliance of HA related ordinances
Physical resources Health and safety: Fire
OSH
Manual handling operations
Compliance /
Visitors requiring medical assistance
Security
8
Physical resources Facility breakdown / Utilization (environmental safety

scanning)
Property /
Security
Security and access to wards / departments
10
IT
Computer virus outbreak led to IT system breakdown
65
2.3
Identified clinical risks (in order of priority) for 2011-2012

Identified clinical risk (in order of priority)
1
Medication Management
z improvement of dispensing accuracy
z
z
medication safety in relation to drug administration

medication safety and storage of drugs in wards (ward stock) including
dangerous and controlled drugs
z
z
Look-Alike Sound-Alike medications

medication safety (Verbal / Phone order of medications)
Patient Falls (with special reference to):

z prevention through standardization of the assessment process
z
z
2.4
streamlining the process of evaluation

inpatient fall assessment and intervention programme
Infection Control
z enteral feeding decontamination
z sluice room environment management
Retained Instruments or Other Material
Blood Specimen Collection in Right Container
Correct Patient Identification for Radiology Service
Identified Non-clinical (operational) risks for 2011-2012 (not necessary in order of

priority)
Identified operation risk (not necessary in order of priority)
1
Workplace Violence
z workplace violence in out-patient setting
Information Technology
z hospital data centre breakdown
z web server failure
z
loss of data due to desk top computer failure
Injury On Duty
z staff slip, trip and fall
z
sharps injury
Telecommunication System Failure (PABX, mobile and internal paging service)
Loss of Records Containing Personal Identifiable Information
Drainage Problem
Theft or Damage of Hospital Property
Unsettled Bills
66
In line with the development 2010 / 11 KEC Risk Register for both clinical and operational
risks, the corresponding risk reduction / quality programs were identified and monitored. The
results are summarized below:
Item
Program name
Result / Evaluation on Effectiveness
Clinical Risks
1
Medication incident
(a) Strategies to reduce incidents on
prescribing / administering
KDA drug to patients.
(b) Minimize risks in the use of
were labelled with alert sign.

z
Neuromuscular Blocking
Agents
2
Wrong site surgery

OR of TKOH
Establish, implement and conduct
audit on Surgical Safety Checklist.
Hospital wide training on use of surgical

safety checklist.
Compliance Audit in 3Q11. Target: 100%
compliance.
Over 92% staff compliance.
The Chinese version of Surgical Safety
Checklist in Chinese version to

facilitate better verbal
communication among surgical
team members.
All neuromuscular blocking agents were

kept in designated container with alert
label.
z
OR of UCH
(a) Conduct audit on Surgical
Safety Checklist.
(b) Develop Surgical Safety
All ward stock penicillin group antibiotics
Checklist was user friendly.

z
Survey on user satisfaction and audit on

improvement of communication among
surgical team members during surgical
safety checking.
67
Item
Program name
Retained foreign objects

OR of TKOH & UCH
(a) Launch web quiz on HAHO
peri-operative nursing standard
z
z
of Counting of Accountable
Items used during Operative
Procedures as a self-test for
every OR nurse.
(b) Develop intra-operative Count
Sheet as medical record and for
hospital accreditation
(c) Devise Gauze Count Bag to
eliminate swab rack in OT room
and to facilitate infection control
& counting, and for hospital
accreditation.
4
Specimen mislabelling
Establish clear instruction for users to
adopt right specimen containers for
specimen collection.
100% compliance.
UCH: Electronic counting program

followed by user satisfaction survey.
z
z
TKOH: Pilot completed followed by trial

run. Target: 100% staff compliance.
UCH: Final version adopted and program
to be rolled out in May 2011; followed by

user satisfaction survey.
TKOH: Sourcing in progress.
z
z
z
z
Patient suicide
(a) Adopt HAHO initiative to further z
strengthen the existing systems
for minimizing suicide incidence.
(b) Incorporate the suicide
assessment tool recommended by
the HAHO TF on Patient
UCH: Achieved over 97% compliance.

TKOH: Quiz under preparation. Target:
Posted up education material in emails

and as screen savers in CMS workstations.
Change of IT set up to print colour code
of bottle caps onto GCRS labels.
Conducted campaign in promotion of
using right specimen containers for blood.
Established search function for
information of specimen containers for
various tests.
The 3 suicidal screening questions had
been incorporated in the initial nursing
assessment forms and performed on
admission in HHH, TKOH and UCH.
Suicide for frontline staff to

early detect those patients with
Suicidal precaution measures and

appropriate nursing interventions were
carried out according to risk of suicide
identified
68
Item
Program name
high suicidal risk in general

wards of HHH, TKOH & UCH.
6
Inter-hospital transfer
Simplified and ensured an accountable system
Streamline HHH Bed Booking System for bed booking with basic statistics on
to facilitate patient transfer from UCH
/ TKOH to HHH.
Patient fall reduction of fall risk

(a) Assessment of fall risk to be
conducted for all inpatients in 3
cluster hospitals.
(b) Individual clinical unit would be
requested to monitor its own fall
rate and recommend
improvement plans.
(c) Fall rate would be monitored in
individual hospital and KEC
NQRM.
(d) Sharing of good practices among
3 hospitals.
bookings available in the system.
and as physical condition required.

z
Fall incident trend was provided to
clinical unit to facilitate monitoring fall

rate and recommendation on improvement
plans.
Fall rate was monitored. It was decreased
by 6.76% in KEC in comparison of 09-10
statistics.
Relevant good practices were shared.
Patient documentation Enhancement

of nursing documentation
(a) Standardize the content of
z
nursing observation chart in
KEC.
(b) Pilot Patient Assessment System
in UCH.
(c) Evaluate the audit result of
Fall assessment conducted on admission
Nursing observation charts with

standardized content had been
implemented in 2Q10: UCH (modified
version); TKOH/HHH version.
Patient Assessment System was piloted in
4 wards of UCH.
The audit result of Nursing
Nursing Documentation
completed in 1Q10 and
recommend improvement
Documentation completed in 1Q10 was

evaluated and practice was reinforced.
actions.
69
Item
Program name
Resuscitation ensure and monitor

the resuscitation of patients both
within the hospital complex and in the

hospital vicinity
(a) Implementation :
z
Staff education
Scheduled training on BLS &
recognition of cardiac arrest and
conditions requiring resuscitation
Staff awareness
Define catchment areas and
corresponding response teams;

availability of resuscitation drugs
and equipment; program
flowchart / algorithm / telephone
hotline for activating the
response team; periodic program
reminders by posters / seminars /
website and drills
(b) Program monitoring
z Capture cases and perform
regular audit by reviewing the
resuscitation records to ascertain
compliance
z
10
Availability of scheduled training

on BLS
Transfusion
Internal audit on compliance with
z
z
Staff training commenced in Feb 2011.

Target: 100 additional staff to be trained.
Resuscitation manual was updated &
published.
z
z
z
Resuscitation manual was updated &

published.
Ensured all defibrillators were biphasic
type. Over 90% completed.
Adopted AHA 2010 guidelines for
planning algorithm for activating response
team.
Website under construction.
7th resuscitation record audit was

completed.
Courses under arrangement.
100% compliance achieved.
requirement for performing ABO on

new cases by 2 independent technical
staff during office hours.
Item
Program name
Action & Result
Operational Risks
1
Information security
(a) KEC (UCH, TKOH & HHH)
Annual ISP Audit.
70
Overall compliance: 99%.
Item
Program name
Action & Result
(b) KEC e-media Disposal Day.
The campaign had sanitized more than

7,000 pcs of e-media. Proper handling
of e-media was standardized in KEC.
Endorsed SOPs on Proper handling of
electronic media with personal
information had been promulgated to all
KEC staff.
Workplace violence
(a) Issue Security Newsletter to
enhance awareness & experience
sharing.
(b) Security Seminar by Crime
Arrangement was ongoing. The next (4th)
issue Newsletter would be published in

July 11.
Annual Security Seminar was held on 25
Prevention Bureau.
(c) Security Training in collaboration z
with PWH.
(d) Purchase of forearm cuff for
z
security team.
(e) Workplace Violence Training

(level I + physical restrainer
skill).
(f)
Consolidate recommendations
made in last risk assessment at
high risk departments.
Mortuary
March 11.
Identity Counterfeit Banknotes Talks held
in collaboration with PWH on 31 Jan 11.
Purchase was done. Protective gears for
security team were improved to enhance
physical protection.
Training for professional staff (Level I)
and supporting staff (Level I & physical
restraint) were held in Jun and Aug
respectively.
Completed in AEDs of TKOH and UCH.
Minor non-compliance noted due to local
(a) Internal audit on compliance with variation in SOP. Rectification already made.
SOP on reception and issuing of
bodies.
(b) Intra-cluster cross hospital audit
on compliance with SOP on
reception and issuing of bodies
4
Compliance of HA related ordinances

(a) Update subject officers about the
The exercise was completed in Dec 2010.
guidelines and related

implementation documents of the
HA ordinances under their scope
71
Item
Program name
Action & Result
of operations.
(b) Consolidate returns from KEC
subject officers to ensure
compliance with HA related
ordinances on an on-going basis.
5
Health and safety: Fire

(a) Cluster Fire Safety Committee to
align standards & practice.
(b) Develop fire safety orientation
checklist for induction and
refresher training purpose at
frontline.
(c) Standardize design of fire
evacuation plan.
(d) Design fire inspection checklist
for routine inspection.
(e) Coordinate Fire Safety
Ambassador Training.
Committee was established.
Orientation checklist and fire inspection

checklist were prepared and issued by
OSH team in Nov 10.
z
z
z
Manual handling operations
(a) Form local support network for

MHO & DSE.
(b) Conduct regular MHO refresher
training to supporting colleagues
who are at high risks.
z
z
(c) Conduct annual MHO refresher

training to MHO
coordinator/subject officer.
The design of fire evacuation plan was

confirmed.
Fire inspection checklist for routine
inspection was confirmed.
Fire Safety Ambassador Training was held
on 28 Feb 11.
MHO incidents were reduced by 10.6%
(104 to 93) [Yr 2010 in comparison to
2009].
Local support network formed by
ergonomic members.
Supporting Service (Care-Related): 5
classes (June, July, Sept, Dec 2010, and
Mar 2011) with duration of 2 hours each.
Supporting Service (General):1-2 classes
per dept. per year. supervisor: 2 hours
front-line: 1 hour (including HSK, TRN,
Catering, Security, Laundry).
For others including nursing, AH and
medical, review would be made by OSH
training sub-committee for addressing
training needs, evaluating progress and
effectiveness.
(d) Conduct OSH/MHO training to
newly-recruited nursing
72
Training was completed on 1 Sept 2010.
Item
Program name
Action & Result
colleagues.
(e) Produce training material in
Production was in progress.
MHO assisted aids/equipment.

