Finalists of the 2023 Business Case for Healthcare Quality

2.7%
5.7%
11%
7.8%
4.8%
4.6%
0.0%
0.0%
1.9% 2.5%
0.0%
J F M A M J J A S O N D
MONTHLY PATIENT FALL RATE (2020)
PER 1,000 INPATIENT DAYS
30%
45%
50% 48%
53%
70%
78%
72% 75%
68%
78% 75% 78%
84%
73%
81%
90%
80% 80% 78% 80% 80% 82%
86% 84%
90% 91%
100%
95%
84% 84%
91%
98%
45%
75%
86%
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
October
November
December
Avenue Hospital's baseline review showed the rate of patient falls in
their facilities had increased sharply from January to March 2020.
There was an increase in the average number of falls per 1,000
inpatient days. The average number of falls rose from 2.7% to 11%.
THE BUSINESS CASE:
FALL PREVENTION
FALL RISK ASSESSMENT COMPLIANCE (%)
INTERNATIONAL PATIENT SAFETY SCORE #6 (%)
REDUCE RISK OF PATIENT HARM RESULTING FROM FALLS
AV E N U E H O S P I TA L PA R K L A N D S , K E N YA
From January to March 2020, Avenue Parklands Hospital observed an uptick in
patient falls. The hospital quickly mobilized a multidisciplinary team to conduct a
thorough root-case analysis. After identifying several problem areas, they designed
and implemented a three-year program of quality improvements. The data below
illustrates the financial benefit of these changes.
2020 2021 2022
To prevent further incidents, Avenue invested in equipment,
services, and repairs. They examined HR, recruitment, training,
and orientation. Over two years, the improvements cost
Avenue less than the cost of falls in 2020 alone.
Between 2020 and 2022, the cost of injury-related care decreased
97%. After interventions, incidents fell, resulting in a total annual cost
of $7K in injury management and $0 in legal fees. These savings
covered Avenue’s investment cost and resulted in long-term returns.
98%
COMPLIANCE
BY 2022 97%
REDUCED
ANNUAL PATIENT FALL COST
AFTER INTERVENTION, IN US DOLLARS
$243K
TOTAL COST
(2020)
$7K
TOTAL COST
(2022)
BEDS: 130
STAFF: 1,700 SIZE: 7,229 m2
COST OF FALLS IN 2020 INTERVENTION COST 2020-2022
INCIDENT VS. INTERVENTION COST
IN US DOLLARS
$188K
LEGAL FEES
$55K
INJURY MANAGEMENT
$141K
STRUCTURAL ADJUSTMENTS
$94K
RECRUITMENT
ORIENTATION AND TRAINING
$65K
SERVICES AND REPAIRS
March 2024 Disclaimer: The figures and information depicted in this document were self-reported by the hospital named above and submitted during the “IFC Business Case for Healthcare Quality 2023” contest.

What problem did the hospital face?
In early 2020, our hospital recorded a significant
increase in falls. During a three-month period, the
fall rate increased from 2.7% to 11% per 1,000
patient days. Three of these cases were sentinel
events, resulting in serious injuries. Apart from the
human tragedy, they cost the organization
$190,000 in compensation payments.
Why were patients falling?
After a root cause analysis, we identified several
factors related to falls, specifically with
infrastructure. Our floors were slippery, especially
the bathrooms. There were no guardrails in the
hallways, no alarms at the bedside or in the
bathrooms. Our policies and procedures needed
attention. Another problem included staffing. We
had to work on nursing hours per patient day. The
number of nurses was inadequate given the kind
of attention patients needed.
What was done to alleviate the situation?
There were many mitigation measures, but a few
important ones included improving the hospital’s
infrastructure. Also, we made it easy for staff to
identify high-risk patients with a yellow wristband
so that when they appeared at any point of care
delivery, staff would see it and pay more attention
to fall prevention measures. We also instituted
new policies and procedures and educated
families on risks.
What role did staff ratio play in falls?
We compared the number of falls when we had
very low nursing hours per patient days from 4.5
hours previously to 9.5 hours today. We tallied
statistics every day and reviewed them monthly to
make decision data. Figures do not lie. Things
improved and we reduced the falls to almost zero.
