WHO/IAPB Meeting on Cataract Surgery Outcomes Monitoring Systems, Kuala Lumpur, Malaysia, 19–20 September 2018 : meeting report

19–20 September 2018 Kuala Lumpur, Malaysia Meeting Report WHO/IAPB MEETING ON CATARACT SURGERY OUTCOME MONITORING SYSTEMS W HO /IA PB M ee tin g on C at ar ac t S ur ge ry O ut co m es M on ito rin g Sy st em s 19 –2 0 Se pt em be r 2 01 8 Ku al a Lu m pu r, M al ay si a Report series number: RS/2018/GE/70(MYS) WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC English only MEETING REPORT WHO/IAPB MEETING ON CATARACT SURGERY OUTCOMES MONITORING SYSTEMS Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC AND THE INTERNATIONAL AGENCY FOR THE PREVENTION OF BLINDNESS Kuala Lumpur, Malaysia 19–20 September 2018 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines May 2019 NOTE The views expressed in this report are those of the participants of the WHO/IAPB Meeting on Cataract Surgery Outcomes Monitoring Systems and do not necessarily reflect the policies of the conveners. This report has been prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who participated in the WHO/IAPB Meeting on Cataract Surgery Outcomes Monitoring Systems in Kuala Lumpur, Malaysia, from 19 to 20 September 2018. CONTENTS SUMMARY ............................................................................................................................................ 1 1. INTRODUCTION .............................................................................................................................. 5 1.1 Meeting organization .................................................................................................................... 5 1.2 Meeting objectives ........................................................................................................................ 5 2. PROCEEDINGS ................................................................................................................................. 6 2.1 Opening session ............................................................................................................................ 6 2.2 Plenary sessions ............................................................................................................................ 6 2.2.1 Plenary session 1 – State of play ......................................................................................... 6 2.2.2 Plenary session 2 – Sector approaches ................................................................................ 8 2.2.3 Plenary session 3 – Strategies and tools for outcome monitoring ..................................... 11 3. CONCLUSIONS AND RECOMMENDATIONS ........................................................................... 16 3.1 Conclusions ................................................................................................................................. 16 3.2 Recommendations ....................................................................................................................... 16 3.2.1 Recommendations for Member States ............................................................................... 16 3.2.2 Recommendations for WHO and partners ......................................................................... 17 ANNEXES ............................................................................................................................................ 19 Annex 1. Cataract outcomes meeting background paper Annex 2. Programme Annex 3. List of participants Annex 4. Opening ceremony Keywords Cataract extraction – standards / Cataract – rehabilitation / Eye diseases – surgery / Vision disorders / Regional health planning 1 SUMMARY Although cataract surgeries are commonly performed in public and private health systems, surgical outcomes are not commonly monitored centrally. Based on population-based evidence, outcomes of cataract surgery in low- and middle-income countries, including countries in the WHO Western Pacific Region, are below WHO-recommended standards. Towards Universal Eye Health: A Regional Action Plan for the Western Pacific (2014–2019) recommends that Member States assess and monitor the quality of cataract surgical services. It further requests WHO to provide training on tools for cataract surgery outcomes monitoring. In Malaysia, a systematic cataract surgery outcomes monitoring system has been in place in the public sector for over 10 years. The Malaysian example is a valuable showcase for country participants. The WHO/IAPB Meeting on Cataract Surgery Outcomes Monitoring Systems was held in Kuala Lumpur, Malaysia, on 19–20 September 2018. This was a joint meeting, with all costs covered by the International Agency for the Prevention of Blindness (IAPB), an umbrella organization of nongovernmental organizations and professional associations in official relations with WHO. Dr Andreas Mueller, WHO consultant, provided technical support, particularly on existing tools for cataract surgery outcomes monitoring. Mr Sean Selby, of the University of Auckland, and Dr Noela Prasad, of the International Society for Quality in Healthcare (ISQUA), developed background papers. Participants came from eight countries in the Western Pacific Region with high-volume cataract surgical programmes: Cambodia, China, Lao People’s Democratic Republic, Malaysia, Mongolia, Papua New Guinea, Philippines and Viet Nam. The objectives of the meeting were: (1) to share successes and barriers for improving cataract surgery outcomes monitoring programmes; (2) to provide information on existing tools and strategies to monitor cataract surgery outcomes; and (3) to develop country-specific action points to strengthen quality assurance for cataract surgical services. Conclusions The meeting successfully conveyed the importance of quality in cataract surgery outcomes. Monitoring is particularly crucial in ensuring quality eye care. Country participants brought up three main areas that require WHO/IAPB support: 1. Technical support. Member States need technical support in developing or modifying existing monitoring software and guidelines as well as software installation and training. A follow-up workshop on outcomes monitoring progress would be discussed further with IAPB and partners, along with the need for a long-term regional course. 2. Changes in human resources in eye care. The meeting successfully communicated the important message of changing behaviour and highlighting the value of quality that we have to offer. Discussions also covered the roles of optometrists and refractionists, and the link between volume and quality. Working effectively in a team, optometrists can have a large impact on national programmes. There is also a need for biometry training and essential biometry equipment in ensuring better quality. 