7
Visitors requiring medical assistance

(a) Conduct drill on relevant
incidents.
Workplace violence drill at AED in

coordination with OSH team and AED was
held on 19 Jan 11.
Facility breakdown / Utilization

(environmental safety scanning)
Medical Equipment
(a) Annual utilization report for
major and selected minor
equipment.
(b) Perform annual equipment
breakdown analysis (on major
and minor equipment) to review
breakdown rate of individual
equipment for management
review.
Half year utilization report (Jan Jun

2010) was endorsed at KEC CTC and
CMC in Sept 10. On going utilization data
was being captured and monitored.
Replacement plan for 4 Types of
mid-ranged ($150K - $1M) equipment
including Endoscopic, Pathology,
Physiologic and Ultrasound with age over
10 years were reviewed with due
consideration of the age profile and
breakdown analysis. Findings had been
incorporated in the CBV planning
exercise in 2011. 3-year replacement
plan for the 6 types of OLV equipment
(value below $150K) was in place and
awaiting funding support. Batch
replacement of OLV equipment and Loose
F&E items were planned with due
consideration of breakdown rate, safety
(c) Aged major and minor

equipment (e.g, equipment aged
over 10 years) with high

breakdown rate and / or no
maintenance support will be
concerns, and age profile.

Replacement plan for other types of
mid-ranged and major equipment
including CT and MRI with breakdown
analysis were conducted and used for
CBV planning for 12-13.
accorded with higher priority

within KEC in the CBV 3-5 year
equipment planning exercise
73
Item
Program name
Action & Result
Hospital Engineering Systems

(a) Enhance planned maintenance
programme.
The planned maintenance schedule for

2011 had been updated and uploaded in
website for sharing.
The drill for other system was scheduled
in accordance with the plan.
(b) Conduct drill on contingency

plan regularly.
(c) Review plant and facility

utilization profile and backup
capacity.
The utilization profile and actual

condition of plant and system were
reviewed and evaluated.
ACS drill was conducted in Dec 10.
Review was done with different risk level

of keys management adopted.
Review was done and safe copying and

record of keys was ensured.
SOP for keys management developed with
access to different risk levels being
incorporated.
Security and access to wards /

departments
(a) Drill on contingency plan for
Access Control System
breakdown.
(b) Review keeping and management
of door keys in Security
Department.
(c) Review the key copying
procedure
(d) Develop SOP for key
management and ACS card
management.
10
Computer virus outbreak led to IT

system breakdown
Based on the weekly PC compliance
reports from HOIT, local ITs would
update the virus definition files on
those non-compliance computers.
98% of the hospital computers had the

latest anti-virus software and definition
files to prevent virus infection.
2% were those who had notebook
computers and might not always get
connected to HA network.
74
4.1
Related to Risk Management / Patient Safety
4.1.1 Sharing on National Forum on Safety and Quality in Health

Care (17 Dec 10)
4.1.2 Review of Risk Register 2011/12 (17 Nov 10)
4.1.3 Forum on Risk Register iSAY (21 Oct 10)
4.1.4 Educational Session on Advance Directive (with illustrative cases) (6 Oct 10)
4.1.5 Complaint Management (TKOH: 4Q 10)
4.1.6 Review of Glass Door Safety and Key Management (15 Sept 10)
4.1.7 A Multi-disciplinary Model of Suicide Prevention in Hospital: Sharing on Experiences and
Use of Suicide Checklist & Observation Record by HKEC (1 Sept 10)
4.1.8 DAMS Friendly Visit Sharing of Good Practices, Opportunities for Improvement (4 Aug
10)
4.1.9 Pain Assessment in Elderly Patient (TKOH: 3Q 10)
4.1.10 SE, SUE, RCA: What have we learnt? (TKOH: 3Q 10)
4.1.11 Basic Life Support Seminar: CPR and Use of Automated External Defibrillator in
Resuscitation (2 Jun 10)
4.1.12 Review of Glass Door / Window Safety and Key Management (21 Apr 10)
4.2
Related to Incident Management
4.2.1 Seminar on Lessons Learnt from Incidents in 2010 (5 Jan 11)

4.2.2 Open Disclosure & Just Culture (TKOH: 1Q 11)
4.2.3 Sentinel Events Sharing by CSD(Q&S) & Colleagues (3 Nov 10)
4.2.4 Review of incident related to injection of Morphine as Midazolam (11 Aug 10)
4.2.5 Review of the incident on mislabeled specimen on 25 October 2009 (21 Jul 10)
4.2.6 Review following 3 incidents related to influenza / pneumococcal vaccination (23 Jun 10)
4.2.7 Review after the suicide incident on 22 Aug 09 (26 May 10)
4.2.8 Quarterly sharing of incident trends through KEC QSD web
4.2.9 Monthly sharing of HA incidents through KEC Quality & Safety Bulletin
4.3
Related to Hospital Accreditation
4.3.1 Preparation for Hospital Accreditation Sharing by QEH & CMC (9 Feb 11)
75
4.3.2 Forum on Preparation for Hospital Accreditation - Sharing by Pilot Hospitals (21 Dec 10)
4.3.3 Forum on Document Control ACHS Accreditation (23 Nov 10)
4.3.4 Staff Forum on Hospital Accreditation (5 Aug 10)
4.4
Related to CQI
4.4.1 UCH Forum on HA CQI Initiatives System (13 Dec 10)

4.4.2 Sharing on CQI Programs - Medical Stream (1 Dec 10)
4.4.3 Sharing on CQI Programs - Critical Care (7 Jul 10)
4.4.4 KEC Convention (19 May 10)
4.4.5 Sharing on CQI Programs - Surgical Stream (7 Apr 10)
4.5
Related to Infection Control
4.5.1 A total of 80 courses were conducted by Infection Control Team with 2,529 staff attendance
4.5.2 12 infection control drills performed
4.5.3 Infection Control Related to Q&S Issues (TKOH: 4Q 10)
4.6
Related to Occupational Safety & Health
4.6.1 Coordinated CQI programs in managing major nature of injuries including

SSF (slips, trips & falls), Percutaneous Injuries, Manual Handling
Operations and Workplace Violence
4.6.2 Organized recognition programs for OSH improvement in 5S, Manual
Handling Operation, Staff Wellness and Others and the Best OSH
Employee
4.6.3 Conducted 32 OSH training sessions/seminars, such as 5S training on
environmental management, refresher and trainer courses on Manual
Handling Operations, Safety Management System, Trainer courses on
Display Screen Equipment, Work at Height and Trolleys Operations etc.
4.6.4 Organized 13 Staff Wellness Programs addressing physical, psychological, nutritional and
social perspectives
4.6.5 Conducted OSH Safety Program at M&G Department of UCH and Domestic &
Transportation Department of TKOH
4.6.6 Coordinated multi-departmental drills in workplace violence and chemical spillage
4.6.7 Conducted 42 OSH Visits/Consultations to help address OSH concerns
76
This report covered the period from 1 April 2010 to 31 March 2011 on a wide range of quality
and patient safety programs in Kowloon West Cluster (KWC).
The Cluster Quality and Safety Coordinating Committee meets quarterly to oversee all the
quality and patient safety issues, such as developing patient safety strategies and programs,
formulating safety standards and policies at cluster and hospital levels, and cultivating a safety
culture through training, sharing and monitoring.
To assist the Committee to execute the KWC
quality and safety annual plan and risk reduction programs, a Cluster Quality and Safety Core
Group consists of representatives from Q&S departments of KWC hospitals would also meet
regularly to implement and review all the activities, and to give expert advices.
Regular training
for staff on incident and risk management would be organized to upkeep the safety culture in KWC
hospitals. Publications on safety events, such as Safety Gist and Quality Bulletin would also be
issued monthly to frontline staff for their alert. Quality and safety forums would be held for staff to
give their feedbacks on the practice of safety programs.
77
In the past 12 month, with good collaboration among representatives of KWC Q&S team,
KWC hospitals had successfully launched a number of quality and patient safety initiatives with
effective measures to advance patient safety.
1.1
Implementation of Interventional Procedure Safety Policy

All hospitals in KWC had implemented the Interventional Procedure Safety Policy in
interventional suites before end of Dec 2010.
The HA Safety Policy on Bedside Procedures which
covers the communication and the process during bedside procedures, would be in effect by
31.8.2011. Details of the timeline and work plan were drafted by a
workgroup.
1.2
Unique Patient Identification ( UPI) Phase III

The Phase III UPI system is a tool to ensure correct patient
identification for all blood tests and specimens by using 2-D barcode
devices. All hospitals in this cluster had implemented the system in 1Q
2011.
1.3
KWC Orientation and Induction (O&I) Programme for new

Residents
86% of the new residents had attended the 3 identical half-day O&I training sessions.
The
scope of the program was to raise the awareness of residents to common pitfalls and risks in
hospital practice, and to strengthen their skill in managing incidents at the beginning of their career.
78
1.4
Patient Safety Walk round

Patient safety walk round had been conducted in all KWC hospitals with participation from
staff of Q&S Department and Hospital Management. The key objectives were to meet frontline
staff at wards or other workplaces, and to collect their views on hospital plans and other concerns
related to staff and patient safety.
Several issues identified during the Walk rounds in their
hospitals had been reviewed and followed up, such as handover communication, SOPD booking
and enquiry system, management of drug trolleys in wards, streamline of blood collection
procedures at blood bank, etc.
1.5
Lean project
KWC hospitals had participated on the HO Lean Management training.
below had been implemented to improve work flows and environment.

selected in the LEAN Roving Exhibition rotated among HA hospitals.
79
The lean projects
These projects were also
Project Name
Hospital
KWC IT
KWC
Account Management System in KWC Finance Division
KWH- Surg
Patient admitted for elective Surgery in KWH
KWH
PMH-AED
AED workflow revamp in PMH
PMH
CMC - AED
CMC
Door to needle time for AMI patient presented to A&E in
CMC
KWH-O&G
Universal Downs Screening in KWH
1.6
KWH
KWC Q&S Forum ( Attendance: 399 staff )

A KWC quality forum was conducted on 9 June 2010 to share with staff on the topics
including Accreditation Program done in CMC, Safe Surgery Audit results, Development of
Document Control framework in KWC, and Incident Report through AIRS.
reinforce staff to keep on providing quality services to patients.
1.7
KWC Incident Management and Root Cause Analysis

Workshop ( Attendance: 291 staff )
Four identical one-day Incident Management and Root
Cause Analysis Workshops were conducted.
The objectives of
the workshop were to enhance the knowledge of health care

practitioners on incident management and provide them with the
skills required to conduct RCA for serious incidents.
80
The objective was to
Risk Prioritization
- By Clusters
2.1
Identified clinical risks for 2010-2011 (as reported last year)

1
2
2.2
Patient care
- fall with serious injury
Medication Safety : patient identification, Drug Allergy, high risk
medication and LASA medication
Medication Safety : Drug reconciliation on admission / discharge
Staff (OSH) Injured whilst lifting or carrying
Infection Control: Infection control practice compliance
Patient Treatment, Care & Monitoring : Patient identification
Patient Examination & Assessment : Care of acute deterioration

patients
Identified clinical risks (in order of priority) for 2011-2012

2.3
Patient Fall
Infection Control
Medication / Dispensing
Clinical Documentation
Manual Handling Operation (MHO)
Safe surgery
Discharge planning
Identified Non-clinical (operational) risks for 2011-2012 (not necessary in order of

priority) (Optional)
Identified non-clinical risk
1
MHO
Fire Safety
81
3.1 Review of 2010 risk reduction program

3.1.1 Medication safety
(a) KWH
z
Sharing sessions on medication incidents was held by CND.
Re-labeling and re-allocation of look-alike & sound-alike ward stock drugs in Private ward.
Inclusion of patients drug allergy status in the nursing handover checklist in M&G.
Promulgation of "Drug prescription Safety Self-assessment guide" by forwarding the link to all
M&G doctors via email.
Hospital wide audit on administration of oral medication was conducted.
Near miss monitoring of prescribing error by Pharmacy.
Colour lettering approach was applied in drug labeling in AED.
Audit on nursing staff handling patient drug allergy in M&G.
Simplified the type and storage of Dangerous Drugs in OT rooms.