Should we aim for zero falls or is it normal
for patients to fall anyway?
Falls still happen even when measures have
been put in place. For us, if there was a fall
despite our best efforts, it was much less
severe. After every incident, it is very
important to identify where things went
wrong. In our case, most of the recent falls
happened when we relaxed a little bit. For
example, when we hired part-time workers to
substitute staff taking vacation.
What challenges did you face?
Introducing and implementing change was
not easy, especially as the program spanned
three years. I was a new staff member
determined to change the culture and
behavior of staff who worked there for many
years. They were used to doing things in a
particular way. I knew that I needed to be
strategic.
What advice can you give to quality teams
to obtain financial support from top
leadership?
In my experience, the only way to effectively
communicate with leadership is through data.
It must be demonstrated and linked. It must
also be continuously tracked and monitored
to show the costs that will rise if there is
nonconformity.
Who were the important key stakeholders
needed to achieve success?
When it comes to healthcare quality, the
nursing team is the driving force. They are
crucial to pushing policy agendas because
they are the majority in any healthcare
facility, and they are the ones who spend
most of their time with patients.
“Figures do not lie.
Things improved and
we reduced the falls
to almost zero.”
___________________
Do patients appreciate these efforts and
that the hospital is safer?
Yes. In fact, we see clear evidence of this
on social media. From a quality
perspective, our Net Promoter Score
(NPS) is public. We embrace transparency.
We have a live screen where patients can
air their concerns, and we address them
positively as they happen. This is further
demonstrated by the fact that we discuss
incidents with patients.
What is next for Avenue Parklands?
We have many ongoing projects. We are
consistently collecting data to identify
areas that need improvement. One of our
current focus areas is the turnaround time
for admission and discharge. Patients have
highlighted this as a significant pain point.
We are also passionate about reducing
maternal mortality rates and have made
significant progress in this area.
Any last words of wisdom?
Maintaining quality in a hospital is not a
one-time task. It requires continuous effort
and improvement. Quality is never
delegated. It is everyone’s responsibility.
HER LIFELONG MISSION:
TO IMPACT HEALTHCARE QUALITY
Penina Kirea of Avenue Parklands describes how her mother’s passing in childbirth fueled her
commitment to improve healthcare quality for all.
Penina Kirea
Group Chief Nursing
Officer and Head of Quality
Avenue Healthcare
The IFC Business Case for
Healthcare Quality contest is
sponsored by IFC’s IQ-Healthcare
program in partnership with the
governments of Japan, Norway,
and the Netherlands.
Contact Us
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How implementing a fall prevention
program directly impacted Avenue
Hospital’s operations.

MONTH 1 MONTH 2 MONTH 3 MONTH 4
Patients began canceling their annual diabetes care memberships,
which adversely impacted patient access in addition to business
results. Implementing software that used clinical guidelines for
medication, significantly decreased cancellations.
C L I N I C A S D E L A Z U C A R , M E X I C O
The software intervention was implemented when Azucar had just
15 clinics. Since then, it has continued to be an important quality
control tool as new service areas have opened. Today, the EHR is
used in Azucar’s 37 clinics across Mexico.
GROWTH IN NUMBER OF CLINICS
AFTER INTERVENTION
2x
SERVICE
AREAS
STAFF: 600 SIZE: 250 m2
CLINICS: 37
Clinicas del Azucar, Mexico's largest diabetes and hypertension clinic network, identified
numerous medication errors causing patient dissatisfaction, appointment cancellations,
and treatment discontinuation. To address this, the hospital implemented medication
guidelines and electronic health record (EHR) improvements, empowering doctors to
improve patient care. The following data highlights the financial benefits of these changes.
BEFORE INTERVENTION AFTER INTERVENTION
THE BUSINESS CASE:
TREATMENT GUIDELINES
COST OF PATIENT CANCELLATIONS
IN # OF CANCELLATIONS
ENHANCED COMPLIANCE
% PRESCRIBED MEDICATIONS OUTSIDE GUIDELINES
In the initial week of measurement, 13% of medication was outside
the guidelines. After four months, this percentage was significantly
reduced to 2%. This reduction in medication errors contributed to a
noteworthy decrease in patient cancellations and complaints.