2 3. Changes in policy. WHO/IAPB would have a role in advocating at a higher level to governments, but requests for support should be initiated at the health ministry level and brought to the attention of the respective WHO country office. Support from WHO/IAPB will be targeted as each country has different challenges and boundaries. Recommendations for Member States Member States are encouraged to consider the following: Cambodia (1) Develop and establish a standard cataract surgery outcome monitoring tool, followed by a pilot study to identify the barriers and challenges in its implementation, and find solutions to overcome it. System to be integrated into the health information system of the Ministry of Health and to include feedback to all eye units China (1) Develop a committee to advocate the importance of cataract surgery quality control, and develop parameters in evaluating cataract surgery quality. (2) Consider quality training for cataract surgeons. Lao People’s Democratic Republic (1) Improve the quality of the existing basic tool for cataract surgery outcomes monitoring as well as its implementation throughout the country. (2) Improve teamwork with ophthalmic nurses/refractionists to improve cataract surgery outcomes. Malaysia (1) Increase efficiency of ophthalmologists in the country by ensuring they have a sufficient number of surgeries without compromising quality. (2) Strengthen the existing eye care services pathway by bringing in universities and the private sector to work together with the public services in ensuring quality cataract surgery outcomes. Mongolia (1) Convey the message learnt from this meeting to the Ministry of Health. (2) Arrange a meeting with information technology and quality assurance departments. (3) Further support consideration of implementing or adopting a specific surgery outcomes monitoring tool and discuss its implementation. Papua New Guinea (1) Strengthen usage of existing Cataract Surgical Outcomes Monitoring (CSOM). (2) Present the plan to the Ministry of Health to set up a technical working group to co-facilitate cataract surgery outcomes monitoring. 3 Philippines (1) Work together with the national health insurance system in implementing a cataract surgery outcomes monitoring system, to be implemented by the first quarter of 2019. (2) Advocate the integration of the role of optometrists into the health system through seminars and conferences. (3) Involve optometrists in six-week post-operative reviews and to be part of the service providers for cataract surgery outcomes monitoring. (4) Conduct a training session for biometry and keratometry. Participants would like to learn from Malaysia on this aspect. Viet Nam (1) Finalize and submit national cataract surgical guidelines to the Ministry of Health. Recommendations for WHO and partners WHO/IAPB is requested to consider the following: Cambodia (1) Provide technical support, especially with regard to the programme software, and training on using the software. (2) Support the dissemination of the software to relevant organizations and eye units, and also in monitoring and evaluating the outcome. China (1) Support the introduction of simple measures in cataract surgery outcome monitoring, such as BOOST. (2) Advocate with the ministry of health, together with support from the ophthalmological society. Lao People’s Democratic Republic (1) Provide technical support in software installation, software training, as well as supervision and monitoring. (2) Conduct an in-country follow-up workshop. Malaysia (1) Provide technical support to develop the country as a training hub for public health ophthalmology for the WHO Western Pacific Region. 4 Mongolia (1) Provide technical support to bring a technical consultant to the country for software implementation. Ideally, the software consultant should attend the upcoming meeting of the ophthalmological society to advocate the importance of software implementation. (2) Provide support to develop guidelines and protocol for quality eye care. Papua New Guinea (1) Provide support to form a technical working group together with the Ministry of Health. (2) Provide technical support to develop guidelines and protocols. Philippines (1) Provide support to integrate eye care into the public health system. Viet Nam (1) Support interaction with the Ministry of Health, particularly in writing an official letter to stress the importance of cataract surgery outcomes monitoring and quality eye care nationwide, recognizing that Viet Nam is still lagging in terms of monitoring as compared to other countries in the WHO Western Pacific Region. 5 1. INTRODUCTION 1.1 Meeting organization Although cataract surgeries are commonly performed in public and private health systems, surgical outcomes are not commonly monitored centrally. Based on population-based evidence, outcomes of cataract surgery in low- and middle-income countries, including countries in the WHO Western Pacific Region, are below WHO-recommended standards. Cataract surgical outcomes are the end result of any cataract surgery performed. Several established outcome measures are used worldwide, a common one being visual acuity. However, the outcome can also be measured by evaluating the biometric results or patient-reported outcome, the use of which is an increasing trend in recent years. Determinants of the outcome are factors along the cataract care pathway. These range from patient recruitment, selection and counselling to occurrence of intra- and post-operative complications. Therefore, evaluation of the outcome should be conducted at every point in the cataract care process. The evaluation findings can then be used to rectify problems along the pathway, thereby improving service delivery to the patients at large. Towards Universal Eye Health: A Regional Action Plan for the Western Pacific (2014–2019) recommends that Member States assess and monitor the quality of cataract surgical services. The Action Plan further requests WHO to provide training on tools for cataract surgery outcomes monitoring. In Malaysia, a systematic cataract surgery outcomes monitoring system has been in place in the public sector for over 10 years. The Malaysian example is a valuable showcase for country participants. The WHO/IAPB Meeting on Cataract Surgery Outcomes Monitoring Systems was co-organized by the International Agency for the Prevention of Blindness (IAPB) and the World Health Organization (WHO) Regional Office for the Western Pacific. It was hosted by Malaysia and was held on 19–20 September 2018 at Shah Alam Hospital, Kuala Lumpur, Malaysia. IAPB is an umbrella organization of nongovernmental organizations and professional associations in official relations with WHO; WHO developed a background paper for the meeting (Annex 1). 1.2 Meeting objectives The objectives of the meeting were: 1) to share successes and barriers for improving cataract surgery outcomes monitoring programmes; 2) to provide information on existing tools and strategies to monitor cataract surgery outcomes; and 3) to develop country-specific action points to strengthen quality assurance for cataract surgical services. 