(b) OLMH
Implementation of Oral Syringe for administer of syrup medication in May 2011.

(c) WTSH
Changed duration of drug supply from 3 to 6 days in one infirmary ward
Monitoring temperature of the Drug Storage by using thermometers.

(d) PMH
Update and distribute PMH Guideline on Handling of Drug Allergy for medical, pharmacy and
nursing staff ( Aug 2010)
Distribute DO NOT USE List 2 additions- Avoid
trailing zero and omission of zero
before decimal point (Jul 2010)

z
Updating of Discharge Summary to minimize risk of mismatch between the medications

dispensed and the discharge drug information printed on the outdated discharge summary (Dec
2010)
Promote Use of DH Website (Registered Pharmaceuticals in Hong Kong) to minimize

prescribing and administration of drugs to patients with known drug allergy due to
unfamiliarity with the drug ingredients contained in certain combination drugs (Dec 2010)
Set up a link to HK registered drug was posted on the front page of PMH web (Useful links)
and front page of pharmacy web to facilitate staff to check on all HK registered drugs,
including combination and OTC products (Dec 2010)
Displayed Screen-saver on drug allergy in all Clinical Management System stations to remind
82
staff in PMH.
(e) YCH
z
A Task Force on medication safety was set up in Q2/10.
Standardization of the drug
administration schedule among all departments in Q3/10.
A standardized MAR form for
intravenous infusion fluid was implemented in Q1/11.

(f)
z
KCH
Communication on medication advice between PMH and KCH were reviewed with
improvement on the advice of legible handwriting in prescription, marking the used row as
invalid in the MAR, and seeking opportunity to double check documents before patient
transferring out of the wards.
3.1.2 Patient identification

(a) KWC
z
Implementation of Phase 3 of Unique Patient Identification System in all KWC hospitals.
3.1.3 Falls
(a) KWH
z
Fall prevention posters was developed and distributed to clinical area.
Sharing sessions on fall incidents was held to raise staffs awareness.
Assessment made on safety of patients' shoes or slippers on admission. Varies sizes of

non-slippery slippers are available for loan in Private Ward.
(b) OLMH
Slogan on fall prevention for patient/relatives was designed.
competition was organized in Jan, 2011
Trial use of non-slippery slippers after conducting survey in M &G unit from Nov 2010
to promote fall prevention.
onwards. 97.3 %-100% of patients agreed very much on the new slippers that the comfort,
non-slippery function, and provision of appropriate size were important to prevent the fall.
z
Inspection on environment and walking aids in clinical area on 24 Mar 2011 to prevent fall.
(c) WTSH
Assessment was made in Rehab ward on patient's safety awareness within the first three days
of admission. Immediate feedback and individual education were provided. Proper signage for
risky patient within work team. Reinforcement in ward
Promotion of fall prevention by using patient safety awareness questionnaire.
Continued staff education was enhanced in WTSH.
Identification of risky patient in Occupational Department. Placed patient at easily monitored

site. Close supervision and monitoring of patient. Apply safety vest if needed
83
(d) PMH
May 2010 EBP study on fall risk assessment tool.
Adoption of Morse Fall Scale for fall risk assessment tool in Jan 2011.
3.1.4 Infection control
(a) KWH
z
Respiratory Protection & Fit Test Workshop was held by CND & ICT.
Audit on Hand hygiene was conducted.
Biological spillage drill in TB lab was conducted.
Drill on handling suspected / confirmed infection of chickenpox by ICT, O&G and Anaes &
OTS.
(b) WTSH
Incidence of resistant microorganisms was reviewed.
Promotion of rational therapeutics and judicious use of antibiotics through various channels.
Audit on staff compliance in antibiotic prescription practice was conducted.
Audit on segregation of clinical waste was conducted and feedbacks were collected.
Reinforcement of cases report on use of IV antibiotics for longer than 7 days.
WHO Hand Hygiene Day was organized, included proper use of gloves as one of the items in
the Hand Hygiene Campaign.
Photo guide in common procedures of Infection control was provided for supporting staff.
Regular infection control training and revision was conducted.
Plastic material was used for boxes so that they could be cleaned and disinfected regularly.
WHO global observation survey on hand hygiene compliance with moment was conducted.
(c) PMH
Hand Hygiene Ambassador Program was organized in June 2010.
Catheter Related Blood Stream Infection Prevention Program was held in July 2010.
An ID drill was taken in 4Q2010 by the Emergency Preparedness Sub-committee.
3.1.5 Occupation Safety and Health (OSH)

(a) KWC
z
KWC DSE Working Group conducted a comprehensive DSE assessment to cluster

procurement office
(b) KWH
MHO Train-the-trainer Workshop was held.
MHO Workshop was held for Supporting Staff and Nurses.
MHO revision course with assessment done in Anaes & OTS.
Proper manual handling was reinforced when assisting inpatients to sit up in bed for
84
assessments in Speech therapy Unit.

(c) OLMH
z
Safety Climate Index (SCI) survey was performed with over 40% of staff return.
Work Safe Behavior (WSB) was performed in CNS for protecting vulnerable staff from
ergonomic risk- comprehensive staff health program for Community Nurse on 1Q11
(d) WTSH
Proper function of panic alarm was ensured.
OSH guidelines were reviewed.
Continued MHO training for new recruit and existing staff.
Reinforcement of proper MHO technique with close monitoring and supervision.
Regular inspection of MHO task (materials) including tools.

(e) PMH
Conducted WSB (Work Safe Behaviour) program in NEATs regarding the patient lifting inside
the vehicle.
Smart Lift Policy implemented in LKB to address the MHO problems.
3.1.6 Physical restraint

(a) WTSH
z
Proper use of restrainer was promoted and reinforced to frontline.
Audit (include surprise audit) was conducted and feedback on staff compliance of using
restrainer was provided.
Wards with good performance / great progress were encouraged and announced
3.1.7 Documents / records handling

(a) WTSH
z
Conducted 10% checking of all case records by supervisor (MSW) before filing. Check all the
referrals and correspondences to outside agencies by supervisor.
Audit on nursing documentation was conducted every year and provide feedback to frontline
staff. Sent reminder to staff with non-compliance on specific criteria via DOMs. Conducted
sharing sessions and facilitate supervisors to debrief result to ward staff by sending
presentation material to supervisors.
Wards with good performance / great progress were encouraged and announced.
3.1.8 Audit
(a) KWC
z
Individual hospital had taken some audits on various kinds programs, such as nursing
documentation, oral medication, safe surgery, pressure ulcer, POCT, informed consent, SUD,
NG Tube, AOM, and so on in order to check that correct procedures, code of practice and
85
newly implemented policies had been carried out promptly and correctly.
3.1.9 Others
(a) CMC
z
Emergency patient evacuation plan was revised.
Establish a tracking mechanism for abnormal test report.

(b) WTSH
Accreditation on joint ISO and HACCP for catering sector was obtained in food poisoning.
(c) PMH
Survey on SCI (Safe Climate Index) of ISWP was completed with over 46% returns.
3.2 Quality initiatives, including accreditation.
3.2.1 Hospital accreditation

(a) KWC
z
A visit to PYNEH organized by the Staff Engagement Team of PMH on 4 Jan 2011. Another
visit to HA & private accredited hospitals including PYNEH & TWAH was organized by
YCH.
CMC experience in Accreditation was shared with YCH, PMH, OLMH, UCH and TKOH in
4Q 2010.
Briefing on HA e-CQI system in CMC and VC to PMH, YCH, KWH, WTSH was organized in
1Q 2011.
(b) OLMH
Document control system was implemented in 2Q 2010.
Newsletter Accreditation Express () are published for promulgation of

Accreditation.
Collection of Preliminary master list of document control in 1Q 2011.
Training and briefing on document control and ACHS were conducted in 4Q 2011.
(c) PMH
CCE forum on hospital accreditation was held on 16 Aug 2010.
Two briefing sessions for Standard Owners and Department Coordinators was organized in 3Q
2010.
Accreditation Forum for Heads of Departments, Standard Owners and Department

Coordinators was held on 22 Oct 2010.
Sharing session on QMHs experience in accreditation related to administration was conducted
86
in Dec 2010.
(d) CMC
z
OWS was conducted in Jul 2010.
A co-jointed hospital-wide study with of CMC and CUHK on Understanding Organizational

Culture and Accreditation Performance on using self-reporting questionnaire was carried out,
and 5 focus groups were formed in 4Q 2010.
Award Ceremony on accreditation was held on 14 Dec 2010.
Sharing of ACHS hospital accreditation projects with Master of Public Health student (HKU)
was conducted in 1Q 2011.
Experience sharing with QMH on ACHS hospital accreditation in 1Q 2011.

(e) YCH
Formation of taskforce for standardization of pressure ulcer assessment and management in 3Q

2010. Pressure ulcer risk assessment and management records were reviewed to meet the
ACHS criterion 1.5.3 in 2010-11.
3.2.2 End of life policy

The PMH Resuscitation Sub-committee had implemented the End of Life Policy with an
objective to alert clinical professionals that patients individual needs, priorities and preferences for
end of life care are identified, documented, reviewed, respected and acted upon, wherever possible.
The ultimate goals are:
(a) to ensure that all people are treated with dignity and respect at the end of their lives;
(b) to ensure that pain and suffering minimum with access to skillful symptom management
for optimum quality of life;
(c) to ensure that all those approaching the end of life have access to physical, psychological,
social and spiritual care.
3.2.3 Other quality initiatives
(a) Oxygen consumption audits jointly conducted by Pharmacist and CND of YCH to
identify areas for improvement and recommended good practices on a quarterly basis.
(b) A Task Force on medication safety was set up in 2Q 2010 in YCH. Standardization of the
drug administration schedule among all departments in 3Q 2010.
A standardized MAR
form for intravenous infusion fluid was implemented in Q1/11.