13%
MONTH 1
2%
MONTH 4
TREATMENT
GUIDELINES
INTRODUCED
EHR SYSTEM
DEPLOYED
BETTER PATIENT
SAFETY
COST OF CARE
DECREASES
ENHANCED DOCTOR
ENGAGEMENT
HIGHER PATIENT
SATISFACTION
BETTER PATIENT
RETENTION
MORE DEMAND
FOR SERVICES
BUSINESS
EXPANSION
FEWER ERRORS
COMPLIANCE
INCREASES
REDUCED
ERRORS
PAID BACK IN
1 MONTH
$360K
SAVINGS PER
YEAR
$20K
INVESTMENT
100
CANCELATIONS
AVOIDED PER
MONTH

What problems did the clinics face?
We were losing patients; they were canceling
their diabetes care memberships.
Why were they canceling?
Patients were having side effects. Others
couldn’t afford the care. The diabetes
medication was also not tailored to their needs.
We found that doctors would recommend the
same prescription for everyone, especially for
low-income patients.
We discovered a hiccup in the way diabetes
patients are treated everywhere. Although
doctors follow treatment guidelines, they
prescribe based on averages. But people vary
greatly. If you look at the ADA and global
guidelines, they are generic and almost the
same for every patient, whether married,
single, divorced, male, female, 40, or 60 years
old.
What was done to alleviate the situation?
We built an electronic system that used
algorithms to open or close medications. Using
a software platform provided protection and
standardization. Following a standard is always
safer because it excludes the human factor. We
had concerns about the type of medication and
the costs and whether doctors were being
pressured by the industry to push a specific
medication. Of course, the doctor had the
flexibility to override recommendations and
prescribe whatever they needed to.
Did doctors still have the final say?
We needed to continue to give the doctor the
flexibility to choose what to prescribe. However,
the system would say to this patient, “Only
consider this list.” So, when the doctor
prescribes something outside that list, the
system automatically first says, "You are
prescribing something outside the
recommendation," and then asks why. The
doctor needed to justify a different medication.
As you implemented the new medication
guideline software, what happened?
It was very interesting. We could see what was
happening in all the clinics at the same time.
There was a lot of variation in treatment
recommendations because doctors were often
overriding the software’s suggested
prescriptions. Some doctors said the patient
requested a medication they thought was
better, but a few weeks later the patient would
come back. Having not taken the medication,
they were afraid to tell the doctor this happened
because they couldn't afford it. The doctors
complied with most of the guidelines but
reducing this trend took a different approach.
Doctors with high compliance scores were
named mentors for other doctors. We
implemented this a few years ago, and it has
allowed us to quickly scale the number of
clinics.
What other supports did you put in place?
We have a patient support center, which is a
call center that reaches out to the patients on
certain days to ask how they are feeling,
whether the amount and cost of the medication
are okay, and whether they understand the
medication change correctly.
As a leader, do you have any tips for those
implementing similar technology?
Build a culture of technology process
improvement from the beginning. That is the
only way to enable delivery at low cost to
“Build a culture of
technology process
improvement from the
beginning.”
__________________
millions. Because we started from scratch,
we were able to set the tone from early on.
It is very important for the CEO to
consistently convey the message. It is
critical to define the strategy and the type
of company you are creating, and have
executive leadership agree on that.
Switching gears, on a personal note,
what compelled you to disrupt the
system?
I had spent years applying process
improvements to chronic care around the
world. The issue became very personal
when it came to researching diabetes, a
disease my mother battled for ten years.
She was exhausted from going from doctor
to doctor, multiple doctors who gave
conflicting advice. She didn’t want
treatment anymore, even if she died. I was
shocked. That was my aha moment.
I realized diabetes care was broken
everywhere. I launched Clinicas del Azúcar
to create highly efficient diabetes clinics so
patients could receive seamless treatment.
I applied all my years of experience with a
mission: to transform care by creating
standardized one-stop shops around the
country.
DISRUPTING DIABETES CARE:
AN ENTREPRENEUR’S ULTIMATE GOAL
In an interview with IFC, Javier Lozano, CEO of Clinicas del Azúcar, describes how gaps in his
mother’s diabetes treatment propelled him to disrupt the entire industry.
