Safety and Quality to Make Patients Feel "At Home", Hangzhou Women's Hospital Passed JCI survey

Praises from reviewers:

"This is my first time to China. But I feel like at home in your hospital."

"As far as I'm concerned, your hospital is the best among the hospitals which receive their first JCI survey."

"Your medical history filing has been the best during my examination in recent five years."

"I see your promise to the quality of hospital and safety of patients."

"If I were a patient, I will choose your hospital!"

"A good organization shall have both good buildings and talents. I think you hire good staff. I hope that I can still have the chance to come to your hospital on the second review of the hospital in three years."

"We will certainly advise JCI headquarter that you should pass the review."

The above words were praises made by four surveyors (from US, UK, Singapore and India respectively) to all staff of the hospital at the closing ceremony of JCI survey in Reporting Hall (6/F) of Hangzhou Women’s Hospital (Hangzhou Maternity and Child Health Care Hospital) (Hangzhou First People’s Hospital, Hangzhou CBD Hospital on December 16, 2016

At 00:46, December 20, 2016, the hospital received the Survey Report sent by JCI Survey Headquarters from Chicago, US, that our hospital passed JCI Accreditation Survey as the first municipal-level hospital in Hangzhou. Our hospital is also the first hospital specifically for women to pass JCI Accreditation in Zhejiang as the youngest (we take only two years) member in JCI organization.

Joint Commission on Accreditation of Healthcare Organizations (JCI) is used for subordinating authorities of medical organizations outside the US to be accredited. JCI consists of international specialists in medical care, nursing, administration and public policies. JCI Accreditation represents one of highest standards for quality management of hospitals in the world. It takes quality of the hospital and safety of patients as the core on behalf of international level of hospital services and hospital management.  

But what makes the only two-year hospital pass the golden standard JCI that represents the highest level for hospital services and management within only 9-month preparation period? It comes down to the hospital's commitment to medical quality and pursuit to patients' safety, but also the guidance of 'Home" culture of Hangzhou Women's Hospital.

Photo with Surveyors

Move hand disinfection solution "1m" forward

Make health education propaganda services available at beds

"Hello, the pink liquid hanging near the ward door and at the bed is instant hand disinfection solution, the green liquid in the washroom is hand-washing solution. The instant hand disinfection solution and hand-washing solution are provided by the hospital for free. Please wash your hands and get them disinfected frequently so that you and your baby can stay away from infection." The words are common conversations for inpatients of Hangzhou Women's Hospital. Nurses from wards have received standardized trainings and they propaganda normalized health education on public health to each patient.

Currently all hospitals pay great attention to hand hygiene of doctors and put hand-washing solution at the door of wards. But few take hand-washing solution into wards like Hangzhou Women's Hospital and it's also rare to provide free hands-washing solution to patients.

"To lower infection risk of the hospital, prepare well in hands hygiene is the basis" The project 'move hand disinfection solution 1m forward' is to enhance execution rate of hands hygiene. We hope that not only our medical and nursing staff do well in that and we can also pass the theory to patients to improve safety of patients together." ZHOU Hong, head of Hospital Infection Control and Prevention Department told us, "I think the project achieved a lot since its launch. With improved execution rate and great reception from patients, the project will keep on."

Multiple Care & Colletive Teamwork

Full Management

Multiple care & teamwork. In Hangzhou Women's Hospital, you can easily feel the power of cross-team cooperation. Leaders of medical teams, doctors in charge, nutritionists, clinical pharmacists consists a powerful collaboration not only for consultation but for everyday morning rounds of the wards in Hangzhou Women's Hospital. It is our innovative move to let clinic pharmacists and nutritionists make rounds of the wards together to ensure our patients get all-round care.

Doctors encouraged the future moms to consult in Clinic for Maternal Nutrition since they begin to prepare for pregnancy. "The preparation and entire pregnancy period is a very important process as nutrition in mom's body will directly influence the growth and development of babies. So we suggest each quasi mom should go through nutrition consulting. " WANG Xiaohua, chief doctor and principal of the hospital's Nutrition Center said so.