(c) Join the WHO International Safe Workplace Program (ISWP) in KWC in 2010-11 with
gap analysis, road show, hospital safety plan, safe climate index and work safe behaviour
conducted.
(d) Publications
Safety Gist on the topics of Early Defibrillation Program and Safety Steps for
87
Interventional Procedures were issued in PMH.
88
Learning and Sharing Information
Staff Education and Training on Q&S
4.1 Quality and risk management

(a) KWC
z
KWC Q&S forum was organized in Jun 2010.
2010 HA Nurses Forum was conducted in Jul 2010.
Crisis Management for Nurse Leaders was held in Oct 2010.
Leadership Development Program for senior nurses was organized in Aug 2010.
KWC pain management education program / symposium was held from 4Q 2010 to 1Q 2011.
(b) OLMH
Fall Awareness sharing session for clinical staff was done in Jul 2010.
One-day Incident Management (RCA) Workshops was held in Nov 2010.

(c) WTSH
Briefing & demonstration on application of 2D barcode technology was conducted.
Sharing session on AIRS incidents & Nursing Quality Indicators was held quarterly.
(d) PMH
Crisis Management for Nurse Leaders was held in Jun & Jul 2010.
Nursing research & EBP training was organized in May & Jun 2010.
Sharing session on the OR experience was conducted in Oct 2010.

(e) YCH
Safety Talks on Medication & Patient Identification to share the related incidents and good
practices on medication safety was held on 17 Feb 2011.
Monthly Patient Safety Leadership Walkarounds in wards was held.
AIRS Forum was organized on a quarterly basis.
4.2 Resuscitation training

(a) PMH
z
BLS provider and renewal course were held.
4.3 Clinical care quality

(a) KWC
z
Chronic disease management to community was organized in Apr 2010.
Program of Application of Psychological First Aid on Children population was held in Jun
89
2010.
z
Refresher course of phlebotomists training was conducted in Jun & Jul 2010.
Social & Professional Reality Integration Program for Nurse Graduates was held.
Basic / Advanced Wound Care Courses was conducted.
KWC Trauma Service Update was conducted in Sep 2010.
Joint Task in Organ Donation & Transplantation was conducted in Dec 2010.
Clinical Enhancement Programs was organized.

(b) KWH
Education talk on New drugs in Diabetes was conducted on 27 Apr 2010.
Talks on Nursing Documentation, Nursing Quality Indicators and Quality & Safety delivered
to newly joined nurses were held on 15 Sep 2010.
Professional Development Program for Nurses in PMH and KWH.

(c) OLMH
Sharing of incident reporting and management SPRING program for new graduates on 14 Sep
2010.
(d) PMH
Professional Development Program for Nurses in PMH and KWH.
Briefing on Automatic Dispatch System was conducted in May 2010.
Spring program for new nurse graduates on AIRS, DSE and medication safety was held in
2010.
Workshop and sharing on Nursing Audit was conducted in June 2010.
Chemotherapy & biological therapy nursing training was held in Jul & Aug 2010.
Joint Orthopedic Traumatology Nursing Forum was held in Oct 2010.
PMH 35th Anniversary Commemorative Scientific Conference in Nov 2010.
Program for Introduction of HA Safety Manual was conducted in Feb 2011.
Psychological Trauma Clinic Talk Series was organized in Feb 2011.
ECG training session was conducted in Feb 2011.
Training on Inter-Facility Critical Care Transport Medicine was conducted in March 2011.
Pressure Care Liaison Nurse Sharing Session was conducted.
Practical Skills Enhancement Workshop was held.
Helping people facing life limiting illness was promoted.

(e) CMC
PRCC (Respiratory nurse) on the role of nurse auditor and risk management was held in 3Q
2010.
Orientation program to EN on AIRS and medication safety was organized in 1Q 2011.

90
(f)
z
YCH
Two workshops on prevention of fall for nurses & care-related supporting staff was conducted
on 9 & 16 Nov 2010.
Nursing Audit Training to train new auditors on Dec 2010.
4.4 OSH
(a) KWC
z
DSE train-the-trainer program was conducted.
Seminar on Anti-workplace violence was organized in Sep 2010.
Risk Assessment for Chemical Substances was conducted in Oct 2010.
Introduction to Nuclear Medicine and Radiation Safety in Hospital on Oct 2010.
ISWP open ceremony was held in Oct 2010.

(b) KWH
was held in 6 May 2010.
workshop was conducted on 16 & 24 Sep, 25 Nov & 2 Dec

2010.
Talk on Safety Management System Training in Health Care Setting was held on 25 May
2010.
(c) PMH
MHO training for MHO trainers was held in 2010.
Program of safe use your computer was organized on 28 May & 30 Jun 2010.
Workplace Violence Guideline update and Magnetic restrainer practice was held in Aug 2010.
competition aimed to promote safety culture

(d) YCH
Two MHO training workshops for care-related supporting staff in Dec 2010 & Mar 2011.
91
1.
During the year, there were 2 PSO (Patient Safety Officer) shortage that the vacant post could
not be filled due to the overall nursing manpower shortage. To prepare for Hospital Accreditation
at PWH, NDH, AHNH, and TPH, three Quality Officers (QO) were appointed in February 2011
under the team of NTEC Quality & Safety.
The Hospital Coordinators for Hospital Accreditation
were also appointed to lead the preparation for each of the four hospitals.
1.1 Incident Management

Root Causes Analysis were conducted on each of the SE / SUE cases.
were made to hospital management and department(s).
Recommendations
The cases were discussed with senior
management every 6 months in the cluster.

After the review meeting and discussion, the major improvements were initiated including:
1.1.1 Instrument Tracking System was implemented in PWH TSSU;
1.1.2 Policy on Counting procedure for major / minor operation was reviewed;
92
1.1.3 Safe Surgery Time Out for Interventional Procedure;

1.1.4 Review of MAR (Medication Administration Record) format
1.1.5 Review of Dangerous Drug Handling procedure (by Nursing)
1.1.6 Review of 3 Checks 5 Rights Procedure (extend to other discipline)
1.1.7 Review of High Risk medication in A&E, e.g. muscle relaxant
1.1.8 Policy on Nasogastric tube insertion, testing and checking of integrity
1.1.9 Strategies for Warfarin handling (prescription in MOE, dose form, and patient education
booklet);
1.1.10 Review the alertness for patient with Known Drug Allergy
1.1.11 Use of protocol and checklist for patient on Chemotherapy;
1.1.12 Replacement of Syringe Driver with safe model
1.2 Safety Culture

The new slogan for safety culture was
()
promoted in NTEC. Staff is encouraged to ask and clarify when there is

doubt in treatment / prescription / procedure, etc.
20101215
20101215
1.3 Medication Safety

Medication safety was the top priority in this reporting period. From July 2010 onward, a
series of activities were organized following the CCE Forum Medication Safety Yes We Can.
An on-line communication platform, iChat, was launched in July 2010 to booster feedback
and suggestions about medication safety cluster-wide. 229 responses were collected over 4 months.
Feedback and suggestions covered broadly the structure, process and outcome of the medication
process.
The Medication Safety Slogan Competition was launched cluster-wide in July - August 2010
to increase the staff awareness of medication safety. 146 slogans were received across the cluster
and 2,841 votes were recorded for final selection.
The Medication Summit was organized in September 2010 with 60 clinical staff from Intern
to CCE joined the discussion.
Six focus areas were defined with strategies proposed.
NTEC Quality & Safety Month focusing on medication safety was held between 15/11 to
15/12/10. A series of activities were organized in NTEC, including REAL day in AHNH/TPH, a
quiz game booth on medication safety, and a staff forum on patient safety culture at PWH.
true-man show was held in NDH, and paper sharing in SH/BBH, and SCH.
The Annual Quality & Safety Forum was held on 15 December 2011. Sir Liam Donaldson,
Chair of World Health Organization World Alliance for Patient Safety was invited to share in the
93
Forum. The NTEC Safety Culture Slogan was launched.
608 attendances at the
Cluster Forum, including 305 staff and 303 medical/nursing students were recorded.
1.4 Surgical Safety

Safe surgery was one of the top priorities of patient safety in NTEC/PWH.
The standardized
NTEC 123 Safe Surgery 123 Checklist was implemented since August 2010 to improve
communication between parties involved in the surgery and facilitate a one-go surgical checking
procedure. 9 Safety Checklists for Minor Operations / Interventional Procedures in interventional
suites were implemented in Dec 2010.
The roll out was smooth. Re-evaluation audit of surgical
safety in the main operation was repeated from 28/2-12/3/11 and 50 samples were taken. The
overall compliance was 99.7% and showed improvement as compared to 98.4% in the same audit in
2010.
1.5 Unique Patient Identification (UPI)

All 2D barcode scanners were uploaded a new version (v.2.34b) and the function of manual
input of HKID was disabled. The use of 2D barcode scanning and labeling to ensure correct
patient identification and specimen labeling was extended to X-ray department, Eye / ENT clinic,
and PWH Operation Theatre for all in-patient operations. The pilot in NDH A&E in 2010 was a
success that no incident related to wrong labeling was reported.
The finding was shared with other
A&E services. There was plan to implement the system to A&E in PWH and AHNH in 2011/2012.
1.6 Patient Safety Round

The Q&S team in individual hospital conducted patient safety walkrounds
to establish lines of communication about patient safety with frontline and
94
management staff and to identify good practices and opportunities for improving
safety.
50 senior hospital staff and the Q&S team attended the commission
training on Patient Safety Walkrounds conducted by Dr. Allen Frankel from
USA in early November.
1.7 Sir Liam Donaldson Visit

In December 2010, during Sir Liam Donaldsons stay in Hong Kong, three talks on patient
safety were arranged in PWH, AHNH, and NDH respectively.
The PWH session was a discussion
and sharing on safety culture, the subject for AHNH was Safety Solution with a clinical visit,
whereas the subject for discussion in NDH was the dilemma on patient safety and clinical efficiency.
The discussion was fruitful and feedback was good.