Javier Lozano
CEO
CLINICAS DEL AZÚCAR
How implementing new
medication protocols dramatically
improved patient retention and
created a reliable system for
quality and patient safety.
Contact Us

72%
OVERALL
-5%
OVERALL
Facilities Growth Patient Growth
Before Intervention After Intervention
2017 2018 2019 2020 2021 2022
The Ministry of Health estimates only 40% of care delivered in
Kenya meets national recommendations. Penda Health was at
a similar level before addressing quality improvements. Now,
they are one of the highest-performing facilities in the country.
P E N DA H E A LT H , K E N YA
The plan, implemented over four years, quadrupled Penda’s
physical footprint. More importantly, its patient volume increased
tenfold while it continued to improve customer satisfaction and
affordability for low-income patients.
GROWTH IN NUMBER OF CLINICS
BEFORE AND AFTER INTERVENTION
10X
PATIENT
GROWTH
Penda Health leads in offering high-quality
primary care. They primarily serve lower-
income markets in Kenya. Standardizing IT and
clinical support mechanisms allowed for the
quicker rollout of new clinics. It also positively
impacted workflow, as staff quickly aligned to
the new systems.
THE BUSINESS CASE:
STANDARDIZING
PRIMARY CARE
BEST IN CLASS PERFORMANCE
COMPARED TO MINISTRY OF HEALTH AVERAGES
IMPROVED EFFICIENCY
AFTER LAUNCHING EHR
Clinical decision support allowed Penda to quickly and easily scale its
quality systems across new clinics – allowing new medical staff to be
quickly trained and onboarded. Clinicians used the EHR in 90% of
visits and adhered to its recommendations more than 75% of the time.
STAFF: 350 FACILITIES: 19
BEDS: 130
EHR FULLY IMPLEMENTED
($250,000)
CDSS LAUNCH & TRAINING ($30,000)
IMPROVEMENTS & ADDITION OF 300+ CONDITIONS
90% UTILIZE CLINICAL
DECISION SUPPORT
75%
ADHERE TO
RECOMMENDATIONS
CDSS FRAMEWORK DEVELOPED
EFFICIENCY
GROWTH
EHR UTILIZATION
90%
COMPLIANCE
40%
COMPLIANCE
NATIONAL GUIDELINE
COMPLIANCE
NET PROMOTER
SCORE
4X
CLINICS
IMPROVED
REFERRAL
SYSTEM

What problem did the company face?
Standardization was lacking which
complicated operations in several areas. For
instance, healthcare providers were
recommending treatments outside of the
national treatment guidelines. This led to
inconsistencies in care and complicated our
pharmaceutical supply chain. At the time, our
pharmacy had 1,400 SKUs.
Using an EHR with clinical decision support
allowed us to standardize clinic operations
and patient flow, so we could frontload
processes in very busy clinics. Ultimately,
reducing costs, which allowed us to expand
services to even more patients.
How does the setting impact the amount
of standardization required?
In the US, doctors typically treat about 20
conditions over and over, because we have
a high degree of specialization. In that
setting, clinical decision support for those
experts is not needed. At Penda, in a week
they are vaccinating children, treating
motorcycle accidents, seeing chronic
illnesses, delivering babies, and taking care
of pregnant moms. The spectrum is truly
massive and the multitasking that each
clinician does requires this support.
Standardization actually makes everyone
much safer.
What were a few important things that
you got right?
Changing culture is incredibly important,
especially when implementing clinical
decision support. A lot of people think
technology is the most important thing, but
it's not.
Operationally, we said, let’s not go straight to
standardizing treatment protocols for 300
conditions, let's start with 20. We did that for
about six months.
We also launched a big change management
effort and made infographics and shared them
on WhatsApp. We put posters up, conducted
Zoom town halls, and explained why we were
standardizing. We bought cakes and celebrated.
It is critical to have champions. Who helped
you through this process?
The group that led the roll out consisted of a
clinical quality team. They would visit different
facilities and involve staff and managers. If I
could do it over again, I would involve frontline
staff even more initially.
How did you help the finance department to
see the value of approving these expenses?
Penda is investor-backed, so we have unlocked
support for scalable growth. Investments in
technology make sense. The good thing is,
electronic health records are becoming
affordable and there are free options.