Let clinic pharmacists be part of wards rounds combines multiple consideration of the hospital: firstly, doctors provide direct medication support and use consulting to patients; secondly, train the hospital's clinic pharmacists teams. Medical and medication are inseparable since ancient times and Pharmacy Department has always been considered as one of supporting departments. But pharmacists in Hangzhou Women's Hospital get special treatment.

Full care and management. Pelvic floor screening at 42 days after birth is one of health theories advocated by the hospital. "We pay attention to the health of lifelong pelvic floor of each female." LI Xiangjuan, Vice President and Principal of Hangzhou Pelvic Floor Rehabilitation Center, said. Led by the team of Vice President LI Xiangjuan, the hospital guided to build up three-layer network for Hangzhou Pelvic Health Floor. District or county-level women's health and child care hospitals, community health service centers will send patients to Hangzhou Pelvic Floor Rehabilitation Center of Hangzhou Women's Hospital in case any patient needs pelvic floor rehabilitation or pelvic floor surgery to achieve full care to females.

Smart Mode Everywhere

Workers Competing to Get More Job

Internet of Things Nursing Management System: In this June, tertiary hospitals in Hangzhou decided to stop outpatients' transfusion one after another in order to lower antibiotic abuse and risk of transfusion in Outpatients. However, Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital) decided to shut down the aforesaid service in November 2014, nine months earlier than overall shutdown, for the sake of patients' safety.

One more new customer "Internet of Things Nursing Management System" came into the wards of Hangzhou Women's Hospital. It's a system to enhance working efficiency of nursing staff and guarantee safety of patients. There is a transfusion auto alarm installed near each transfusion bottle. Once the liquid in the bottle is less than the quantity that set by the alarm, the alarm will let out sirens to remind patients and send the reminders to the nursing desk. At that time, nurses will immediately go to the wards to change transfusion bottles for patients.

"We used to feel assured when families were around as we were afraid of falling asleep in the halfway or we didn't notice that our intravenous drip was gone. Now I can do it by myself and still feel so assured." Ms. ZHANG who was having intravenous drip in the transfusion room told us that she had been in the hospital alone and she didn't feel so bad without the company of families.

Smart Transportation of Things of Internet: In Hangzhou Women's Hospital, you will notice QR codes in all floors, Operation Room, Delivery Room and Blood Bank. The official account is not for advertising but the smart Transportation System installed by the hospital to enhance initiative of logistics workers to convey specimens, transfer patients and convey blood products. The workers compete with each other to get more work--The workers scan QC code by phone and calculate work load, and the managers will check the transportation and handlers through backstage in the real time so as to guarantee the timeliness of specimen transportation and safety of specimens.

Mr. WANG who is scanning the QC code is a senior member of the hospital. He came to the hospital at the launch of the hospital. He's very satisfied with the mode :"To work in this way makes us get to know who have done a good job and who have not at the backstage! Doctors and nurses can directly get contact with us at the backstage when they are sometimes in a rush. So it's also very efficient."

Full-round Staff Orientation

No Limitation to "Medical Education"

Each staff member in the hospital gets grasp of cardiopulmonary resuscitation with a pithy formula "Call CAB to be ready to deal with possible danger at any time."

Each staff member in the hospital is in strict accordance with "seven-step washing method" : the palms of the hands, the backs of the hands, narrow space, between the palm of one hand and the back of the other hand, thumbs and fingers against the palm during hands washing. Repeat each step for six times.

Each staff member in the hospital bears "emergency code" in heart: 111 for fire outbreak; 222 for security (violence) outbreak; 333 for poisoning or trauma outbreak, 666 for infants thefts, 999 for emergencies in the hospital.

Each staff member can handle small fire that easy to deal with -- treat as per "RACE" international standard. And each exit has been patrolled and eliminated for obstacles.

Each staff member in Hangzhou Women's Hospital including logistics workers and maternity matrons goes through the hospital's safety cultural trainings, ethnics trainings and hospital quality management trainings, BLS trainings and fire protection trainings, etc. Hangzhou Women's Hospital gave its answers by organizing over 20,000 person-times to attend over 50 members' trainings.