6 2. PROCEEDINGS The meeting comprised three plenary sessions, a panel discussion and a workshop in addition to opening and feedback sessions. During the opening session, Malaysia shared their experience and evolution in cataract surgical performance monitoring for the past 10 years. Dr Nathan Congdon introduced a self-monitoring tool (BOOST) in assessing cataract surgical outcomes in areas of limited resources. Representatives presented the current situation of cataract surgical outcome monitoring in their respective countries. The barriers and challenges in monitoring cataract surgical outcome were discussed during the group work and plenary sessions. The panel discussion covered gender equity and cataract services utilization issues, mainly in the Malaysia context. During the second plenary, three main approaches in ensuring high-quality cataract outcome were presented. Strategies and tools for outcome monitoring were addressed during the third plenary session. A full outline of the programme is provided in Annex 2. 2.1 Opening session Opening remarks were delivered by Dr Ying-Ru Jacqueline Lo, WHO Representative to Malaysia, Brunei Darussalam and Singapore, Professor Serge Resnikoff from the International Council of Ophthalmology, and Mr Drew Keys from IAPB. The meeting was officiated by Malaysia’s Director General of Health, Datuk Dr Noor Hisham bin Abdullah. Dr Nor Fariza Ngah, National Head of Ophthalmology Services, Malaysia, was elected as Chairperson for the meeting, while Dr Nor Anita Che Omar and Dr Azlina Mokhtar were elected as the Rapporteurs. A list of participants is available in Annex 3. 2.2 Plenary sessions 2.2.1 Plenary session 1 – State of play (1) Evolution of cataract surgery performance monitoring in the Ministry of Health, Malaysia – Dato’ Dr Goh Pik Pin, Director, Clinical Research Centre, Ministry of Health Malaysia Performance indicator monitoring at the Ministry of Health Malaysia was initiated in 1998 by Tan Sri Dato’ Dr Abu Bakar Suleiman, who was the Director General of Health during that time. Key performance indicators (KPIs) were introduced in 2006 as part of a government transformation programme to measure the structure, process and outcome of medical services. Cataract surgery is the main area for performance monitoring in ophthalmology services. It is the main eye care service and serves an essential part in training as it involves the whole ophthalmic team (nurse, medical assistant and optometrist). The outcomes of cataract surgery were monitored under the Cataract Surgery Registry within the National Eye Database (NED) system. NED, as part of performance indicator monitoring, was started in 2002 by manual charting and progressed to a real-time online database from 2007 onwards. It expanded its ability to monitor intraoperative complications such as posterior capsule rupture (PCR) and post-operative endophthalmitis from all 36 eye departments in the Ministry of Health. The monitoring includes aspects such as quality (visual acuity outcome at 12 weeks post-cataract operation), safety (PCR, post-operative endophthalmitis and rate of unplanned return to operating room and workload (waiting time for cataract surgery of more than 6 months). Other performance indicators include new referral for diabetic retinopathy, port-related break during vitrectomy, buttonhole of conjunctiva in trabeculectomy, muscle slip for strabismus surgery and wound breakdown after elective oculoplastic surgery. 7 Besides visual acuity outcome monitoring, patient-reported outcomes such as the CATQUEST questionnaire for use in cataract surgery care also would be conducted as a global standard set of outcome measurement (2) Sharing Malaysia’s experience in cataract surgical outcome measurement – Dr Mohamad Aziz Salowi, Public Health Ophthalmologist, Ministry of Health Malaysia Conceptual monitoring of the cataract care pathway in Malaysia begins with patient recruitment, followed by pre-, intra- and post-operative assessment until the end of the process, which is the final visual acuity outcome after cataract surgery. This cataract services monitoring involves different levels, from individual surgeon to department and also the country/state. At national-level monitoring, NED would be able to show and compare the total number of cataract surgeries in the Ministry of Health system, the presenting age group, systemic comorbidity, and the presenting visual acuity for cataract surgery for every year. It also helps to monitor the quality of cataract services by observing the rate of post-operative endophthalmitis and the visual acuity outcome after cataract surgery at the country level. At institution/department-level monitoring, heads of respective departments would receive reports on cases with complications and poor visual acuity outcome in real time using NED. This would help to improve the visual acuity outcome in every eye department. At individual-level monitoring, the e-CUSUM chart, dynamic tool for monitoring competency in cataract surgery developed in Malaysia, is able to monitor surgical complications such as PCR rate and the need of intervention at a certain level. Surgeons also would be able to produce their logbooks by downloading the data from NED, which would be generated in Excel format. Malaysia’s mission is to involve the private sector and universities as well as to collaborate with international agencies for cataract monitoring services and patient-reported outcome data. (3) Assessing cataract surgical outcomes in areas of limited resources – Professor Nathan Congdon, Queen’s University Belfast Professor Nathan Congdon began his talk by addressing the importance of providing good-quality and sustainable cataract services. Some available systems to record cataract outcomes offer very powerful functionality but may be challenging for new users. Issues in monitoring include a complicated system to use and poor follow-up post-operatively. Therefore, the PRECOG project was launched to assess cataract outcomes with the aim to determine early vision assessment (day 1) that will predict late results (follow-up at six weeks). This study demonstrated that visual acuity results immediately after surgery are highly predictive of final vision. PRECOG provides a potential tool, known as BOOST, for assessing outcomes with a better operative outcomes software tool, which has simple default settings and is user-friendly. It is a freely downloadable application to help users through the process of collecting data on cataract outcomes. It is also a cloud-based database, which can compare results anonymously, locally, regionally and globally. It could also determine the most common causes for poor outcomes in different areas and suggest specific corrective measures. It benefits users, administrators and researchers as it is based on a stable platform for long-term use and could provide comprehensive reports comparing multiple users. BOOST V2.0 was launched at the World Ophthalmology Congress in June 2018 in Anhui. V1.0 was field-tested in more than 100 hospitals and showed strong demand and support from the users. At the end of his talk, Professor Congdon encouraged the audience to download and try BOOST as well as join the BOOST Research Study to determine whether use of BOOST improves outcomes. 