Did success depend on technology
solutions, such as EHRs?
Yes. My advice is to invest fully in EHR first,
then build in digital support. This is the hardest
part but if you want scalable quality, you must
have it.
Once you installed the new clinical system,
did you notice any reduction in the number
of incidents or other improvements?
Yes. We now have a really robust system that
compiles a patient safety report every other day
or so. We're very much on top of the safety
“EHRs are becoming
vastly more affordable
and there are lots of
free options”
____________________
issues. The wrong treatment of a diagnosis
has gone way down. The beauty of clinical
decision support is that it is a cloud-based
record. No matter which facility of Penda
you're at, it's the same record, notes and
clinical decision support tools. This has
improved consistency. The system allows for
communication through the medical record
that all doctors can access.
Has the outside world noticed?
Yes. There has been a lot of interest in what
Penda has done with clinical decision
support from other Chief Medical Officers.
They are our competitors, but they're also our
friends and colleagues within the ecosystem
and we've been talking very openly about
what we've done. Everyone is interested in
doing it. So basically, with this initiative, we
were the first, so we actually impacted the
market as well. The rest of the market will
follow after us.
The barrier is that so few healthcare
organizations that provide outpatient services
in Kenya have electronic records. If you're
not actually paperless then you can't
implement clinical decision support even if
you want to. Making a commitment to
become fully digital is key.
A DOCTOR’S DREAM:
TO STANDARDIZE OPERATIONS
Robert spoke with the IFC from his office in Nairobi about his journey standardizing operations
and how using electronic health records (EHRs) has unlocked growth at scale.
Dr. Robert Korom
Chief Medical Officer at
Penda Health
How technology solutions
standardized clinical decisions, led
to better quality outcomes, and
reduced costs. The greatest
outcome of this? The ability to
reach more patients.
Contact Us

January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
19.2%
7.5%
10.2%
13%
8.9% 8.9%
7.9%
3.1% 3.4%
13.1%
4.9%
3.3%
1.4% 4.4%
6.4%
4.1% 0.7% 1.2%
0.4% 0.7%
IMPLEMENTED FAST-TRACK CLINIC
The number of emergency department cancellations in January 2022
resulted in a financial loss of about $5,000 per month. After
implementing fast-track clinic operations, the losses prevented
amounted to over $60,000 annually.
In June 2022, the fast-track clinic served 634 patients.
This number grew to 1,577 patients by October 2022. As
of August 2023, 16% of emergency department patients
were being served in fast-track clinics.
DA R A L S H I FA H O S P I TA L , K U W A I T
Dar Al Shifa Hospital (DASH) was established in 1963; it was the
first private hospital built in Kuwait. The hospital provides inpatient
facilities and emergency medical services across the region. In
2022, staff observed that patients left the emergency room without
receiving care. What followed was an intensive quality improvement
project focused on enhancing Emergency Department (ED)
practices and patient flow.
THE BUSINESS CASE:
FAST-TRACKING
EMERGENCY TRIAGE
INCREASED PATIENTS SERVED
THROUGH FAST-TRACK CLINIC
BETTER EMERGENCY ROOM ACCESS
BY INDEXING EMERGENCY SEVERITY
DASH emergency department observed that 16% of patients triaged
were Emergency Severity Index Levels 4 and 5, meaning the cases were
less urgent and non-urgent. Fast-tracking these less-urgent and non-
urgent cases led to shorter wait times and increased patient satisfaction.
STAFF: 2,700+ BEDS: 249
PATIENT CANCELLATIONS DUE TO “CANNOT WAIT” FROM TOTAL CANCELLATIONS IN ADULT EMERGENCY DEPARTMENT
COMPARED TO 5% DASH TARGET
FINANCIAL RESULTS
IMPACT OF INTERVENTION, IN US DOLLARS
2022 2023
16% CAN WAIT
Redirected to fast-track clinic
Level 5: Non-Urgent Condition
Level 4: Less Urgent Condition
84% CAN NOT WAIT
Level 3: Urgent Condition
Level 2: Emergent Condition
Level 1: Life-Threatening Condition
-$5K
MONTHLY LOSS OF
REVENUE
$60K
LOSS OF REVENUE
PREVENTED PER YEAR
AFTER INTERVENTION
BEFORE INTERVENTION
634
JUNE 2022
1,577
OCTOBER 2022
85%
SATISFACTION
ACHIEVED
2X
SERVICE CAPACITY
5 MONTHS
SIZE: 34,972 m2
IMPROVED
REFERRAL
SYSTEM

What problem did the hospital face?
