Innovation case study – Bronze Prize winning submission by Tawam Hospital during 3rd Continual Improvement & Innovation Symposium organized by Dubai Quality Group's Continual Improvement Subgroup to celebrate World Quality Day 2011.

1. Innovative Approaches in
JCIA Training
Tawam Hospital in Affiliation with Johns Hopkins
International

2. About Tawam Hospital
• 477-bed tertiary hospital in Al Ain
• Highly specialized and well trained doctors and
nurses.
• In affiliation with Johns Hopkins Medicine from 2006
• JCI accredited since 2006 and reaccredited in 2009.
• Recognized as Baby Friendly Hospital.
• An educational hospital and training center for
faculty of medicine and health sciences- UAE
University

3. Mission Vision & Values
• Mission:
To provide a continuum of quality health care which meets the needs and
expectations of the UAE population and the surrounding GCC countries.
Vision:
Tawam Hospital believes in treating all Patients, Visitors and Employees
with Respect, Dignity and Equality, guided by UAE laws and respect for
patients' rights.
Values:
Tawam Hospital will provide high quality, affordable medical services
delivered in a friendly, safe and caring environment which meets JCIA
Standards of Care.

4. Team Members
• Dr. Mahyar Sadeghi , Chair Dental Center
• Azhar Atlal , Pharmacist
• Dr. Manjula Duhan, Dentist
• Sumaya Al Meqbali, Senior Quality Officer
• Margaret A. Lambert, Senior Risk Officer
• Judy Warren, Infection Control Nurse
• Bachar Mamich, Clerk and Graphic Designer
• Patient Safety Team
• Janelle Quijano, Medication Safety Officer
• Team leader: Mervat Mansour, Section Head , Quality

5. Challenge
A big challenge of educating non interested
staff on important and new topics in a short
period of time

6. How was the Innovative
Approach created?
• Intrinsically motivated multidisciplinary team
– Pharmacist , dentist , nurse , 2 quality officers and
graphic designer
• Given both the tools and the incentives to
produce creative work
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7. Innovation Development-
Preparation
Understanding the problem:
• Low number of attendants for Joint Commission International
Accreditation lectures
• Ineffective traditional lecturing approaches (dissatisfied attendants )
• JCIA Mock Survey results: Areas of concern:
• Incomplete documentation
• Environmental risks
• Incomplete Medication Prescriptions
– Many newly introduced concepts (sentinel events, Patient Safety Goals,
new PPGs )
• Under reporting of incidents
• Loads of new information
11/27/2011 7

8. 4 Phases of Idea Creation ‘
(Wallas, The Art of Thought)
– Preparation
– Incubation
– Illumination
– Verification

9. 4 Phases of Idea Development
(Wallas, The Art of Thought)
– Preparation
– Incubation
– Illumination
– Verification

10. Innovation Development – Preparation &
Information Gathering
• Explored different practices used in other hospitals as
Sheikh Khalifa Medial City , Rashid Hospital and Johns
Hopkins /USA
• Studied attendants feedback from previous training
sessions
• Mock survey results  areas of concern
• Literature reviews for best practices
• Identified stakeholders interests
11/27/2011 10

11. Innovation Development -
Incubation:
• Several meetings were held
• Idea generation techniques used
• Active search, research
• Brainstorm
• Critique
• Role Playing
• Sketching
• Attributes listing
11/27/2011 11

12. Free flow of ideas without deliberate
concentration. The attributes wanted:
• Violate previous approaches, assumptions, and
conventions
• Grasp attendants attention
• Memorable
• Respects adult learning experiences and help them
correlate

13. Illumination
• A flash of light and joy overwhelmed when
innovative ideas have been generated as:
• Lecture- Hall wide snake and ladder game
• Tropical zoo with hanging fruits of knowledge
• House of horror
• Sport games and fun
• Role play as a JCIA assessor for environmental risks and
document review
11/27/2011 13

14. Verification/Evaluation of Ideas
• Anonymous voting
• Cost benefit analysis
• Criteria Weighting Technique
• Objectives Hierarchy
• Prioritization matrix
– Impact
– Ease of implementation
– Attraction
– # of objectives met
– Innovation
Idea Impact Attraction Ease of Objectives Innovation
Implemen met
tation
A
B
11/27/2011 14