8 (4) Panel discussion – Gender gap Chaired by Ms Jennifer Gersbeck, The Fred Hollows Foundation Australia, and Chair, IAPB Gender Equity Working Group Proactive action needs to be taken to improve eye health outcomes for women globally. WHO proposed an action agenda to improve health equity outcomes while balancing gender equality and women empowerment. The approach to tackle the gender gap in the uptake of eye care services has been among the key agenda items undertaken by the prevention of blindness committee/public health ophthalmologists in Malaysia. The Malaysian National Eye Survey II (2014) estimated that cataract blind persons (corrected vision lower than 3/60 in the better eye) were predominantly women in the eastern part of the country and Sarawak. The contributing factor to the large gender gaps in accessing eye care in those stated regions were social, cultural and geographical barriers. However, there were no differences of cataract surgery numbers and outcomes between genders; hence, an indicator of eye health gender equality. Women often accept vision loss as a natural consequence of ageing, a perceived concept similar to presbyopia in older people as well as fear of surgery itself. The geographical remoteness and actual distance and physical access to facilities that offer eye health services involve long journeys, thus leading to high transportation costs. Lack of autonomy and support from family members were some factors for these women seeking traditional alternative treatment. Women who bear the greater burden of blindness are mostly unaware of their right to sight, as well as constrained by traditional and religious beliefs to access alternative remedies for cataract. Therefore, increased awareness among women would lead to more equitable access to better health outcomes, reveal their fullest potential and consequently increase their contribution to their communities – economically, socially and culturally – leading to greater gender equality. Addressing the gender gap in treatment of avoidable blindness specifically also brings economic benefits. In Malaysia, optometry services are integrated within the health system at the primary, secondary and tertiary levels. These services have contributed much to the prevention of blindness programmes, especially with primary eye care provider bridging the gap to provide accessible eye care for marginalized or minority ethnic groups. To tackle this issue, the action plan includes a proposal for collaboration between the Ministry of Health and the Ministry of Women, Family and Community Development to empower women seeking eye health services. The community groups can reach out to women, as well as create and increase awareness of cataract as a preventable condition in the older illiterate population, children and among the primary eye care personnel in the rural areas. Engaging community leaders and nongovernmental organizations in cataract find-and-outreach programmes in remote areas could help bridge the gender gap. Gender-mainstreamed and -targeted projects could be implemented to achieve gender equity in eye heath care. Technology could play a major role in improving gender equity. The central database should be aggregated by gender to increase information on gender-related service gaps and be beneficial for outreach teams to increase efficiency and efficacy of the screening programmes to benefit women. 2.2.2 Plenary session 2 – Sector approaches In ensuring high quality outcome of cataract surgeries, three main approaches have been highlighted during the meeting. 9 (1) Developing a monitoring system - Dr R.D. Ravindran, Aravind Eye System The Aravind Eye System approach to monitoring was developed with the purpose to: improve cataract surgeries, minimize complications, track the outcome of cataract surgeries, and also benchmark outcomes between individual surgeons and between hospitals. One of the greatest challenges in monitoring is ensuring complete documentation in medical records. A good system should be able to document all the pre-operative records, intraoperative details including the complications, post-surgical complications and re-surgery. Follow-up visits are mandatory with documentation on post-operative visual acuity, refractive outcome and complication. The Aravind Eye System software has helped standardize work processes across the organization. It ensures data entry is done for all cases. The software also enables the authority to develop strategies to reduce complications and monitor surgeons’ competencies. It also allows benchmarking among hospitals. Audit and research can also be done using the monitoring system, hence improving the cataract services provided. (2) Importance of infection control in cataract surgeries – Professor Fu Qiang, China National Institute of Hospital Administration Blindness treatment may turn into blinding activity if infection in eye hospitals occurs. Environment, equipment and behaviour are three main risk factors and aspects for control strategies. Eliminating vision loss in infection control within eye hospitals should focus not only on improving visual acuity but should also on managing the risk factors. Cataract surgeries are minimally invasive but delicate. The surgeries are fast with high case turnover. This commonly leads to inadequate disinfection and sterilization of instruments, especially when there is a limited number of instruments and equipment particularly in low-resource settings. Neglecting risk factors of infection in patients, lack of infection monitoring and follow-ups, and sharing of medications can all lead to an increased risk of infection. Infection control should be included in the work process of patient management – from pre-, intra- and post-operative aspects. In addition, infection control should also include the operative personnel, disinfection and sterilization of instruments and equipment, and the hygienic status of the operating environment. Prevention of eye infection can be achieved by improving system management, which includes: 1. developing national strategies and standard measures on infection control; 2. incorporating infection control into the learning syllabus in medical universities; 3. continuous data monitoring and feedback at the national level; 4. awareness-raising campaigns on hospital infection control to medical personnel at all levels; and 5. implementation of continuous assessment and surveillance of infection control measures in hospitals. Strategies in eliminating “vision loss” in ophthalmic infection control can be achieved by promoting the establishment of an integrated management pathway (IMP), which includes: 10 1. developing professional technical standards and regulations based on accurate concepts of infection control; 2. developing clinical protocol in managing infection control for specific diseases; 3. multidisciplinary participation in hospital infection control management; 4. developing a mechanism for data