In January 2022, we noticed a 19% increase
in canceled invoices in the Emergency
Department (ED). This resulted in an
estimated financial loss of 5,000 USD per
month. Because we are a private facility,
anybody can walk in at any time. Patients
come to the ED, check in, and receive an
invoice followed by an appointment to be
seen by a doctor. At some point in that
process, patients began to leave the hospital.
We discovered that our 20-minute wait to see
a doctor was too long for most patients.
How did the hospital alleviate the
situation?
We brought together the ED doctors, nurses,
customer service, and IT staff from the
Health Information department to hear from
patients. Many of the ideas generated were
simple but highly effective. For example, our
patient’s top concern was having their
feedback heard. So, we monitor it via an
online platform called Press Ganey. When
there were comments that required follow-up,
our ED head called the patients directly to
ask about their experiences and how we
could improve. This had the greatest impact
on return visits.
We noticed that 20% of our patients were
level 4 or 5 on the Emergency Severity Index
(ESI), which meant they were less severe
and did not need hospital resources. The
question was how non-serious patients could
bypass occupying an emergency bed, which
added to wait time. Some of those patients
needed sick leave notes. Others needed to
be seen by a doctor because insurance
demanded it, even
if it was just a medication refill, lab, or routine
checkup. Patients would even walk in for a copy of
their medical report. So, we realized if we targeted
this group differently, it could improve patient
satisfaction and revenue. We decided to implement
a fast-track clinic and educated patients and staff
on the importance of using these services to
reduce wait times.
Can you talk more specifically about the steps
taken to improve the situation?
We assigned four additional nurses in the female
section and three in the male section of the hospital
during evening shifts. We installed screens in the
waiting area to show each patient’s turn based on
the queue number and triage level. We began
using a color-coded process on ID bands that
displayed the expected wait time. We changed the
priority of lab tests to urgent if needed. We
implemented a bedside payment process across
the ED. Our ED charge nurse closely monitored
patient discharge records via electronic medical
records. Ultimately, we reduced the number of
patients leaving without treatment within a month or
two.
Why does data make a difference?
Data always provides insight into larger situations.
For us, it was critical to identify patterns. In the
case of the ED, we correlated the data to see
which interventions would have the greatest impact
on positive patient feedback, patient volume, and
ED revenue.
What challenges did the hospital face?
We had a huge manpower shortage at this time,
which made it difficult to effectively distribute staff
across the hospital. One of the biggest obstacles
was finding doctors who could be dedicated to
staffing the fast-track clinic. These physicians do
“We correlated the
data to see which
interventions would
have the greatest
impact on positive
patient feedback”
__________________
not see very critical cases, so for multiple
reasons, there was less interest in staffing
this function. So, we started with
dedicated fast-track nurses. They were
trained on patient intake, collecting and
recording basic information, and were
responsible for calling the doctor so that
no time was wasted.
Are there plans for the future?
Yes. We have recently expanded our
overall hospital with the addition of three
new wings. This allows us to offer
additional inpatient services. One of the
closest areas to the emergency
department was the laboratory. Due to the
success of our fast-track clinic, the lab will
be shifted out to create a full-fledged
expansion of the Emergency Department.
This expansion will actually double the
emergency department capacity. We plan
to have dedicated fast-track areas, areas
for the Adult Emergency Department,
Pediatrics, and Obstetrics.
RESHAPING EMERGENCY CARE
AMONG KUWAIT’S LARGEST HOSPITALS
In an interview with IFC, Dar Al Shifa Hospital describes sweeping changes implemented after it
observed almost 20 percent of patients leaving the Emergency Department without being treated.
Jessy Jacob
Quality Director
Dar Al Shifa Hospital
How Dar Al Shifa Hospital used
data as its first line of defense in
improving satisfaction, reputation,
patient volume, and revenue.
Contact Us

Finalists of the 2023 Business Case for Healthcare Quality

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