15. Strengths/Weakness of the
Approaches Used
Tool Strengths Weaknesses
Allows a large volume of ideas to be generated in a while suspension of judgment and going for quantity is
short period of time. Also strives to ensure all necessary for creative thinking, this is not sufficient
Brainstorming of Mind parties are involved
Brainstorming sessions naively assume that no prior
Showering No ideas are discounted initially (later evaluation preparation is needed
and filtering undertaken)
List pro's and con's.
List actions and reactions.
List strengths and weaknesses.
Subjective, not quantitative
Forced field analysis Compare ideal situations and reality.
Difficulty of change is not identified
In negotiation, compare the perceptions of
opposing parties.
Offers numerical criteria with which to prioritize.
Mathematical process (this is a weakness for some.)
Criteria Weighting Objective; may be best in situations where this is
Can become a prolonged and complicated exercise
competition among the issues. Allows group to
Technique weight criteria differently.

16. People Involvement
• How was the stakeholder buy-in acquired?
– Cross representation from different disciplines
– Stakeholders analysis : needs and expectations
– Sketch drawing of the creative ideas
– Open discussion
– Forced field analysis
– Plan and budget approval

17. Who Sponsored The Project?
• Minimal costs of the sports games < AED 500
• Department Performance Innovation

18. How Concept was Developed
Into A Detailed Plan
• Objectives highlighted and made visible to all.
• Decision tree was depicted
• General theme of “sports day” or fun city
• All possible formats for each topic to be
presented were considered with the
educational topic owner
• Framework drawn , staff flow sketched

19. Process
• How was the feasibility of the solution evaluated?
– Sketch of the workflow
– Simulation
– Role playing
– Breakdown of work activities determine staffing, time and
resources needed

20. Risk Assessment
• FMEA , possible failures were identified and counter measures taken
to prevent:
– Low attendance  Strong marketing plan , prizes, word of the mouth , idea
supporters
– Crowdedness  timed attendance , proper staffing, U-shape flow, clear
instructions
– Physicians resistance : Adult learning techniques and variety of approaches
• Discussion with the senior management
• Piloting on a small number of staff
• Team walk through

21. Implementation
• The training program included 4 parts:
• Clinic Simulation Room and Role Play
• Document Review
• Sports club
• Room of Horror

22. Role Play & Simulation
Room
A simulation room of “A Dental Clinic “ was prepared with all
possible environmental and medication risks.
Playing the role of a JCIA surveyor, the staff has to assess 36
different environmental aspects and safety practices using a
printed checklist for compliance with JCIA requirements.

23. Department of Performance Innovation
Dear Staff ,
Please read the scenario and enter simulated patient room to discover all compliant
and noncompliant areas with the JCIA requirements; Surprises are hidden… Mark
this sheet then check your observations posted on answer sheet. Scenario:
Non
Observation Compliant
compliant
Environment of Care
1 No electric hazards could be identified
2 There is no potential risk of injury for patient or staff
3 Eye wash is available to use when needed
4 Instrument Cabinet is used only for instruments
5 Sharp boxes are correctly utilized , and locked
6 Fire exit is clear and safe to use
Extinguishers are available / ready to use when needed (After you finish the
7
tour , check extinguishers in the waiting area)
Infection Control
8 Red bags are used for medical wastes
9 Black bags are used for non medical, non hazardous wastes
11 Contaminated instruments are properly stored
12 Suction equipments and water lines are flushed through
13 Used single use disposable consumables are disposed properly
14 The patient's room is clean ;body fluid spills are properly cleaned
15 Personal protection equipments, as gloves, are available to use when needed
16 Personal protection equipment, gloves and gowns are available to use when needed
Medication Safety
17 Medications are stored in their specified cabinet/drawer
Medications used for external use are stored separately from those
18
for internal use
19 Dental drug box is appropriate
20 Dangerous abbreviations are not used in the medication prescriptions
21 As needed "PRN" prescriptions are written correctly.
Assessment of Patient
22 Patient is identified correctly
23 "Medical History Form: is filled properly
24 "Medical History Form " is complete
25 Patient pain is assessed and reassessed when needed
Care of Patient /PFR
26 Patients file/information is kept confidential
27 General Consent Form is properly filled
28 Specific Consent Form is properly filled
29 Time out is documented before procedures
30 Treatment Plan is properly filled
31 Name and signature are written for each entry
32 Referral Form is properly filled
33 X- ray is verified for the name and Health Card Number
Patient and Family Education ( PFE)
34 Patient and family needs were assessed and addressed
35 Patient and Family Education Record is multidisciplinary
Name, signature and designation of staff providing the education are
36
documented