Structure in NTEC, PWH, AHNH/TPH, and NDH for preparation of Hospital Accreditation
were formed to coordinate quality improvement initiatives in patient care and to prepare for hospital
accreditation.
Three Quality Officers and clerical staff were recruited and in post in Feb 2011.
series of staff engagement, training workshops, briefings and coaching sessions to departments were
held in 2010. Subject Officers for each criterion were appointed in cluster as well as in hospital.
The Subject Officers are requested to review the standard and practice, and identify the gaps for
improvement. The web site iHosp was used as a platform for department to upload their
departments guideline / protocols. Progress is good.
NTEC Ops Meeting
NTEC Hospital Accreditation

Steering Committee
Chairman: Dr. SF Lui
Co-Chairman: Dr. HY So
HAHO Working group

Hospital Accreditation
Co-ordinator
Ms. Ellen WONG
Shatin Area
AHNH/TPH
NDH
Steering Committee
Dr. Fung Hong /
(Dr. Susanna Lo / Mr. Herman Lau)
Steering Committee
Dr. B Cheng
Steering Committee
Dr. CY Man
SH/BBH
AHNH/TPH
Project Team
Project Team
Project Team
Project Team
Dr. L. P. CHEUNG
PWH
Dr. Christopher LUM
Dr. Eddie YUEN
Dr. Michael CHEUNG
NDH
Functional
Coordinator
Nursing
Ms. Jane Liu
Ms. Becky HO,
Ms. Angelina TONG
Allied Health
Mr. Benjamin LEE,
Mr. Herman LAU
Admin:
Ms. Lucia LI
HR:
Mr. Francis WONG
IT:
Ms. Christine Choi
SCH
Hospital
Accreditation Team
Mr. Herman Lau
95
2.
Risk Prioritization
2.1 Identified clinical risks for 2010-2011 (as reported last year)
1
Medication incidents
Misidentification of patients
Fall Incidents
Infectious Disease Outbreak
Missing patient (at risk)
Work Place Violence
Patient restraint
Mislabel specimen / blood from wrong patient
Patient Transfer
10
Suicide
2.2 Identified Non-clinical (operational) risk for 2010-2011 (as reported last year) (Optional)
1
Aging hospital facilities / faulty biomedical equipment
OSH Manual handling Injury
Manpower / Workload
OSH Workplace violence
Staff morale
insufficient space / bed
Data Security
IT system breakdown
Safe custody of patients' specimen
10
Security
96
Medication incidents
Patient Fall
Patient Misidentification
Patient injury during procedure
Outbreak of infectious disease
Communication between staff/patient/relative
Risky Patient care
Specimens error
Physical restrain
10
Wrong site surgery
2.4 Identified Non-clinical (operational) risks for 2011-2012 (not necessary in order of
priority) (Optional)
1
Shortage of manpower
Aging hospital facilities / faulty biomedical equipment
Workload
Insufficient space
OSH Workplace violence
Quality of Hot Water Supply
Insufficient patient beds (e.g. PICU beds)
OSH Manual handling Injury
Patient record - missing/documentation/storage
10
OSH Needle prick injury
97
3.

3.1.1 Medication Safety
The Medication Safety was rated as top high risk area with high priority for improvement in
NTEC.
In 2010, a series of risk reduction program was commenced in NTEC as well as in
individual hospital.
(a)
July 2010 Cluster Chief Executive (CCE) Forum for clear message to staff: yes we can
(improve medication safety)!
(b)
July 2010 On-line discussion using iChat platform started after CCE Forum to promote
participation and generate ideas. 3 questions asked: What will you do? What do you want
your colleagues to do?
What do you want your seniors to do?
A total of 229 responses were
collected from web (iChat).
s
and
ack C
edb iNTE
e
f
t
a
he
of t -line ite)
sis le on ety s
f
al y
An vailab n Sa
o
is a dicati
(Me
(c)
ugg
i on
est
September 2010 Medication Safety Summit. 60 staff of all grades to discuss on possible
strategies, taking into account all the ideas collected from online platform. 6 key areas that
flow through the discussion at the Summit formulated the direction and strategies for action
plans.
Program 4
NTEC
911
MEDICATION
SUMMIT
Zero ERROR
Culture
Mind set
Team work
Teamwork setting
Doing ward rounds together
Clinical pharmacists
Drug reconciliation
Drug safety ambassador
Safety first culture

Safe practice / conduct
Professionalism
Role model, Collective behaviour
Staff engagement
Team work
Work flow
Work load
Patient
engagement
Drug knowledge
11 September 2010
98
Work flow
Work load
IP MOE, 2D bar code

Human machine interface
print MAR on admission
simplify 3C5R
System / flow control
Reduce variability
Activity control
Standard scheduling
Protected time
Smart prescribing
(d) October 2010 Slogan Competition.

Slogan competition was called in NTEC in October to arouse the staffs attention on
medication safety.
A total of 145 slogan was received. The panel selected ten slogans and
put it for open voting in web. The response was encouraging as 2800 colleagues participated
in the voting at web, and the winner was :
150 submissions
10 submissions selected for on-line voting
Working together for medication safety

Protect our patients benefit everyone
Scored 4.98 by 1703 / 2809 votes
(e)
December 2010 Patient Safety Forum: Sharing of successful examples from within the cluster
to stimulate ideas and participation. Before the cluster Forum, individual hospital organized
their Medication Safety Forum in their own hospital.
On 15th December 2011, the cluster
Forum on Medication Safety was organized with Sir Liam Donaldson as the guest speaker,
followed by 7 presentations from individual hospital.
The Forum was a success with 600
attendances (300 medical / nursing students). The main theme was promoted, i.e. Medication
Safety: Yes, we will!
Program 5
(f)
Jan 2011 onwards Monitoring and Sharing, Quality Circles for Improvement Projects.
Four
Cluster wide projects and Six departments wide (Prescription / Dispensing / Drug
Administration) projects.
Senior Staff /
Management
YES WE CAN, YES WE WILL

Way forward
Doctor
(Prescribing)
Frontline staff
SMART
prescription
Clear
prescription
Smart
Workflow
+ safety
measures
Sound alike,
Look alike
drugs
Smart
Workflow
+ safety
measures
Strict 3C5R
Every
occasion,
every drug
Cluster Q&S
Pharmacist
Safety Culture
(Dispensing)
Drug information
Review MAR
Reaffirm 3C5R
Nurse
(Administration)
(IT solutions)
Presentation by Dr. SF Lui at NTEC Q&S Safety Forum 15 Dec 2010
99
(g)
Measurement and Monitoring

Incident rate The medication incident in cluster per million bed days was monitored.
As at
end of 1Q2011, the incident rate was 102 per million bed days, which was a decreased in trend.
However, the target of zero incident was still a long way to be achieved.
Incident Rate Medication (In-patient)
NTEC Trend - up to 1Q2011
180
160
140
120
100
80
60
40
20
0
per 1000000 patient days
2007
2008
2009
1Q10
2Q10
3Q10
4Q10
1Q11
98
114
116
167
111
124
119
102
3.1.2 Surgical Safety

(a)
Phase I Safe Surgery in Operation Theatre

A Policy on Time-Out to ensure Correct Patient and Correct Site Surgery was developed in
2009, and a checklist 123 Surgical Safety 123 was pilot in October 2009.
To further enhance the
effectiveness and efficiency of the Safe Surgery policy and to improve the communications between
all parties involved in surgical procedures, a combined Safe Surgery 123 and Nursing Pre-Operation
Checklist was developed and implemented in August 2010.
The implementation involved three
major and acute Operation Theatre, and 30 wards in the NTE cluster.
(b) Phase II - Interventional Procedure Safety Procedures

In December 2010, the implementation of safe surgery was extended to outside Operating
Theatres so as to reinforce interventional procedures safety in interventional suites, such as Minor
Operating Suites, Interventional Procedures performed in
Radiology suite, gynaecology procedures at interventional site,
Endoscopy Units, venues for performing Electroconvulsive
Therapy, Cardiac Intervention Centre, etc. A Generic Checklist
was developed.
Different specialties add extra items required
for their specialty on top of the Generic Checklist.
The
implementation involved 22 Interventional Suite, and 130 wards

in the NTE cluster.
100
(c) Phase III - Safety Policy on Bedside Procedures

The policy for bedside procedure was endorsed and effective on 1st March
2011.
It applies but not limited to Chest tapping, drainage and paracentesis, and
Insertion of intravascular catheter with the use of guide wire.
The
implementation involves all clinical areas (total 140 wards) where tapping and insertion of
guidewire will be conducted when necessary. The full implementation will be commenced with
effect from 15 August 2011.
(d) Measurement and Monitoring
Incident Track - Incident related to Wrong Site Surgery / Retained Instrument were tracked. In
2010, the incident related to wrong site surgery down to zero, and the incident related to retained
instrument down to 2 in NTE cluster.
Audit on Compliance
A cluster-wide audit on compliance to surgical safety policy in Operation Theatre had been
conducted in March 2010 after the pilot stage. The compliance rate was 98.8%. The same audit was
repeated again in March 2011 after the implementation, the compliance rate was increased to 99%.
For Phase II Checklist, the compliance rate was 99.5% as audited in April 2011. The compliance
rate demonstrated an improvement in quality.
Staff Feedback
The staff's opinion / feedback on the use of Checklist and the item of Checklist were collected
throughout the process at each stage. The majority of staff were happy of the simplified and unified
checklist which enhance the operation / procedure safety.
3.1.3 Fall Prevention Study

The NDH Fall Prevention work group worked with Quality & Safety team formulating
strategies on fall prevention.
A study on the effectiveness of the fall alarm pad for the elderly in a
period of 4 months was conducted and total 300 samples were recruited. A total of 10 fall cases
were recorded and 9 out of 10 fall cases were from the control group without using fall alarm pad.
The result showed a significant difference.
The use of fall alarm pad for at risk patients would be
a valuable tool in prevention of fall while in the mean time keeping the restraining rate at a
minimum.
101
3.2
Quality initiatives, including accreditation
3.2.1 Policy developed and endorsed related to patient safety

The following policies were endorsed and put up in iHOSP: Policy for Administration of Research Medication in In-patient Service
Policy and Procedures for Use of Potassium Chloride for Adults
Procedures to Prevent Airway Fire During Tracheostomy
Policy for Prevention of Naso-gastric Tube Mal-position or Retention
3.2.2 Patient Safety Round
In PWH, 10 sessions of patient safety walkrounds to 3 GOPC including their pharmacies and 9
clinical areas in 4 departments including AED, M&T SOPD, Surgery and Paediatrics were
conducted. Visits were withheld in Nov and Dec 2010 due to relocation to the new clinical block.
The focus of the walk rounds in 2011 was the set up, patient flow and workflow related to the new
clinical block after relocation. Junior doctors and frontline nurses were invited to join the
discussion.
In AHNH, Safety Ward Round on Fall Prevention was conducted to all wards,
recommendations will be followed up by Central Nursing Division.
In NDH, 31 sessions of Safety Walk Rounds were conducted. Total 63 departments/ units/
wards were visited during the reported period.
3 patient safety walkrounds conducted in BBH to enhancing the awareness of patient safety in
operation among staff.
3.2.3 Preparation for Hospital Accreditation - Progress in NTEC

The NTE Cluster Hospital Accreditation Steering Committee was established since March
2010.
In 2010, the Steering Committee conducted a series of activities focusing on promotion and
training. Hospital Coordinators for individual hospital was appointed.

