Findings of first review of health care chain released

PHILIPSBURG–Some of the findings of the first review conducted of the country’s health care chain were released in a press release issued by the Cabinet of Health Minister Emil Lee on Thursday.

Lee had engaged the services of Everard van Kemenade, a quality and management auditor, to review the healthcare chain, in keeping with the minister’s goal to have an integrated healthcare system where stakeholders work together, dialogue and synchronize their efforts to deliver “the best quality and affordable healthcare.” Lee began this process with governmental organisations that interact with St. Maarten Medical Center (SMMC) and SMMC itself.

The minister said in a lengthy press release that the procedure to establish qualified specialists that meet the country’s legal standards is a very big challenge for SMMC. As a result, first in the review process was how the Public Health Department evaluates specialists and the amount of time it takes for the Department to process and approve new specialists who want to practice in St. Maarten.

“It has happened on more than one occasion that a specialist has been identified by the SMMC and the processing time has resulted in the doctor finding other employment,” Lee said in the release. “On the other hand, time is required for this review process as it is the responsibility of the Public Health Department to ensure that the advice given to the Minister for medical professionals establishing themselves in St. Maarten meets the standards of the Netherlands in education and training as stipulated by law.”

He said steps are already being taken to improve the specialist establishment process and the results of that process. An action plan from the present through 2019 is in place. Among the short term measures being looked at are accrediting degrees obtained from non-Dutch institutions whose curricula and content are at the least equal to that of the Netherlands. An exchange of specialists between St. Maarten, Curaçao and Aruba is also being investigated.

Differences in interpretation of regulations between the Inspectorate of Health and SMMC over the years have resulted in disagreements that have slowed progress. The auditor found that the Health Inspectorate is “highly motivated and committed” to the quality of healthcare.

The last major audit by the Inspectorate was carried out in 2012 which resulted in 36 areas of improvement identified. Van Kemenade notes that SMMC is making progress on compliance with the Inspectorate’s evaluations. The Inspectorate will conduct a fresh audit of SMMC to assess this and further evaluate the current situation.

The auditor also found a number of areas for SMMC to improve its quality management systems. This is the same process that all quality hospitals worldwide have to do on a regular basis it was stated in the release. The audit was performed to be able to identify the specific areas for improvement in SMMC’s quality management system in a constructive manner. In the report these areas have been identified and are combined with specific recommendations for action to be taken, the release said.

“What is encouraging is that the SMMC has fully embraced all recommendations to improve its procedures and the Health Inspectorate is also in agreement with this plan of action. Some of the areas of the needed quality improvements had already been started at the time of the audit. SMMC has employed a full-time quality control manager,” the release said.

“SMMC has all the committees required by law and is quite proud of its low infections rate, but it can also be noted that not all committees function optimally and that certain data is lacking due to IT [Information Technology] challenges. The IT upgrade being undertaken by the SMMC is robust and should meet the quality and data standards.”

The release said also that SMMC is in a state of transition as it has embarked on the human development to match the new hospital building development. The auditor found that SMMC has made strides on the action points from the Health Inspectorate’s 2012 audit, which has not yet been completed partially due to structural budget problems that were realistically solved last year. “This financial improvement of the SMMC has allowed renewed progress on quality management issues; the SMMC has now made the commitment to receive JCI [Joint Commission International] accreditation in approximately four years. Both Aruba and Curaçao hospitals have also made this same commitment.”

The renewed quality management with the aim of JCI accreditation involves improving both people and system capacities and will require also the new facilities to be built with the new hospital building. SMMC Management” realises this is an ambitious undertaking as JCI has over 1,000 procedures that must be verified and certified and is making a presentation for both the staff of the SMMC and the Ministry of VSA with a trajectory and timelines.”

According to the release, the research question of the assessment has been: how can the Ministry increase the effectiveness and efficiency of the process for exemption of federal ordinance restricting the establishment of medical professionals. This assessment took three days and consisted of desk research and the topic was raised in six interviews.

Areas for improvement that were identified include having a list of approved universities in the future. If the applicant does not have a diploma from those universities, their application must have a proper assessment track. The Ministry of Health says Public Health has been actively engaged in the first part with an initial list of universities and needs to develop effective strategies for the second.