monitoring and quality control based on risk management; and 5. encouraging an infection control culture within the hospital institution. (3) Hospital accreditation and patient safety – Dr Noela Prasad, ISQUA Hospital accreditation is a voluntary programme in which trained external peer reviewers evaluate a health-care organization’s compliance and compare it with pre-established performance standards. It is part of an effort to assess and improve health care. Accreditation has a set of minimum standards that focused almost entirely on care within the hospital. The first five minimum standards include: • organizing hospital medical staffs; • limiting staff membership to well educated, competent and licensed physicians and surgeons; • framing rules and regulations to ensure regular staff meetings and clinical review; • keeping medical records that include the history, physical examination and laboratory results; and • establishing supervised diagnostic and treatment facilities such as clinical laboratories and radiological departments. WHO published a global review on quality and accreditation in health-care services that looked into three aspects of standards: 1. Structure standards look at the system’s inputs, such as human resources, the design of a building, the availability of personal protective equipment for health workers, such as soap, gloves, and masks, and the availability of equipment and supplies, such as microscopes and laboratory reagents. 2. Process standards address the activities or interventions carried out within the organization in the care of patients or in the management of the organization or its staff. Process standards for a hospital or health centre might address areas such as patient assessment, patient education, medication administration, equipment maintenance or staff supervision. Recently, professional bodies have developed explicit process standards called clinical guidelines. Such guidelines are based on scientific medical evidence (evidence-based medicine). Government agencies, insurers and professional bodies are promoting their use in the management of common or high-risk clinical conditions. 3. Outcome standards look at the effect of the interventions used on a specific health problem and whether the expected purpose of the activity was achieved. 11 Examples of outcomes, both positive and negative, are patient mortality, wound healing without complications (e.g. infection), delivery of a healthy infant without complications, and a resolution of an infection through the appropriate use of antibiotic therapy. The purpose of accreditation encompasses the following: • Improve the quality of health care by establishing optimal achievement goals in meeting standards for health-care organizations. • Stimulate and improve the integration and management of health services. • Establish a comparative database of health-care organizations able to meet selected structure, process, and outcome standards or criteria. • Reduce health-care costs by focusing on increased efficiency and effectiveness of services. • Provide education and consultation to health-care organizations, managers and health professionals on quality improvement strategies and “best practices” in health care. • Strengthen public confidence in the quality of health care. • Reduce risks associated with injury and infections for patients and staff. Accreditation has led to the development of the National Quality Policy and Strategic Plan, which looks into eight elements: 1. defining and aligning with national health goals and priorities 2. developing a local definition of quality 3. stakeholder mapping and engagement 4. situational analysis to determine the state of quality and guide the policy 5. selection of improvement methods and interventions 6. development and clarification of governance and organizational structures for quality 7. development of health management information and data systems 8. selection of quality indicators and core measures. 2.2.3 Plenary session 3 – Strategies and tools for outcome monitoring (1) Ophthalmologist and optometrist: sharing the burden of cataract blindness – Dr Elias Hussein, Ophthalmologist, Ministry of Health Malaysia Dr Elias highlighted the increasing demand for cataract surgeries in Malaysia, estimated to reach 100 000 cases by 2020. The main challenge is the access to human resources to deliver cataract services, as other types of practitioners such as primary care doctors, family health physicians, assistant medical nurses and primary care nurses have high turnover and require immersive training in eye care. He mentioned a proposal to enhance and develop optometrists’ role as primary eye care providers, on the basis that optometrists are legislated and have specific training during their bachelor’s degree with a focus on ophthalmology services. 12 Other important points were discussed: • The different roles of optometrists at primary, secondary and tertiary care levels. • Malaysian optometrists are also conducting outreach activities. • Legislation has to enable and empower optometrists to act as health-care professionals. • Ophthalmologists need to work towards optimizing optometrists’ role for eye care delivery and sharing the burden of cataract blindness. • Combination of optometrists and ophthalmologists warrants efficient, comprehensible, accessible and equitable eye care in Malaysia. (2) Role of optometrists in the local action plan to eliminate avoidable blindness – Dr Duratul Ain Hussin, Optometrist (Public Health), Ministry of Health Malaysia Dr Duratul opened her presentation by asking all delegates if they knew who an optometrist was. She later presented results of her study on the low awareness of the optometrist profession. She related the importance of having a correct definition with the expectation that care service can be offered to the public. Approximately 90% of optometry posts are occupied, with the majority working at hospitals with ophthalmologists. Dr Duratul presented the roles of Malaysian optometrists in the prevention of blindness through vision screening activities; cataract, diabetic retinopathy and school screening. Her talk then focused on the cataract care pathway, and how Malaysian optometrists have contributed to the service: • Cataract care is divided into hospital based and outreach. • The job scope at hospitals includes refraction (pre- and post-operative), A-scan and keratometry. • Types of outreach are grouped into mobile cataract clinics and cataract finders. • For mobile cataract clinics, optometrists’ tasks are for before, during and after trips. These are inclusive of administrative, clinical and quality assurance. • For cataract finders, the approach is to create a network with health-care practitioners, increase awareness and improve access for referral to cataract surgery. Optometrists act as trainers with ophthalmologists. • The number of procedures conducted by optometrists is collected in an orderly manner, which is useful for expanding the profession in Malaysia. (3) Importance of Nurses in Ensuring Positive Cataract Outcomes – Mr Toksin Toki @ Tokisan, Ministry of Health Malaysia Mr Toksin presented the roles of nurses as health educators, organizers, facilitators, doctors’ assistants and documenters. Roles are divided into primary, secondary and tertiary care levels: • At the primary care level, nurses participate actively in the prevention of blindness activities through cataract finders, mobile cataract clinics and cataract carnivals. 