Hospitals in NTEC establish their own Steering Committee to prepare for the Hospital
Accreditation, i.e. Shatin area (PWH / SH / BBH / SCH), NDH, and AHNH/TPH. Each hospital
appointed the senior staff as Co-ordinators / Subject Officers for the different standards / criteria,
whereas some of the standards / criteria will be reviewed at cluster wide approach.
In February / March 2011, three Quality Officers were appointed to assist the Hospital
Coordinators in preparing the Hospital Accreditation in PWH, NDH, AHNH and TPH.
In 2010, the web site of iHospital was developed, and departments were requested to upload
their department protocols / guidelines to their department web site. A stock take was done on 31
102
December 2010 to have a preview of protocols and guidelines in department web site.
The departments are also requested to conduct a Risk Registry and plan for the program of
Continuous Quality Improvement (CQI) and the next stock take will be conducted in June 2011.
103
4.
Learning and Sharing Information
Cluster
Cluster
Commissioning
50 senior hospital staff and the Q&S team attended the
Training on
commission training on Patient Safety Walkrounds conducted
Patient Walk
by Dr. Allen Frankel from USA in early November to learn more
Round
about the effective execution of patient safety walkrounds
Sir Liam
While Sir Liam Donaldson was invited as speaker for Medication
Donaldson Visit
Safety Forum in December 2010, he was invited to hold three

sessions with NTEC senior staff. The PWH session was a
discussion and sharing on safety culture, the subject for AHNH
was Safety Solution with a clinical visit, whereas the subject for
discussion in NDH was the dilemma on patient safety and clinical
efficiency. Feedback was good.
Cluster
Cluster
Cluster
Certificate course
6 Patient Safety Officers attended the Certificate course organized
on Patient Safety
jointly by CUHK and NTEC Q&S Division.
Workshop on
1-day training workshops on Basic Patient Safety were
Basic Patient
co-organized with CUHK and 2 workshops were held and 50
Safety
doctors and nurses in NTEC attended.
Workshop on
Workshops on Documentation and Document Control were held
Documentation
the second year with 5 sessions being conducted and around 300
staff in NTEC attending.
Cluster
Cluster
iSMART (alert
iSMART was issued monthly and the main emphasis was
flyer)
medication safety which was the theme of the year.
Workshops on
From May 2009 to January 2010, a total of 15 engagement
Hospital
Accreditation
sessions involving 1335 attended staff were arranged in NTEC.

Pamphlets and souvenirs were made to promote the Hospital
Accreditation.
From April 2010 to July 2010, in-depth training sessions were
arranged to managers and professional staff, including 6 sessions
with clinical staff (doctors, nurses and allied health staff), 1
104
session with administrative staff, and seven sessions with various

committee members, a total of 503 staff attended the training.
Feedback from the attendants was good.
Since September 2010, individual department coaching was
commenced in PWH and AHNH / TPH. The concept on CQI
(Continuous Quality Improvement) was further explained and
shared.
Cluster
Risk Watch
In PWH, Risk Watch (forum) for sharing and learning of

incidents reported via AIRS was held monthly in 2010 and
bi-monthly from 2011. A total of around 670 attendances were
recorded.
In NDH, SH, BBH and SCH, Risk Watch was held quarterly.
Cluster
Patient restraint
A Train-the-Trainer workshop on physical restraint was

conducted at cluster wide approach. The physical assessment and
observation form was revised.
PWH
Hospital Grand
Hospital Grand Rounds - 4 rounds was held with an emphasis on
Round
surgical safety and medication safety. Administrative Services,

Physiotherapy, Pharmacy, Surgery, Paediatrics and Central
Nursing Division participated in the sharing.
400 attendances were recorded.
105
A total of around
1.1 Executive Safety Walkround (ESW)

With the positive outcome and experience on unit-based walkround when preparing for the
organization-wide survey in 3Q 2010, NTWC had modified the format from theme-based (i.e. with
focus on medication safety or patient restraint) to unit- or ward-based walkround, so that all areas in
the hospital would be covered throughout the accreditation cycle for assuring safe practices were in
place. Since November 2010, two hospital executives were invited to walk through selected
patient care units, allied health or supporting service areas on a weekly basis.
Frontline staff and
unit managers were encouraged to discuss patient safety concerns and quality improvement
programs being implemented in the unit with the executives during the walkrounds.
As of 1Q
2011, the executive team had visited 19 patient care units, allied health and supporting service areas,
61 concerns were recorded and most of the action plans were in good progress. Good practices
were shared at 20 different meetings included Cluster Clinical Governance Committee and
106
Department Operation Managers meetings.
ESW not only facilitated the identification of patient
safety risk, but also empowered frontline managers and clinical staff to engage in quality and safety
issues.
1.2 Hospital Accreditation Scheme in TMH

Tuen Mun Hospital underwent the first Organizational-Wide Survey (OWS) in September
2010 and was awarded full accreditation for four years with 13 Extensive Achievements (EA).
The criteria that rated as EA are listed in the table below:
Clinical
Support
Corporate
114 care evaluation
211 quality improvement
314 contractor management
117 death & dying
213 incidents & complaints 321 occupational safety and
121 info & access
management
health
122 access prioritisation
224 staff training
323 waste management
151 medication safety
241 health promotion
325 security management
In preparation for the OWS, gaps were identified and

recommendations were made by the consultancy surveyors.
Committees and working groups were set up to follow up the
recommendations. In order to address the surveyors potential
concern over the sterilization practice of surgical instruments, an
overseas expert was invited to offer consultancy services on the
decontamination services in the cluster and improvement actions were taken according to his expert
advice.
Other improvement measures had been implemented, such as
the development of document control system, establishment of a
credentialing system with defined scope of practice
for healthcare professionals and the development of
electronic training platform to facilitate staff
learning. Patient Charter pamphlets were published
in four different languages, including Urdu and
Nepalese to enhance patients awareness of their
107
rights and responsibilities.

A post-accreditation survey was jointly
conducted by TMH and Nethersole School of
Nursing of the Chinese University of Hong
Kong. The results were analysed and discussed
in HA.
1.3 NTWC Quality (Lean) Journey

Kaizen Sharing Forums
Twenty six departments had presented their Lean/ Continuous Quality
Improvement (CQI) projects in the monthly sharing forum. These forums
attracted a total audience of over 880. Kaizen Coordinators were invited to give
suggestions on each individual project. Many outstanding project teams were
recommended to submit abstracts to local and overseas conferences.
Kaizen Room Open Day
Six open days were organized during the lunch period in the Tuen Mun
Hospitals Kaizen Room. The NTWC Quality Journey as well as the selected
CQI projects were introduced to staff attending the visit.
Gemba Walks
Hospital management engaged in Gemba walks had visited 8 clinical
areas over the past year. Many new ideas were written by frontline
staff on the NTWC suggestion boards. Frontline staff have actively
exchanged opinions and raised suggestions to the top management.
Good practices were video-recorded and the video clips are shared in
the Q&S website.
Staff Training
Induction of NTWC Quality Journey was provided in the
Orientation and Induction Program to all newly joined staff.
Experienced clinical and administrative staff were also invited to
attend an advanced 2-day training on Process Improvement, focusing
108
on the identification of values and application of quality tools in healthcare.

1.4 Cluster Clinical Governance Committee
The committee was restructured into a 5-pillar format aiming at a wider coverage of clinical
governance including clinical effectiveness, clinical risk-related, clinical audit, education and
training, incident and complaint.
The number of members was increased from 13 to 16 with effect
from 1 January 2011. In the new format of the meeting, Mortality & Morbidity (M&M) case
review sharing became a regular agenda item for multi-disciplinary discussion. The committee
would also keep track of the follow up actions.
Cluster Clinical Governance Committee

(CCGC)
Quality & Safety
Division
Clinical
Risk-related
Committees
Clinical
Effectiveness
Medical
stream
Surgical
stream
Clinical
supporting
Nursing
Allied Health
Clinical Audit
Correct Patient Identification

Decontamination
Drug Administration Safety
Chemotherapy Advisory
Committee
Fall Prevention and
Management
Infection Control
Informed Consent
Pain Management
Patient Pacification
Point of Care Testing
Coordinating
Pressure Ulcer Prevention and
Management
Procedural Sedation
Resuscitation
Single Use Device
Transfusion
Trauma Advisory
109
Education &
Training
Clinical Skills
Training Centre
(CSTC)
Medical staff
Nursing staff
Allied Health staff
Incidents &
Complaints
2. Risk Prioritization
2.1 Identified clinical risks for 2010-2011 (as reported last year)
1

Medication - administration (intrathecal + IV + oral)
Medication prescription - allergy + dosage
Mis-identification of patient (consultation)
Handling lab result filing error + miscommunication
Handling of specimen - mis-labelling
Care of acute deterioration patients
Handling of fragile patients
Fall
Patient choking + ingestion of FB
10 Suicide (in-hospital)
2.2 Identified Non-clinical (operational) risk for 2010-2011 (as reported last year) (Optional)
1

Maintaining a quality workforce (loss of key staff/ workforce planning/ recruitment)
Capacity of Facilities (insufficient space and equipment)
Budget Control
congestion in ward (patient overcrowded)
Equipment breakdown/ failure
Resource Allocation (Insufficient fund for rising demand)
Performance (Staff morale /absence)
IT system failure / not able to support changing needs timely
IT security/ unauthorized access/ use
10 Cash collection
110
Identified Clinical Risks in NTWC (2011-12)

Ranking Clinical Risk Description (General)
1
Medication - prescription (allergy, dosage)
Medication - administration
Care of patient with acute deterioration of condition
Wrong drug dispensing
Handling of specimen
Patient identification - consultation
Care of critically ill patients - transfer and interdepartmental consultation
Team communication for caring of patient
Patient fall
10
Retention of medical items inside patient bodies
Identified clinical risks in Psychiatric Settings in NTWC

Ranking Clinical Risk Description (Psychiatry)
1
Patient Violence
Patient Suicide
Choking
Fall
Medication error
111
2.4 Risk Reduction Strategies by Clinical risk-related Committees

Committees
Risk Reduction Programs
Clinical Audit
1.
Staff education through Clinical Audit Conference
2.
Cluster clinical audit programs according to risk assessment and

ACHS recommendations.
Pain Management
1.
Nurse Recognition Program via E-learning system
2.
Collaboration with HK Pain Society to organize the workshop on

interventional pain management
3.
Consolidate the pain assessment and pain protocols\
4.
Collaboration of Chinese Medication for chronic pain.
Procedural
1.
Mandatory procedural sedation training and workshops
Sedation Safety
2.
Credential list is prepared
3.
E- learning program
4.
Establish the committee website for staff information
1.
Fade out high risk Class II SUD based on the HAHO allocated budget
SUD
and direction
2.
Assure NTWC compliance with the corporate SUD policy
1.
Staff training on the latest cardiopulmonary-cerebral resuscitation
2.
Pilot on using end-tidal CO2 monitor for Advance Cardiac life support
Ulcer 1.
Promotion of pressure ulcer care to patients and their carers aimed to
Resuscitation
Pressure
Prevention
Management
and
enhance pressure ulcer handling skills of patients and their carers.