It was recommended that the draft medical professional registration and regulation system BIG be implemented soonest. The release says this legal process must follow normal creation rules and will take some time before implementation is possible so in the meantime Public Health will design a list of approved universities. “This process has already begun with the drafting of the medical registration system and can be jump started in the near term. My suggestion is to have with high priority e.g. people from the Council, Public Health and the hospital sit together and make a draft of such a list, that then can be presented to the Inspectorate, decided upon, and used until the St. Maarten registration is installed,” Lee said.

Other recommendations include SMMC recruiting staff, who comply with qualifications; that control is done by Public Health on completeness of the application; by the Council on needs assessment and study and competency. Thereafter the Head of Public Health, mandated by the Secretary-General, sends the advice to the Minister. Thereafter the oath can be taken, prior to starting the immigration process.

According to the release, the Inspectorate acknowledges that JCI accreditation and other standards most of the time are very alike and that JCI provides lots of necessary prerequisites (like documents, protocols) for any other standard system. There is a need for certain standards to be set within the boundaries of the law. The Inspectorate is not legally bound by the quality standards put in place by the hospital, but having one would facilitate the work of the Inspectorate.

The Ministry said the Minister is in favour of having standards set. SMMC with support of hospitals in Aruba and Curaçao will pool resources and talent to propose standards that meet international levels in a manner appropriate to the Caribbean. The goal is to have these standards consistent throughout the three island countries of the Kingdom and approved by the Health Inspectorates of each country.

In 2012, the Inspectorate of Health in St. Maarten did an inspection of SMMC, using Dutch standards. They reported 38 non-compliances. SMMC has worked since then on improvements. From 2013 to 2016, financial constraints limited the progress enormously. The focus was on the direct care and on survival. The financial situation now seems to have improved. That gives the hospital the opportunity to move on energetically towards the desired quality, the release said.

“There is a hospital vision, but needs to be described explicitly and more elaborate. The hospital has a Strategic Business plan, 4.0 and a Year Plan for 2017. The strategic planning process needs to be cascaded to the departments, teams and individuals and must be consistent throughout. The hospital is creating a: Vision 2020. It should be a shared vision, based on discussion with all staff.”

Also, there is a Quality Management Development Process, dated February 2015. There is a vision specifically on the Quality Management structure, not written down: This is now being completely documented by the new Quality Management Director.

The instalment of a Quality Bureau expanded from the current one to three members is being implemented; the instalment of two internal auditors: one on Quality, one on Finances. The organisational structure will be changed, where quality will be the main responsibility of the General Director and both units will directly report to him. Three lines regarding the vision on quality will be started. Central is the objective to get JCI accredited.

The ministry said Dutch standards will be evaluated for their use in St. Maarten, Aruba and Curaçao and used where they support the JCI standards that all three islands have embraced as the goal for quality. “Strategic alliances with such institutions as Erasmus University Hospital will provide visitations by medical specialists that will also support the JCI standards. For the JCI process an external soundboard group will be formed.”

SMMC has begun writing a JCI action plan and implementing it as the numerous sections are completed. SMMC has also started projects for improvement. A main project throughout the hospital provides protocols, procedures and guidelines for staffers. A working group chaired by the Quality Care and Safety Officer coordinates these activities. A special project is working on medication management with support of a former pharmacist. A risk analysis to prioritize the protocols and procedures is needed. Hand hygiene protocol is practiced. Time out procedure is executed. The dialysis department as an example made an important quality step forwards.

   Patient files are also digitalized and the system works, although it needs to be finished for use by all doctors and adjusted due to the first experiences, the release said. There are staff files and there is a performance appraisal system in place. Medical staff are to be included.

There is also a patient satisfaction measurement system and data is collected. The software programme does not work well as it was purchased via a third party vendor. The ministry said this is being remedied by the IT department in conjunction with the company that developed the software.

A committee is also in place, but few incidents are reported. The audit says there must be more medication errors than reported as happens in all hospitals. The recommendation is to provide leadership training on creating a safe and fearless environment for staff, and increase communication from management to all staff and vice versa.

The report says SMMC needs to share and discuss the implicit vision on the future within the organization; SMMC needs to be clear on the path towards JCI; a feasible action plan with a clear focus on JCI needs to be produced before June 1; from that moment on, step by step SMMC can be held accountable for the realization of its steps towards JCI accreditation.

Also SMMC needs to show it can improve. Constructive meetings with the Inspectorate on the real progress of the 2012 non-compliances would be the best start. Furthermore, the hospital reports every month to the Ministry in a meeting the progress on the milestones as mentioned in the action plans. Later this can be bi-monthly meetings.

Source: The Daily Herald