"It's accurate to say that each staff member in our hospital is able to handle emergencies." Vice President CHEN Changgui told the journalist, "In addition, we also pay great attention to emergency drills of the hospital. We holds 72 field simulations this year to enhance adaptability and systematize the procedures. The quality and culture of the hospital stands itself out among homogeneous trainings."

Quality in Every Detail

We Didn't Think Too Much for Doing So

Infants Double Wristbands. A wrist is RMB 2-3 Yuan. Ordinary patients need one and infants need two. Who will pay for the cost? The answer is still the hospital. "Actually we didn't think too much for doing so. What we take into consideration most is the safety of patients." President ZHANG Zhifen laughed. The hospital began to perform health numbers in the hospital: each patient whoever comes to the hospital for treatment has a unique number and medical staff will check health numbers with patients before each medical operation since the hospital determines to get JCI Accreditation. The wristband bears health number and other basic information of patients. "It can avoid any medical accidents caused by duplication of names or different identification numbers in different departments. There are obstacles in the execution of the system especially update of forms and information systems of the hospital. But we have done a great job!" President ZHANG Zhifen said.

Our hospital arranges two wristbands for each newborn as it cannot express itself and it is also for the sake of preventing newborns from losing their wristbands in actions when no care is taken. 

Patients Fall Prevention: If you observe carefully in Hangzhou Women's Hospital, you will see all kinds of reminders of "Caution for Falls!" in nearly every corner and phased place; regardless of emergency or inpatient, nurses conduct a fall prevention evaluation. It's the specialty of patients in the hospital: women and children. There is pretty high risk of fall for pregnant women, postpartum women and infants. The hospital exerts great efforts in evaluation of fall prevention, which also comes down to safety of patients.

LI Haiyan, Director of Nursing Department, says:"It requires great personnel and materials support in fall prevention greatly increasing workload for nurses. But we consider it very worthwhile."

B-ultrasound Coupling Agent Heating. Your experience for B-ultrasound in winter can be described in one word "cold"! With the air-conditioner in the B-ultrasound room, it would not be too cold when you take off clothes, but people will still couldn't help feel cold with shivers once the instrument comes in contact with human body. In our B-ultrasound Room. doctors are quite careful and they will heat the liquid (coupling liquid) for ultrasound. The heated coupling liquid gets close to body temperature so that patients will not feel the freezing thrills when the machine comes into contact with human body during B-ultrasound process.

"Now there are more than half hospitals equipped with B-ultrasound of such feature, which is greatly welcomed by patients and pregnant moms. We are planning to equip the functionality to all machines gradually this year." Director GAO Jiansong said.

"Wireless" hospital construction. There is an interesting phenomena that you cannot find an extension cord in Hangzhou Women's Hospital.. To prevent safety hazards brought by earthing of extension cords or concentrated grounding connection of high power electric appliances, the hospital will uniformly cancel all extension cords and install equipment belt on the wall. The work requires a lot time, energy and economic support. But our hospital still insists on it. "We also motivate all our chief nurses to educate not to use electric appliances of power of over 500W. Because it is one of main reasons why we consider the cause to potential fire hazards in the hospital. Now our staff members and patients get accustomed to that. That's the charm of uniform standardized management."XUAN Junfang, principal of General Affairs Dept. told the journalist.

Why our hospital want get JCI? According to President ZHANG Zhifen...

1. Our Mission

The two-year old hospital is still very young. Our staff members come from different units with short adjustment period, and differences occur in culture and management mode of the hospital. JCI survey can help us to be a collective hospital timely , which is beneficial to the transformation of members' theory and close collaboration of the hospital. It can help the hospital to get leap-forward growth and progress. The core of the hospital is quality and safety. JCI standards is a set of strict hospital management standards in constant improvement focusing on quality and safety. Passing JCI survey also means that we should constantly require ourselves with high standards for further improvement. So JCI survey is not only for the result, but the process to carry out the mission and vision of the hospital.

2. Culture of Home

I have always been advocating to create the culture of "home" as I hope all staff members and patients can feel at home. Surveyor Ms. Dewan from India in this survey told us that "She sensed the feeling of home in the hospital", which greatly pleased me. It means that our culture is so thick that new comers can easily feel it. To a great degree, it also perfectly fits the spirit of JCI.