13 • At the secondary and tertiary care levels, their main roles are in preoperative activities (performing electrocardiograms or ECG, blood pressure and counselling), intraoperative (scrub and sterilization of surgery instruments) and post-operative care (pain score, eye hygiene/care advice, medication advice and giving follow-up appointments). These are imperative in ensuring no complications develop post-operatively. Summary from the Ministry of Health Malaysia All ophthalmologists, optometrists and nurses in Malaysia have successfully demonstrated strong teamwork in cataract care detection and surgery care. Integration of these three types of practitioners is very well coordinated in hospital-based and outreach activities, supported by solid and comprehensive data collection for cataract care in the country. (4) Human-centred design: improving the quality of care from patients’ point of view – Ms Mardi Mapa-Suplido, Philippines National Committee for Sight Preservation How can we help our partners increase quality of care with outcomes defined by what matters most to patients? Can a human-centred design (HCD) process help to improve eye health equity and outcomes? Human-centred design (HCD) approach By using the HCD approach, quality of care is achieved through interactions between patients and health-care providers. They look at quality of care from different perspectives. The HCD process enables these to be merged to get at solutions in meeting the needs of both groups, hence achieving quality of care. This HCD process to increase quality of care helps to improve eye health equity and outcomes by identifying solutions that matter most to patients. Engaged patients will lead to better post-surgery actions and outcomes, and engaged health providers may help structure innovative solutions. HCD also identifies low-cost but high-impact improvement strategies for greater efficiency, patient satisfaction and continuous quality improvement. (5) Maintaining quality whilst on outreach – Dr John Szetu, Pacific Eye Institute Eye care in the Pacific has different challenges as the countries are made up of small islands in a vast ocean. Transportation is not easy, as the main mode of transportation is by boat. There are also aviation issues with runways, making it very costly to transport equipment, medication and the eye care team. Countries are also exposed to natural disasters such as tropical cyclones and earthquakes, as well as disease outbreaks. 14 Nevertheless, Dr Szetu and his team have managed to maintain a quality cataract outreach service. The team ensures that portable surgical equipment is transported by air and by boat, with a full medical supply team and human resources. Surgeries are done using full infection control techniques. Monitoring of cataract surgery outcome was previously done manually on paper, but has since switched to the CSOM (Cataract Surgical Outcomes Monitoring) software. Manual recordings are also done using Excel spreadsheets. The outcome of the last three years shows that the team has been able to maintain good quality. The average best-corrected visual acuity outcome for outreach services was 77%, comparable to 82% for hospital-based services. The PCR rate has also been kept below 5% for the past three years. The key learning points are: • monitoring improves quality; • monitoring is useful for planning; and • monitoring is essential for policy-making. (6) Novel technology for self-testing of visual acuity – Dr Andreas Mueller, Centre for Eye Research Australia Visual acuity testing is a very important aspect in eye examination, particularly in documenting the pre- and postoperative visual acuity. However, visual acuity testing is time-consuming, requires training and may lead to congestion in the eye clinic. Dr Mueller shared the technology developed on self-testing of visual acuity by a company collaborating with the Centre for Eye Research Australia. The technology allows self-testing of visual acuity by a patient. The patient sits or stands in front of a monitor, holding a board covering one eye at a time, holding a remote control in the hand, which allows the patient to press a button in response to a tumbling E shown on the screen. The prototype uses LED technology that can detect distance and automatically adjust the size of the tumbling E accordingly. The system is fully automated, and the result is automatically uploaded and documented onto the system. The use of this prototype saves time and human resources. Discussions: • It would be of benefit to explore technology that allows visual acuity testing at home using a web-based system connected to the hospital system. This would save a lot of time. • Promising technological advances have been made, with many ways of visual acuity testing using tablets and mobile phones. However, sometimes technology does not take into consideration certain aspects of head positioning, timing and contrast sensitivity, causing issues with reliability of the test. The right balance is needed between technology and making sure that information is not lost. • Technology is good but can be costly – and may not be accessible to the community. • Technology might be easy to use by younger age groups and educated people, but might not be user-friendly for older people who might have poor coordination and are not familiar with gadgets. 15 Country Which tool is most appropriate for central outcomes monitoring in your country? Where would you use the tool? Who would be responsible for overseeing data collection and translation? Cambodia A simplified version of the CSOM tool All eye units throughout the country Logbook to collect data. A subcommittee will assimilate the data. The data would be used for planning intervention and quality control. China Cataract surgical form. BOOST. All eye hospitals. Department of health – should receive a monthly summary outcome. Ministry of health to monitor the outcome for quality control. Lao People’s Democratic Republic Cataract surgical record form. Consider using BOOST in the future. Will start using BOOST in the central area and then expand nationwide. Ophthalmic nurse would capture the date and fill in the forms. Feedback mechanism to the province. Malaysia National Eye Database – Cataract Surgery Registry. Would also try out BOOST with some modification. All eye centres under the Ministry of Health and outreach programmes. BOOST would be used in Federal Territories Islamic Religious Council (MAIWP) Cataract Surgery Satellite Centre. Monitoring using web- based National Eye Database. BOOST also can be monitored online. Data would be used for quality outcome monitoring and future interventions. Mongolia BOOST – at hospital and individual level. Simplified version of Malaysian National Eye Database or Aravind, at national level. To be used by all hospitals. Data collected by department of ophthalmology and department of health insurance. Data would be used for research. Advocate to the Ministry of Health so that all hospitals should report to national centre for health development and monitored by the Ministry. The feedback would be used as quality indicators and for resource allocation. Would also link to health insurance system for funding. Papua New Guinea BOOST – for individual trainees and doctors. Reinforce the use of monitoring cataract surgical outcome tool. To be used by all hospitals. Report to the Ministry of Health and chief ophthalmologist. 