2.
Staff education for enhancing nursing knowledge and skills on

advanced pressure ulcer care
3.
Provide multidisciplinary consultation service on pressure ulcer care
4.
Conduct road show on appropriate use of pressure ulcer relieving

devices
112
Committees

5.
Set up Central Inventory Management System of pressure relieving

devices
Laser Safety
6.
Develop pressure ulcer electronic reporting system
1.
Staff training on advance medical laser safety
2.
Formulate an inventory record system on Class 3 or above medical

laser machines using in the cluster
Blood transfusion
3.
Initiate the 1st laser safety self-audit program
1.
Developed massive transfusion protocol
2.
Revision of NTWC transfusion guidelines
3.
Briefing and orientation of new intern and residents
Trauma
Promote preventable trauma mortality through staff education and audit
Infection Control
1.
Conduct training sessions with the supplier for the use of new devices
with aim to prevent sharp injury
2.
Minimize the use of chemical disinfectant in general ward/unit:

a)
Disposal medicine cup will be used to replace the plastic

medicine cup
b)
Drinking cup will be cleansed by central kitchen daily
3.
Carry out audit on the use and placement of sharp box
Patient
1.
Formation of the Patient Pacification Committee
Pacification
2.
Study on staff attitude in the use of physical restraints and assess for
(Restraint)
any knowledge gaps

3.
Develop e-learning website for modern concepts in using Physical and

chemical Restraints
4.
Conduct NTWC forum on safe use of physical restraints
113
Committees
Medication Safety 1.
Promotion of medication safety by printing of high risk medication

label for top-up cupboard, IV bottle opening and expiry label,
education booklets
2.
Pilot programs for introducing preset Heparinized syringes for arterial

blood sampling.
3.
Introduce magnifying glass to staff for reading small but important

information printed on label of drug ampoule.
Decontamination
1.
Promotion on safe use of cidex and cidex-OPA
Safety
2.
Carry out audit on the quality and completion rate of the scheduled
PM and/or functional test of various sterilization and disinfection
equipment
Fall
1.
Staff education on Morse Fall Assessment Scale by developing an

e-learning course
2.
Promote patient empowerment in fall prevention by developing a

video patient education program
3.
Provide yellow vest to patient for easy identification of patients with

high falls risk
4.
Carry out audit on Falls screening
114
3. Risk Reduction and Quality Programs

3.1.1 Prevention of Patient Scald during baby bathing
In view of a serious incident related to scald of baby during bathing happened in another
hospital in March 2010, TMH has taken a proactive approach for checking the temperature of all
hot water outlets in the Paediatrics and Post-natal wards.
After consulting the EMSD and
Infection Control team, mixers of water tap with temperature regulators that set at below 40
were installed immediately to all water outlets in these two departments to prevent accidental scald
by improper manual mixing of hot and cold water in ward.
Besides, safe practices of water
temperature testing by staff elbow or digital thermometer were also reinforced in these units.
3.1.2 RFID Wireless Body Temperature Monitoring System

In September 2010, TMH had installed an advanced body temperature monitoring system in
the isolation ward system by using Radio-frequency Identification (RFID) technology. This system
not only could promote patient comfort by reducing the disturbance to patient due to frequent
temperature taking but also saved the time and reduced the risk of infection to nursing staff. With
the introduction of this system, at least 3 minutes could be saved per temperature taking due to the
elimination of bedside body temperature taking, manual charting and hand washing before and after
entering the isolation rooms.
115
3.1.3 RFID Body Identification System in Mortuary

In March 2011, Tuen Mun Hospital has also successfully
installed the body identification system by applying RFID
technology in the Mortuary.
This system can improve the
efficiency and reliability in the processes of body identification,

stock taking and tracking of body location within mortuary.
3.1.4 Innovative Audible Drug Label to enhance Medication Safety

In view of some past medication incidents that
were related to the administration of an antibiotic
(Augmentin) to patients with history of allergy to
penicillin, an innovative Audible Drug Label system
is implemented in the satellite pharmacy in POH in
November 2010.
The Audible Drug Label is
powered by replaceable batteries and is installed in the

drawer for the storage of Augmentin. The light
sensor would be activated when the drawer is opened when the nurse taking out the drug, a
10-second alerting note would be played from the speaker. Three key messages are played which
including the drug name (i.e. Augmentin), the antibiotic group (i.e. Penicillin) and a reminder to
confirm patients allergy history before the administration of the drug. Since the implementation
of the Audible Drug Label, the three M&G wards in POH have achieved zero medication error
related to the administration of Augmentin.
3.1.5 NTWC Correct Patient Identification (CPI)
Working Group
The first NTWC Correct Patient Identification Forum was held on 17 March 2011 with a
hundred and fifty attendances from NTWC and other clusters. Representatives from Princess
Margaret Hospital, POH and TMH presented their CPI improvement projects in the forum, which
provided a platform for colleagues to share their achievements and experiences on prevention of
misidentification of patients.
116
In 2010, the working group worked with the HAHO and local Information Technology team to
implement the CMS enhancement function Next Patient Reminder in the AED of TMH and POH.
Staff awareness of the importance to verify patients
identity was heightened. As a result, the reported
incidents of misidentification of patients due to data
entry to the previous patient from CMS has dropped
significantly after the rolling out of this new module.
3.1.6 NTWC Pressure Ulcer Prevention and Management Committee (PUPMC)

Electronic Pressure Ulcer Reporting System (EPURS)
The Cluster PUPMC and the Information Technology Section developed and launched the first
electronic reporting system for pressure ulcer in HA. This system was implemented in most of the
acute and rehabilitation wards in TMH. 8 training workshops were conducted. Over 200 nursing
and clerical staff attended the workshops.
117
Pressure Ulcer Staging Assessment Tool

The Cluster adopted the pressure ulcer staging system from the National
Pressure Ulcer Advisory Panel (NPUAP) and incorporated the staging system
into the EPURS. A cue card with measurement tool was designed and
distributed to every nursing staff in the cluster.
Pressure Ulcer Experts Visit
In order to enhance quality of care and provide expert advices on pressure
ulcer management, the Cluster PUPMC initiated a PU Round.
multi-disciplinary group of experts visit wards to give advices on management of

patients with pressure ulcers. Clinical colleagues welcomed this initiative and
expressed that their advices on managing pressure ulcers are useful.
Pressure Ulcer Certificate Courses

Two levels of certificate courses were formulated and conducted in 2Q and 4Q 2010.
The
aim was to enhance knowledge and skill of our professional staff in management of pressure ulcer.
Over a hundred staff attended the certificate courses. Apart from providing training to professional
staff, the PUPMC also worked with the Cluster HRU team to conduct a lecture on
in the program of 10/11for supporting staff.
3.1.7 Fall Prevention and Management Committee
Annual Fall Prevention and Management Seminar
A seminar on "Effective fall screening and assessment was organized in August 2010.
Distinguished guests were invited to share their life-long expertise in their medical and nursing
management in fall prevention.
Over 100 NTWC colleagues came to this meaningful sharing
event.
118
Standardization of Fall screening in TMH and POH

Morse Fall Assessment Scale has been adopted as the standardized fall screen tool in general
adult wards in TMH and POH.
The standardization was fully implemented in 4Q 2010.
An
e-learning course on the appropriate use of the Morse Fall Scale for NTWC nursing colleagues will
be launched in April 2011.
Reduction of fall risk due to slippery shower trays
Being aware of a potential fall risk of the slippery rim of wet shower trays, the committee
quickly enhanced the alert signage in all shower cubicles in TMH in August 2010.
With the
enhanced signage, no more fall cases related to wet shower trays were reported in 2010/11.
In a
further attempt to reduce this risk, a trial on an anti-slippery spray treatment has been performed in
1Q 2011.
With the positive feedback from the trial ward, a larger scale trial will be planned in
2011/12.
TMH + POH combined annual Fall rate
0.80
0.65
0.62
0.60
0.53
0.40
0.20
0.00
2008/09
2009/10
2010/11
3.2 Quality initiatives, including accreditation

3.2.1 Hospital Accreditation Pilot Scheme
Taking reference from the successful experience of the Hospital Accreditation Pilot Scheme,
the Castle Peak Hospital would participate in the extension phase of the Hospital Accreditation
Scheme.
The Hospital Accreditation Taskforce, chaired by HCE, was set up under the command
of the Cluster Hospital Accreditation Steering Committee.
The taskforce works closely with the
Hospital Clinical Governance Committee and the Hospital Management Committee to ensure
smooth collaboration in the hospitals effort toward a successful accreditation. Same as any work
towards quality and patient safety, hospital accreditation relies much on active support from
frontline colleagues. Staff engagement started early with two introduction and sharing seminars
organized in November 2010.
Colleagues from Tuen Mun Hospital shared the learning points in
their successful accreditation exercise.
An expert from Australia also shared his experience in
119
accreditation in psychiatry.
The seminars were warmly received by a total audience of over 200.
In preparing hospital accreditation in POH, a series of staff training activities, focusing on

engagement and readiness, commenced in November 2010.
3.2.2 Surgical Safety
Study on compliance of Surgical Safety Checklist was conducted on the 2nd and 13th of July
in 2010 at TMH operating theatres.
meeting.
Good practices were shared at the Cluster OT Committee
A workgroup of Surgical Safety Checklist Programme Enhancement in Operating
Theatre was formed in December 2010 to strengthen the good practices and work on the
improvement initiatives.
3.2.3 Surgical Quality and Safety Circle
Continuous quality improvement and ensuring our patients safety is an endeavor of NTWC.
A Surgical Quality and Safety Circle was formed in February 2011, with health care professionals
from different teams and specialties, to ensure clear communication between parties involved in the
management of complicated surgical patients and to improve the co-ordination between various
specialists involved in the care pathway.
3.2.4 Clinical Audit Committee
Clinical Audit Conference was held on 9 July 2010, 36 abstracts were collected and 8 team
leaders have presented their projects. More than 200 attendants participated in the event and
suggested many invaluable comments. It was followed by six regular clinical audit sharing sessions
with the contribution from 11 departments including P&O, Psychiatry, Pharmacy, Surgery, A&E,
Anaes &IC, Dietitian, Diagnostic Radiology, ENT, M&G and Neurosurgery. The Q&S Division has
also initiated a process audit by reviewing the timeliness on performing initial patient assessment,
447 patient records across the department of GYN, NEU, ORT and SUR were studied in 3Q 2010.
3.2.5 Laser Safety Committee
In July 2010, the Cluster Laser Safety Committee was set up and the
first Cluster Policy on Laser Safety was endorsed. Staff training and
credentialing for users and assistants were formulated. Asset record for
Laser equipments (Class 3B or above) was developed and would be updated
regularly for better management. A new mechanism for purchasing class 3B
or above laser equipments was developed and trial run of this mechanism
was commenced in 1Q 2011.
120
3.2.6 Patient Focus Group

The cluster also committed in providing quality patient services from the eyes of patients.
In
2010, NTWC had further organized the Patient Focus Groups for the families of Paediatric patients
in TMH, the ethnic minorities patients who attended POH AED regularly as well as the outpatients
who attending mental health specialist clinics in CPH.
Valuable opinions were solicited.
Improvement measures were taken accordingly, which included the provision of comfortable chairs
for parents who wished to stay overnight with the young patients, and more information about the
consultation process in different languages for ethnic minority patients who were waiting for
consultation.
3.2.7 Integrated Patient Care Plans