24. Part 2 :Document Review
• The simulation room is followed by document review for a
medical file that has copy of real progress notes, x rays and
medication prescriptions with errors ( details of patients and
physician were deleted) = staff identify 10 different errors.
 Learning by doing.

25. Part 3 Mini- Sports Club
– The lecture hall was turned into
a mini-sports club hall for 3
days: 6 different sport games
including basket ball, shooting,
Boling , cricket , darts ,etc
– To participate in each game,
staff has to answers 4- 6
different questions related to
the topic.

26. Part 3 Mini- Sports Club
– The information were
presented in posters , take
away leaflets , question &
answer quizzes , videotapes
broadcasting and JCIA Q&A
booklet.
– “ Fishing your prize” after
finishing all the games.

27. Room of Horror
• Underreporting of incidents: fear of
blame
• 3 incidents only reported in 3
months
• Room of Horror
– Anonymous reporting of
incidents
– Dual objectives: Education about
the 28 different types of error
that should be reported
– Based on Trianti’s Thoery of
constraints
– Analogy: fear of error, ease
when reporting it

28. Trianti’s Theory of
Constraints
• Based on Triantis’ Behavioral Modeling Theory,
probability of behaving in a particular situation is
governed by the following equation:
• Probability of act = [habit + intention *] x [motivation
x facilitating condition]

29. Heinreich’s Ratio1
For each 1 major incident reported , it is expected to have 29 minor injuries and
300 no –injury accidents 2.
 1 Major injury
1
 29 Minor injuries 29
 300 No-injury 300
accidents
1. Heinreich HW Industrial Accident Prevention, NY And London 1941
2. An Organization With a Memory, A report of an expert group on learning from adverse events in the NHS chaired by the
Chief Medical Officer, The Stationary Office, London 2000

30. Room of Horror
• A small room (1m x 1m ) that
has no light
• Covered ceilings with black
textile
• Hanged scary masks
• Played scary music and
sounds
• Provided a small lantern
• “Do you dare to enter?”

31. Room of Horror
• A2 size check sheet of the common incidents with clear instructions on how
to fill and a message: “By reporting Incidents, you Might Save live “We
posted the check sheet in the room.
• At the entrance one staff for instructions
• One staff at a time was allowed to enter.
• In a confidential and exciting way staff reported any accident he/she had
experienced in the last 3 months by ticking the incident/s from a list of
possible incidents that could happen at the Dental Center.

32. Results
• Dazzling results
• 85 % of Dental Center staff attended voluntarily
• Happy and satisfied clients -92% overall staff
satisfaction with the JCIA Fair
• # of reported incidents increased by 125 times
• Idea replicated at Tawam Hospital JCIA Fair and
other satellites
• Substantial increase in documentation compliance
• Reduction in the number of rejected medication
prescriptions

33. Indirect Benefits
• Increased patients and staff safety
• Less medication errors
• Reduction in the number of rejected mediations
prescriptions
• More awareness about environmental risks
• A more realistic estimate of the number of incidents
• Memorable experience
• Satisfied staff

34. Way Forward
• Recognition :
– Party for all staff involved
– Thank you letters
• The idea was replicated in Tawam's
JCIA Fair, simulating a patient room
– Patient had pressure ulcer and
wound scoring was required from
the visitors in addition to
identifying all risks in the room
– More topics included
• No intellectual property, everyone is
encouraged to replicate 

35. Lessons Learnt
Never get afraid of thinking outside the box.
It is always nice to see life from a different
perspective

36. A Final Thought
Innovation is both art and science… It feeds on
big challenges, sharing of information,
collaboration , freedom to explore, and
endless flow of ideas.

37. Q&A

38. Thank you