16 Philippines Simplified CSOM tool, and incorporated in Eye Disease Registry (web-based system). To be used in all Ministry of Health hospitals and community eye health programmes. Mandatory by department of health, to produce report to get funding from the national health insurance system. Monitoring by Department of Health. Fact sheets would be produced quarterly. Results would be used for programme planning. Viet Nam Web-based tool QCCI, which is an adaptation of the CSOM tool. To be used throughout the country. Data to be collected by each hospital and reported to the Ministry of Health. Ministry of Health would monitor and use the data for quality control and intervention. 3. CONCLUSIONS AND RECOMMENDATIONS 3.1 Conclusions The meeting successfully conveyed the importance of quality in cataract surgery outcomes. Monitoring is particularly crucial in ensuring quality eye care. Country participants brought up three main areas that require WHO/IAPB support: 1. Technical support. Member States need technical support in developing or modifying existing monitoring software and guidelines as well as software installation and training. A follow-up workshop on outcomes monitoring progress would be discussed further with IAPB and partners, along with the need for a long-term regional course. 2. Changes in human resources in eye care. The meeting successfully communicated the important message of changing behaviour and highlighting the value of quality that we have to offer. Discussions also covered the roles of optometrists and refractionists, and the link between volume and quality. Working effectively in a team, optometrists can have a large impact on national programmes. There is also a need for biometry training and essential biometry equipment in ensuring better quality. 3. Changes in policy. WHO/IAPB would have a role in advocating at a higher level to governments, but requests for support should be initiated at the health ministry level and brought to the attention of the respective WHO country office. Support from WHO/IAPB will be targeted as each country has different challenges and boundaries. 3.2 Recommendations 3.2.1 Recommendations for Member States Member States are encouraged to consider the following: Cambodia • Develop and establish a standard cataract surgery outcome monitoring tool, followed by a pilot study to identify the barriers and challenges in its implementation, and find solutions to overcome it. System to be integrated into the health information system of the Ministry of Health and to include feedback to all eye units. 17 China • Develop a committee to advocate the importance of cataract surgery quality control, and develop parameters in evaluating cataract surgery quality. • Consider quality training for cataract surgeons. Lao People’s Democratic Republic • Improve the quality of the existing basic tool for cataract surgery outcomes monitoring as well as its implementation throughout the country. • Improve teamwork with ophthalmic nurses/refractionists to improve cataract surgery outcomes. Malaysia • Increase efficiency of ophthalmologists in the country by ensuring they have a sufficient number of surgeries without compromising quality. • Strengthen the existing eye care services pathway by bringing in universities and the private sector to work together with the public services in ensuring quality cataract surgery outcomes. Mongolia • Arrange a meeting with information technology and quality assurance departments. • Further support consideration of implementing or adopting a specific surgery outcomes monitoring tool and discuss its implementation. Papua New Guinea • Strengthen usage of existing Cataract Surgical Outcomes Monitoring (CSOM). • Present the plan to the Ministry of Health to set up a technical working group to co-facilitate cataract surgery outcomes monitoring. Philippines • Work together with the national health insurance system in implementing a cataract surgery outcomes monitoring system, to be implemented by the first quarter of 2019. • Advocate the integration of the role of optometrists into the health system through seminars and conferences. • Involve optometrists in six-week post-operative reviews and to be part of the service providers for cataract surgery outcomes monitoring. • Conduct a training session for biometry and keratometry. Participants would like to learn from Malaysia on this aspect. Viet Nam • Finalize and submit national cataract surgical guidelines to the Ministry of Health. • Introduce BOOST in the annual eye conference, which would be a good platform for advocating surgical outcome monitoring to ophthalmologists. 3.2.2 Recommendations for WHO and partners WHO/IAPB is requested to consider the following: 18 Cambodia • Provide technical support, especially with regard to the programme software, and training on using the software. • Support the dissemination of the software to relevant organizations and eye units, and also in monitoring and evaluating the outcome. China • Support to introduce simple measures in cataract surgery outcome monitoring, such as BOOST. • Advocate with the ministry of health, together with the support from the ophthalmological society. Lao People’s Democratic Republic • Provide technical support in software installation, software training, as well as supervision and monitoring. • Conduct an in-country follow-up workshop. Malaysia • Provide technical support to develop the country as a training hub for public health ophthalmology for the WHO Western Pacific Region and as an example of integrated ophthalmology and optometry processes. Mongolia • Provide technical support to bring a technical consultant to the country for software implementation. Ideally, the software consultant should attend the upcoming meeting of the ophthalmological society to advocate the importance of software implementation. • Provide support to develop guidelines and protocol for quality eye care. Papua New Guinea • Provide support to form a technical working group together with the Ministry of Health. • Provide technical support to develop guidelines and protocols and monitoring systems. • Provide technical support to conduct a surgical workshop for surgeons within the next two years. Philippines • Provide support to integrate eye care into the public health system. Viet Nam • Support interaction with the Ministry of Health, particularly in writing an official letter to stress the importance of cataract surgery outcomes monitoring and quality eye care nationwide. • Support setting up of monitoring tools at provincial and national levels. 