In 2010, four patient care programs have joined the Dendrite
Clinical Audit Database.
They include the management of breast
cancer, colorectal cancer, upper GI cancer and urology disease

program. Process and outcome data were retrieved and analyzed to
identify gaps proactively.
Care program for ST elevated
myocardial infarction patients are also planned fundamentally and

the structured database for data collection has been developed in cluster
web. Patient education booklets for breast cancer management program were launched and
distributed to the concerned clients in 2Q10.
3.2.8 Cluster Procedural Sedation Safety Committee
With an aim to ensure patient safety in receiving procedural
sedation, the TOR and policy on the captioned were well
developed and fully implemented in July 2010.
E-learning
system for nurses and credentialing workshops were formulated for
121
staff enhancement. The training curriculum was set up by

the panel which was collaborated with Hong Kong College
of Anaesthesiologists. Two identical train the trainer
workshops were conducted in May and June 2010 for
preparing subsequent safe sedation workshops to our
medical staff. Fifty-four medical and nursing staff were
trained as the trainers.
Seventeen credentialing workshops were conducted in 4Q 2010 and 1Q 2011, a total number
of 252 medical staff from various departments including A&E, DR&NM, M&G, NEURO, O&T,
Paed and SURG passed the sedation training and have the privilege to conduct sedation to patients
who are undergoing selected procedures. The on-going credentialing workshops will be conducted
in Jul and Jan yearly for the new comers or those missed the previous training.
We expected that 70% of nurses who are working in the department of A&E, DR&NM, M&G,
NEURO, O&T, Paed and SURG would undergo E learning in 2Q 2011 and achieved 90% in 3Q
2011. The complication reporting mechanism was established. The checklist for procedural
sedation was used and the significant incident/complication will be reported monthly. The case
study will be shared in the committee meeting. Some departmental guidelines on patient discharge
and information sheet to the discharged patient will be standardized.
3.2.9 Pain Management Committee
Guidelines on Use of Opioids, Cancer Pain Management, Postoperative
Pain Management in Adults were endorsed and adopt for cluster use in August
2010. E-learning system for nurses was developed and has been incorporated in
HAHOs eLC in 1Q 2011. Nursing Forum for introduction of Pain Resources
Nurses Recognition Program will be held in 2Q 2011 and workshop on the Interventional Pain
Management would be held in 2Q 2011.
3.2.10 Patient Pacification Committee (PPC)
The PPC was established in December 2010, which was chaired by
Deputy Service Director (Q&S), with members come from different
specialties in the cluster. The committee would review guideline and
observation chart as well as develop KPI for monitoring physical use in
the cluster.
Meanwhile, a survey on the changing staff attitude for
physical restraint use as well as a pilot programme for new designed

restrainer would be carried out.
122
3.2.11 Patient Opinion Survey at Tuen Mun Mental Health Centre (TMMHC)
An opinion survey was conducted at TMMHC on 10 June 2010 for obtaining feedbacks from
service users on the new registration and queuing system implemented in November 2009.
The
survey also helped to collect our clients opinion on their preferred time slot for registration. The
overall response rate was 45%. 66% of respondents had a general impression that the new system
was excellent or good with 82% respondents commented that the queue discipline was better or
much better. However, improvements were required for waiting time for drug collection (only 41%
reported a shortened waiting time) and time spent on direct medical consultation (only 25%
reported a longer consultation session).
For the preferred time slot for consultation, the result of this survey showed that any clients
may have their own reasons to prefer a specific time slot no matter they need to work or not.
Actually, there was higher percentage of those not at work (91%) than those at work (83%) who had
chosen a specific preferred time slot.
All comments collected would be served as a reference where further improvement programs
would be based. The results had been presented to the HGC in March 2011.
3.2.12 Patient Satisfaction Survey (PSS) in CPH
The PSS was launched to better understand patients experience and perspectives in their
journey of recovery. Aiming at maintaining neutrality, the study was conducted in collaboration
with the department of Sociology and Social Policies, Lingnan University for the design of the
survey and analysis of data. In view of the lack of a validated and scientifically sound instrument in
studying patients satisfaction within the context of psychiatric service, a research team was set up.
In December 2010 the Perception of Care, Chinese version was developed, and the result
was accepted for presentation at The International Society for Quality in Health Care. After the
123
Hospital Clinical Governance Committee (HCGC) was formed in March 2011, the Clinical
Incidence and User Experience Pillar developed a mechanism for structured collection and
monitoring of patient feedback from different aspects of services using scientific methodologies.
The aim was to deploy quality improvement plans by annual review of the satisfaction indices. This
also allows future benchmarking between different psychiatric units.
3.2.13 Major Kaizen Initiatives in CPH
Queue Display Management System (QDMS)
The QDMS has been put into service since 17 January 2011 after a preparation of more than
one and a half year, patients now know about the real time situation of the individual consultation
room, so they can choose to go to other area of TMMHC instead of crowding the waiting hall.
Moreover, doctors or other user of the consultation room can have more information of the
condition of the queue, including the number of the patients registered and the identity of next
patient.
Satellite Pharmacy Room
A pilot Satellite Pharmacy Room was established in July 2010 with a view to optimize
medication inventory management, so that resources could be saved, and possibly minimize the
occurrence of medication incidents.
Project Submissions
Nine projects with very good quality and high service impact were submitted to Conferences
in 2010 and 2011, they included queue management in Pharmacy, QDMS, satellite pharmacy room,
follow-up appointment booking and paperless medical record forms management.
124
4. Learning and Sharing Information
4.1 Leadership Safety Walkrounds

NTWC had engaged a Patient Safety consultant, Dr. Allan Frankel, to demonstrate the key
characteristics of Leadership Safety Walkrounds in November 2010 for OT and HDU in POH.
Clinical staff were more receptive to the walkrounds with the Executive Team by sharing and
discussion on patient safety issues.
4.2 Annual Quality Conference

In 2010, the cluster had received more than forty quality improvement projects that joined
NTWC best quality projects competition. Following the successful 2009 NTWC Quality
Conference, the cluster continued to organize a two-day Annual Quality Conference in November
2010 with great accomplishment. Three pre-conference workshops and three renowned keynote
speakers including the Vice-chancellor of CUHK, Chairperson of Alliance for PatientsMutual Help
Organisation, and the President of the Youth Foundation had attracted more than 500 staff to share
their life experience and achieved the theme of the Conference Enrich the Soul, Excel in Action.
125
4.3 Sharing forums on Hospital Patient Safety Rounds (HPSR)

We had successfully conducted 10 HPSRs in cluster from March to July. In order to promote
patient safety culture, sharing of good practices observed and work together for other observations.
In Jul, two forums were organized for sharing some observations and recommendations/
improvement measures made during and after the HPSR.
CCGC members had invited in Panel
Discussion. Over 180 staff of TMH and POH attended the forum and exchanged their invaluable
views.
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4.4 NTWC Safe Clinical Practice Bulletin

The monthly bulletin was launched since
March 2011 to share with clinical staff on the
learning points of different clinical cases locally
and internationally. Senior staff of respective specialty was invited to express their comments on
each case. The topics shared in the bulletin include speak-up culture, readiness of handwriting and
clinical practice of tracheostomy.
The bulletin was uploaded to the Q&S Divisions website for
wider accessibility.
4.5 Radiation Safety Forum

With the aim to advise clinical departments on radiation safety matter, a
Radiation Safety Forum was held on 10 August 2010 with 140 participants
attended.
126
4.6 Complaint and Incident Sharing Sessions

In order to enhance communication and complaint management skills for our frontline staff,
Complaint and Incident Sharing Sessions were held at TMH, POH and CPH.
Doctors, nurses,
allied health professionals and frontline supporting staff from various departments were our target
audience.
The sharing session was a treasurable opportunity for Patient Relations and Safety Officers
and patient safety and quality improvement team staff to meet the frontline clinical and supporting
staff.
This sharing session served as a chance to build up rapport for PRO and PSO with staff of
different departments.
There were 6 sharing sessions were held in NTWC from April 2010 to
March 2011.
4.7 Practical Communication Skill Workshops

SM(PR&E) supported the Cluster Human Resources Department by introducing practical
communication skill and conflict management skills in Orientation Programmes for newly recruited
doctors and frontline staff.
Deputy SD(Q&S) also shared with the new residents on how to
communicate with patients relatives effectively.
4.8 End-of-Life Care Symposium

A whole day End-of-Life Care Symposium was held in June 2010. The members of the
organizing committee include our Patient Relations Officer and the doctor representatives from
Paediatrics & Adolescent Medicine, Medicine & Geriatric and Clinical Oncology.
Apart from
inviting our doctors and nurses to share their valuable experience in End-of-life care, we had also
invited some University professors, a social worker from St. James Settlement and a
nurse-in-charge of Childrens Cancer Foundation Respite Care & Rehabilitation Centre for sharing.
Patient Relations Officer had presented the topic of Care of Relatives for the Dying Patient.
127
Copyright Hospital Authority, 2012
Published by the Patient Safety and Risk Management Department

Hospital Authority
Hong Kong
February 2012
Available from www.ha.org.hk/visitor
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Hospital Authority

Quality And Risk Management

We would also like to thank them for their

contributions in the risk mitigation strategies and programmes.

Patient Safety and Risk Management Department

Head Office Chapter

Hong Kong East Cluster Chapter

Dr. SF Lui, Consultant (Q&S), HAHO

1. Structure & Initiatives

In the last year, both Quality

Partnering with the Australian Council on

Healthcare Standards (ACHS), HA continued the Pilot Scheme of Hospital

Five public hospitals

safe practices and environment.

They are part of the Hong Kong

This HA-wide database on quality

The first issue of Quality Times, a periodic

publication on quality initiatives in HA, was launched in Feb 2010.

4-monthly publication is aimed at enhancing communication through sharing

1.2 Access Management

For specialist outpatient service, the electronic referral system

The patterns of referrals were

Prioritization guidelines were developed to

1.3 Clinical Measurement

1.4 Unique Patient Identification (UPI)

It planned to roll-out its application to all HA hospitals

1.5 Surgical Safety

The phase III of Surgical Safety

1.6 Patient Safety Round

The training comprised a one day forum and

1.7 Revamp of Advanced Incident Reporting System (AIRS)

This new version would be simple, user-friendly

and easy for reporting and is named as AIRS 3.

The AIRS 3 has added a new feature of

Prototypes testing were

conducted prior to pilot in clusters by November 2011.

1.8 Crew Resource Management (CRM)

An advisory group under the Central Committee on Quality & Safety;

Registration of SUD reused in HA;

Requirement for hospitals to develop a reprocessing protocol; and

The challenge is to draw together the lessons learnt and to continue

implementing measures to reduce the reuse of SUD including the followings:

Ensuring registration data of SUD is accurate, complete and consistent;

Providing feedback to clusters to ensure consistency in the type of devices reused

Establishing guiding principles in the registration and funding of SUD;

Exploring better options in improved procurement of SUD.

Structure & Initiatives

1.1 Engaging Clinical Leaders

1.2 Hospital Accreditation

1.3 Crew Resource Management (CRM)

By March 2011, over 1,400 doctors and nurses

Multiple channels and media are being used in the

promulgation, including a CRM Gallery, an intranet webpage as well as distribution of useful

1.4 Correct Patient Identification

The Campaign promoted the use of at least two

1.5 Prevention of Patient Suicide

HKEC has been invited to share the experience in

various safety seminars after the HA Convention.

1.6 Surgical Safety