Cambodia Situation on Patient Safety Dr. Sok Po Deputy Director Hospital Services Department In Charge of Quality Improvement Ministry of Health

GEO- SOCIO DEMOGRAPHY OF THE KINGDOM OF CAMBODIA GEOGRAPHY - Location : South-east Asia - Surface area : 181,035Km2 - Border : Vietnam, Laos, Thailand - Administration : 25 Provinces/Cities - Capital : Phnom Penh - Language : Khmer Religion : Buddhism 90% - Climate : Tropical climate (Rainy/Dry Season) THAILAND LOA PDR Pailin Battambang Banteay MeanChey Udor Meanchey Siem Reap Pursat Kg. Chhang Sihanouk Ville Kampot Kep Kandal Kg. Speu Kg. Cham Svey Rieng Prey Veng Kratie Mondul Kiri Rattanakiri Steung Treng Kg. Thom Preah Vihear Takeo Koh Kong Gulf of THAILAND VIETNAM

Operational District (OD): A Referral hospital and HCs Overview of Government Health Care System Central Level Provincial Level Operational District (OD): A Referral hospital and HCs Ministry of Health University Health Science Nat’l. programs Nat’l. hospitals Nat’l. Institute for PH… Provincial Health Dept. Regional Training Centers: (4 Kg. Cham, Battambang, Steung Traeng & Kampot ) The OD is the most peripheral and sub-unit within the health system closest to the population which consist of health centers and a referral hospital. 3

Policy and National Initiative to Improve Patient Safety QI roadmap Accreditation for health care facilities in 2015

National Policy for Quality in Health Oct 2005 Six strategies: Empowering consumer Institutional Management Clinical Practice Professional Development Management Development Institutionalization of Quality

Road map for Quality Improvement, Oct 2006

Health Strategic Plan 2008-2015 Chapter 1, Policy Direction no.5: “Reinforce health legislation, professional ethics and code of conduct, and strengthen regulatory mechanisms, including for the production and distribution of pharmaceuticals, drug quality control, cosmetics, food safety and hygiene, to protect providers and consumers’ rights and their health.

Health Strategic Plan 2008-2015 Chapter 1, Policy Direction no.6: “Improve quality in service delivery and management through establishment of and compliance with the national protocols, clinical practice guidelines and quality standards, in particular establishment of accreditation systems.”

Master Plan for Quality Improvement in Health 2010-2015 Activities Monitor client satisfaction in public health service through regular client surveys; and improved communication and coordination between health facilities and Health Centre Management Committees (HCMC), VHSGs, Health Equity Fund implementers, health insurance agencies or HI committee and Commune Councils.

Activities on Patient Safety Ministry of Health, with technical assistance from WHO, developed the 'Clinical pathway for safe surgical care' (2013) based on WHO Surgical Safety Checklist local advisory group (Cambodian surgeons, anesthetists, nurses and Cambodian Society of Surgery) participated Pilot tests (Nov 2012 – Jan 2013) Rolled out nationwide to all national and provincial level hospitals with operating theaters (Feb 2013)

Results 33 (67.3%) hospitals routinely use clinical pathway Provincial hospitals generally showed higher utilization rate compared to national hospitals National Hospitals Provincial Hospitals Total Number of hospitals visited 6 43 49 Number of hospitals currently using the CP 4 (66.7%) 29 (67.4%) 33 (67.3%)

Results Routine use of clinical pathway contributes to a decrease in surgical complications Data from 4 National hospitals Before After Number of cases reviewed 112 117 Post-surgical complications Overall complication rate 13 (11.6%) 3 (2.6%) Surgical site infection 1 (0.9%) Fever after surgery 12 (10.7%) 2 (1.7%) Data from 2 pilot test hospitals Before (July-Oct, 2012) During pilot test (Nov2012 – Jan 2013) After (Mar-Apr 2014) Number of cases reviewed 100 177 50 Post-surgical complications Overall complication rate 20 (20.0%) 4 (2.3%) 1 (2.0%) Surgical site infection 16 (16.0%) 3 (1.7%) 0 (0.0%) Unplanned blood transfusion 2 (2.0%)

Results Staff agreed that the clinical pathway: improved the safety of patients Improved communication among the surgery team National Hospitals Provincial Hospitals Total Number of staff interviewed 57 192 249 CP is easy to use 53 (93.0%) 173 (90.1%) 226 (90.8%) CP improves the safety of patients who have operations 57 (100.0%) 173 (90.0%) 230 (92.3%) CP improves communications among the operation team CP should continue to be used in this hospital I experience some difficulties when using the CP 11 (19.3%) 11 (6.4%) 22 (8.8%)

Results Staff’s reception of clinical pathway is higher in pilot test hospitals where more intensive staff training was provided Data from 2 pilot test hospitals Before Nov-Dec 2012 After Mar-Apr 2014 Number of staff interviewed 69 20 CP is easy to use 64 (92.7%) 20 (100.0%) CP does not take long time to complete CP improves the safety of patients who have operations 68 (98.5%) CP improves communications among the operation team CP should continue to be used in this hospital 69 (100%)

Results “What do you think is the most important factor for sustainable use of the clinical pathway?”

Difficulties faced by hospitals in using the clinical pathway Insufficient understanding of the clinical pathway Lack of cooperation and coordination among staff and teams Lack of staff (esp. anesthetists) Lack of commitment from senior staff Lack of guidance materials and information sources Recommendations by hospitals for better use of clinical pathway On-site staff training on proper usage of the clinical pathway Refreshment courses for trainers Monitoring, coaching and follow-up by MoH or other recognized body (e.g. professional societies, universities) Continuous medical training on patient safety in general

Recommendations by hospitals for better use of clinical pathway On-site staff training on proper usage of the clinical pathway Refreshment courses for trainers Monitoring, coaching and follow-up by MoH or other recognized body (e.g. professional societies, universities) Continuous medical training on patient safety in general

Activities on Patient Safety Infection Prevention and Control (IPC) National Strategy Plan for IPC (2011-2015) Policy on Infection Control

Activities on Patient Safety Infection Prevention & Control Guideline IPC Curriculum for training

Challenges Lack of guidance materials and information sources on Patient Safety There is no training on patient safety in general Health care provider fear to report on medical error

E-mail: soksrun@camnet.com.kh Thank You For your Attention 25 Oct 2002 E-mail: soksrun@camnet.com.kh