19 ANNEX 1 CATARACT OUTCOMES MEETING BACKGROUND PAPER 20 21 22 23 24 ANNEX 2 PROGRAMME Day 1: Wednesday – 19 September 2018 (Venue: Shah Alam Hospital) Time Session Notes 0730H-0830H Registration 0900H-0930H Arrival of VIP guests and photo session 0930H-1015H Launching Event Master of Ceremonies – Dr Noor Farizah Ngah Welcome speech and Official Opening by the Director General, Ministry of Health Malaysia (15min) Welcome by CEO Shah Alam Hospital (5min) Speech by WHO Expert Consultant (5min) Speech by IAPB Regional Chair (5min) Speech by ICO representative (5min) Dr Andreas Mueller Ms Amanda Davis Professor Serge Resnikoff 1015H-1045H Morning Tea Press Conference for VIP; tea for all 1045H-1145H Plenary Session: State of Play Snapshot: Evolution of Cataract Surgical Performance Monitoring in Malaysia (15min) Snapshot: Sharing Malaysia’s Experience in Cataract Surgical Outcome Measurement (15min) Snapshot: A self-monitoring tool: BOOST – introductory video and presentation (15min) Dr Goh Pik Pin Dr Mohamad Aziz Salowi Dr Nathan Congdon 1145H-1245H Panel Session: Gender and Cataract Services Utilization Case Study: Initiative to address Gender Gaps in the uptake of Eye Care Services in Malaysia – Panellists: Farizah, Amanda, Manfred Ms Jennifer Gersbeck Dr Nor Fariza Ngah 1245H-1400H Lunch and Prayer LAUNCHING EVENT ends – WHO/IAPB/MOH workshop starts at 1400H 25 Day 1: Wednesday – 19 September 2018 (Venue: Shah Alam Hospital) 1400H-1410H Election of Officer Bearers (Chair and Rapporteurs) Ms Amanda Davis 1410H-1420H Expectation and Outcomes What is required to advance better quality outcomes? What is and isn’t working? Where are the gaps? Professor Serge Resnikoff 1420H-1430H Statistics on what cause poor outcomes – what is the distribution? Dr Andreas Mueller 1430H-1530H Plenary Session: State of Play Fast Five Country Introduction 1. Who am I? 2. What Cataract Surgery Monitoring is undertaken in my country? 3. What are the Barriers & Challenges? 4. What do I hope to achieve from the workshop? Cambodia, China, Lao People’s Democratic Republic, Mongolia, Papua New Guinea, Philippines, Viet Nam Moderator: Dr Nor Fariza Ngah Each country delegation will be given a template of 5 slides to present in 5 minutes 1530H-1600H Afternoon Tea 1600H-1700H Workshop Session: Quality vs Quantity How do we reduce Backlog and Maintain Quality? Group work (20min) Group report back (20min) Moderators: Dr Andreas Mueller & Dr Manfred Moerchen Facilitator: Datuk Dr Raja Norliiza Raja Omar Outcome: An understanding of the link between quality and quantity? 1900H-2100H Welcome Reception Holiday Inn Glenmarie 26 Day 2: Thursday – 20 September 2018 (Venue: Shah Alam Hospital) Time Items Remarks 0900H-1030H Workshop Session: Cross-Cadre Cooperation Highlighting Importance of Government Sector – Hospital Infection and Ophthalmology De partment (20mins) Ophthalmologist and Optometrist – sharing the burden of cataract blindness (10min) Role of Optometrists in the Local Action Plan to Eliminate Avoidable Blindness (10min) Importance of Nurses in ensuring positive cataract outcomes (10min) Group discussion (20min) Feedback (20min) Facilitator: Dr Zaharidah Abd Kadir Outcome: Identification of cadre-gaps by country? What are the barriers? Professor Fu Qiang, National Institute of Hospital Dr Elias Hussein Mdm Noor Zahirah Husain 1100H-1130H Tea Break 1130H-1245H Workshop Session: Monitoring Quality Introduction: What is Quality? How important in your country? What is being done? BOOST Presentation (Nathan Congdon) (20mins) Group work (30min) Group report back (20min) Facilitator: Dr Mohamad Aziz Salowi Outcome: identification of equipment and technology gaps by country Discussion: How can BOOST technology be best utilized. Engagement and research? 1245H-1400H Lunch and Prayer 1400H-1420H Plenary Session: Education What is best practice and what does ICO have to offer? Professor Serge Resnikoff 1420H-1445H Wrap Session – chaired by Serge Resnikof Rapid Fire feedback Post submissions 1445H-1700H From Shah Alam Hospital
Cataract Centre, Federal Territories Islamic Religious Council (MAIWP)/ Hospital Selayang (40km) Managing Outcomes in Practice Briefing on KK1M Concept as strategy to overcome Cataract Blindness Care Pathway discussion Live Surgery 1700H Close Lunch & Learn – 20 minutes Rapid Fire discussion Day 1: OUTREACH – Equipment, Technology, Monitoring and Evaluation. Dr John Szetu Day 2: EDUCATION – Cambodia Example / ISQUA. Dr Noela Prasad 27 ANNEX 3 LIST OF PARTICIPANTS COUNTRY REPRESENTATIVES Cambodia Dr Sok Kheng, Dr Khou Iengou China Professor Zhao Jialang, Professor Fu Qiang Lao People’s Democratic Republic Dr Khampoua, Dr Bouakhanh Phakhouthong Mongolia Dr Chimgee Chuluunkhuu, Dr Oyunchimeg Maamkhuu Papua New Guinea Dr Robert Ko, Mr Wilhem Paik Philippines Dr Noel Chua, Dr Rosario Uy Viet Nam Dr Tran Minh Dat, Dr Tran Huy Hoang Malaysia Dr Haizul Ikhwan Murat, En Ku Hazemi Ku Ismail, Dr Noor Raihan Khamal, Dr Naning Sachima STAKEHOLDERS REPRESENTATIVES World Health Organization (WHO) Dr Andreas Mueller International Agency for the Prevention of Blindness (IAPB) Mr Drew Keys International Agency for the Prevention of Blindness (IAPB) / The Fred Hollows Foundation Ms Jennifer Gersbeck International Council of Ophthalmology (ICO) Professor Serge Resnikoff Queen's University Belfast - BOOST Project Professor Nathan Congdon The Fred Hollows Foundation - BOOST Project Ms Sarity Dodson The Fred Hollows Foundation, Cambodia Mr Paul Humphrey BEQUAC Project Mr Nguyen Tien Long Eye Care Working Group, Viet Nam / The Fred Hollows Foundation, Viet Nam Dr Pham Quoc Anh Eye Care Working Group Viet Nam / Eye Care Foundation, Viet Nam Ms Luong Thi Quynh Lan Eye Care Foundation, Viet Nam Dr Luong Huu Thien Eye Care Foundation, Cambodia Mr Sambath Pol CBM Dr Manfred Moerchen Brien Holden Vision Institute Dr May Ho Pacific Eye Institute Dr John Szetu The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Mr Gerhard Schlenther International Society for Quality in Healthcare (ISQUA) Dr Noela Prasad National Committee for Sight Preservation, Philippines / The Fred Hollows Foundation, Philippines Ms Mardi Mapa-Suplido 28 ANNEX 4 OPENING CEREMONY Opening ceremony officiated by Dato' Dr Norhisham, Director General, Ministry of Health Malaysia – group photo 29 Speeches by Dr Jacqueline Ro (WHO Representative), Mr Drew Keys (IAPB Regional Manager), Professor Serge Resnikoff (Chairman, ICO) and Dato' Dr Norhisham, Director General, Ministry of Health Malaysia Dr Andreas Mueller (WHO/CERA), Dr Nathan Congdon (Global Eye Health/Orbis), Dato' Dr Goh Pik Pin (National CRC) and Dr Nor Fariza Ngah (National Head of Ophthalmology Services) www.wpro.who.int