Since the establishment of the Quality Assurance and Standardisation Division (QASD) at the national referral hospital in Thimphu in March 2017, the office has to date recorded 60 incidences, including near miss incidents.

Near miss incidents are those that have not resulted in damage or harm to the patient but have the potential to do so.

QASD’s officiating chief programme officer, Jigme Choden, said the office maintains an incident database. “We record all the incidents including the near miss cases to prevent serious and fatal incidents.”

With the institution of the incidence reporting policy, it mandates any incidence to be be notified and reported to the QASD within 24 hours.

Jigme Choden said each incident is analysed for human errors that may have occurred in patient care and any organisational issues that might have contributed to the incident.

The incident has to be reported to the concerned in-charge who will report it to the head of the department. A team is formed to investigate the incident and to recommend corrective measures.

The final report is submitted to the QASD. All incidents that are reported to the office are discussed by the Quality Management Committee, which has 12 members including representatives from departments.

She said the findings of the investigation are also shared with the caregivers and the head of departments involved in the incidents to implement corrective actions.

The office debriefs the staff and monitors implementation of suggested corrective actions in the concerned departments.

QASD was established to enhance the quality of services at the hospital.

With financial support from the health ministry, the QASD recently coordinated a four-day meeting in Paro where 16 clinical departments and six divisions under the administrative and finance division including the QASD office shared and reviewed its Standard Operating Procedures (SoP).

About 55 participants including officials from the quality assurance division at the health ministry and Bhutan Medical Health Council participated in the meeting where more than 200 SoPs were endorsed.

Jigme Choden said that earlier, most of the standards were in the guideline form but it is now converted into SoPs format where objectives, procedures and responsibilities are clear.

JDWNRH’s director, Tshering Yangden, said several departments at the hospital had developed SoPs several years ago. By the end of this month, all the departments will have their SoPs reviewed and finalised.

The Royal Audit Authority’s performance audit on the delivery of OPD (out-patient department) services at JDWNRH in August 2017 pointed out that although the hospital has separate SoPs for each department, they were not comprehensive enough to carry out its mandate.

The report found that the staff lacked awareness and knowledge on the existing SoPs. The RAA had recommended the hospital to develop comprehensive SoPs and create awareness among the staff.

Currently, 10 hospitals including two regional referral hospitals and the national referral hospital are implementing the Bhutan Healthcare Standard for Quality Assurance (BHSQA).

Jigme Choden said the standard has ten chapters, which include care of patients and continuous quality improvement.

She pointed out that most of the reported errors occurred because there was no consistency due to a variant in practice by health staff, and lack of communication. “The SoPs are aimed at improving the coordination,” she said. “We have people working in the hospital who have studied and practised in different countries so there are some variants in the procedures of treatment though the principle of treatment remains the same.”

Similarly, for admissions and discharge of patients, different procedures are used. For instance, some doctors write advice note on the discharge form while some don’t.

She said the SoPs have the procedures in detail and it is a guide to the hospital’s routine work so that they practice in a uniform manner with less variance. “SOPs will make the individual responsible and accountable for their action. Roles of each staff are spelt out.”

The SoPs are expected to improve the overall quality, efficiency and also maintain professionalism in the hospital. The SoPs will be reviewed every three years.

Jigme Choden said the hospital already has a guideline for patient safety and the hospital will be using it. “We don’t have a separate SoP for patient attendant’s safety because we are more focused on patient safety.”

However, she said every incident is a lesson for them. After the recent incident of the aesthetician technician’s case, the nursing department has come up with a procedure to handle calls during night shifts and to verify any calls or information asked about an attendant.

Tshering Yangden said having SoPs in place cannot guarantee 100 percent safety and efficiency in delivering services. However, she said it will enhance patient safety, efficiency in delivering services and reduce wastage of resources if the SoPs are implemented effectively.

It will also strengthen accountability among the staff, she added. “The effectiveness of the SoPs will depend on the monitoring and support services provided by the heads of the departments and individuals.”

Dechen Tshomo