“I have greater assurance about product quality and service quality when I walk into a Sagar for a snack than when I go into a hospital!” (Sagar is a chain of restaurants in Delhi best known for serving South Indian food.) I have often said this to our consultants and managers to illustrate the unacceptably low levels of reliability in most healthcare delivery encounters – including at our hospital. And despite my having this realization and my being chief executive, there has been limited progress on improving safety and reliability in our own organization. So the natural question is, Why?
There is no simple answer. It’s a bit like asking why driving on Delhi’s roads is so chaotic and unsafe despite it being the capital of the country. Safety is impacted not just by your behavior and choices but also the environment. Behind an unsafe act of someone driving in the wrong lane may lie contributory factors like poor road conditions or lack of a safety culture which in turn may reflect a governance failure. In healthcare delivery, an unsafe act may reflect poor education (the quality of graduates of India’s medical and nursing schools is very variable), lack of standardization (often different consultants within a specialty in a hospital insist on different pathways for “their” patients thus increasing complexity and the chances of error), and inadequate staffing (many hospitals face high turnover and chronic shortages in the ranks of nurses and junior doctors). But this is not the complete story.
Consider the case of an elderly patient who requires surgery and has diabetes and hypertension. Often investigation and management of pre-existing conditions in such patients is postponed until admission on the night before for surgery. Even if blood sugar or blood pressure control is found to be inadequate, the admitting surgeon feels hesitant to postpone the surgery. If post-operatively the patient develops a cardiac complication, the nurse or junior doctor may not detect the condition in time, and thus increase risk. Should the patient die, it would not be uncommon for the surgeon and hospital to engage in finger-pointing –with the hospital blaming the surgeon for proceeding without adequately controlling risk factors and the surgeon blaming the hospital for poor support. The potentially preventable nature of the complication will not likely be disclosed to the patient’s family and the hospital and surgeon will want to “move on” from the memory of the “unfortunate” event.
Let’s analyse this case from a systems perspective. Private medical practice in urban India takes place in a competitive marketplace and both consultants and hospitals don’t want to risk losing patients by demanding treatment that may increase cost, fully discussing risks of the surgery, or revealing limitations of a hospital. Hospitals rely on consultant reputation to attract work and feel compelled to defer to consultant judgement about selecting patients. When complications occur, weaknesses in the system get revealed – particularly the inadequate defences to protect the patient.
There are other challenges – such as limited requirements for transparency making it difficult for anyone to really know about the safety record of a hospital or a consultant. Most of the time, unsafe acts don’t result in serious harm and this leads providers and patients to ignore the potential for harm. An environment in which any error is seen as negligence on the part of the providers also discourages openness and thus learning. Within the medical profession, understanding of safety science and capacity for leading change is limited as these topics are not part of medical education. In summary, the framework for clinical governance is weak in most hospitals.
Beginning the journey of making our hospital safer
So what can we do other than simply raise our hands in frustration and blame the “system”? The National Patient Safety Foundation of USA has outlined five concepts for transforming healthcare safety:
- Integrated care platform
- Consumer engagement
- Joy and meaning in work
- Medical education reform
We are beginning to apply this framework in our hospital. We’ve started measuring outcomes in select specialties and sharing this information internally; we’ve publicly disclosed our caesarean rate and aim to share our patient feedback data soon. We’re working to redesign our care platform to enhance reliability and are exploring adoption of group practice for maternity care and checklists for making surgery safer. We’re improving consumer engagement by empowering patients with relevant information and giving them more time for informed decision-making. We’re training our nurses one-on-one to enhance their skills and engaging the entire care team to make them feel valued. And we’re encouraging doctors and other staff to enhance their ability for leading improvement – through lectures, case discussions, and online courses such as The Science of Safety in Healthcare offered by Johns Hopkins University on Coursera and the Open School of the Institute for Healthcare Improvement. Most of all we’re trying to get everyone to reconnect with their original purpose for entering the health professions and asking ourselves how we can be more in sync with that calling.
Taking on the goal of improving safety is like committing to a marathon without a finish line – it is daunting but also exciting. Along the way we hope to enjoy the highs of running a good race and doing our best for patients!