Tag: Standardization in healthcare Ghana

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THE NEED FOR STANDARDIZATION IN THE HEALTH CARE SYSTEM IN GHANA

All things being equal, you should get the exact same experience in the same industry every single time. That is what standardization is about. If I fly Emirates or Delta or American Airlines fifty times, I should have no ordinary way of knowing which specific pilot was in the cockpit. The takeoff experience should be the same, and the landing experience should be the same too, all things being equal. You don’t want to board a flight not knowing what to expect. That is called standardization. The airline industry has almost perfected this art and science. Now I am not talking about whether they serve you potato or beans. As important as that is, that usually has nothing to do with whether you arrive safely at your destination (unless you have some kind of food allergy).

One important outcome of standardization is automatization – the elimination of discretion from the dispensing of a service.

For example, no matter the cook, kitchen hand or chef in a McDonald’s, a hamburger at McDonald’s will taste the exact same way. This is so unlike your local bread baker – one day the bread is soft and tasty, and the next day the bread is half – burnt, depending on the mood of the baker.

Whereas such discrepancies can be acceptable when it comes to bread, in terms of health care it could mean the difference between life and death. If a patient presents to two different facilities with the same complaints at the same time (if that were possible), the clinicians at both places should be able to come to the same diagnosis or diagnoses. Otherwise, one of them is wrong. It’s that simple.

That is called standardization. God is the architect of standardization. A second has the same value in Accra as it does in Beijing, Sydney, and New York City. If it weren’t so, there would be no way to compare various athletic competitions held in different cities at different times.

The Airline Industry understands this very well. A typical preflight checklist consists of well over 30 items for the pilot and crew to check before takeoff. A Boeing B-17 prototype crashed in Dayton, Ohio, in 1935. The pilots, both of whom were killed in the crash, had “forgotten” to disengage the gust locks before takeoff. The result was costly for Boeing and the pilots’ families. The management and engineers of Boeing introduced the checklist into their operations. Checklists have since become the industry norm in aviation. The industry figured that it was simpler to have it written and checked off every time than to rely on the pilots’ good intentions.

In 2014, a Gulfstream IV crashed during takeoff at Bedford-Hanscom field in Massachusetts, killing all four passengers and three crew members. It was found that the crew had failed to disengage the gust lock. Not only that but if they had run a preflight control check, they would have found out that the gust lock was still engaged. In fact, in that case, the National Transportation Safety Board found out from the plane’s records that 98 percent of the plane’s previous 175 flights were conducted with incomplete flight control checks. Further studies also found out that many business jets conducted only partial control checks before takeoff – a significant 15 percent of them. About two percent actually performed no checks whatsoever.

These numbers are much better where commercial airlines are concerned, because of tighter regulatory controls. In fact, it is the introduction of these standards, coupled with innovation, which has made flying the safest mode of transport. If automobile drivers would engage the same level of seriousness to their trade, traveling by road for many people would be much safer.

According to Investopedia, Standardization is a framework of agreements to which all relevant parties in an industry or organization must adhere to ensure that all processes associated with the creation of a good or performance of a service are performed within set guidelines. This ensures that the end product has consistent quality and that any conclusions made are comparable with all other equivalent items in the same class.

In essence, where standardization is applied, the quality of a good or service should not vary widely from point to point.

Many of us have had various experiences with healthcare providers. We have our favorite and least favorite doctors and nurses. Now, where proper standardization is in place, you should not be too worried whether or not your favorite health worker is on duty, because you will get the same quality of service from whoever is on duty.

The Health Sector has embraced some degree of standardization, especially when it comes to the field of surgery. Properly ran operating rooms use checklists. There is very little room for assumption, right from the proper identification of the patient, to the signing of consent forms, to the draping of the patient, to the type of incision, to the manner in which knots are tied.

The field of obstetrics, because of the huge outcry against maternal mortality, has adopted stringent standards as well, and these have led to significant reductions in maternal mortality, even though the situation is still largely unsatisfactory because of the inadequate numbers of suitably qualified health professionals.

Other fields within the health sector need to begin to adopt similar systems in order to enhance the quality of healthcare delivery. For example, instead of leaving the management of the patient to the discretion of the practitioner, some things need to be standardized. These industry standards do exist but are not being practiced universally. Because of this discrepancy, a patient with the same complaints will get two very different management systems from two hospitals a few blocks from each other. Whereas the specific treatments may differ from practitioner to practitioner, the diagnoses should not. A patient who presents with diarrhea and vomiting to a hospital, for example, should always have their electrolytes checked and corrected, in addition to being rehydrated. A diabetic patient who reports for review needs to have their eyes checked as a matter of protocol. Their urine should be checked for microalbuminuria.

Even though various checklists have been developed over the decades by various reputable bodies, many health professionals still rely on their own discretion in the management of patients, with the inevitable results of inconsistency and unreliability in the delivery of health services. One study conducted in Sub-Saharan Africa revealed that eighty percent of anesthetists said they did not know about the WHO surgical safety checklist or did not use it.

There are algorithms that have been developed, tested and found to be effective. It will pay a great dividend to both service providers and patients alike if service providers begin to actively make use of these checklists. There are internationally accepted guidelines for the management of virtually any condition under the sun. This does not mean that a certain outcome is necessarily guaranteed, but it does largely eliminate avoidable errors. In the United States, hospital errors are the third leading cause of death, after heart disease and cancer. That is a whopping 250 000 people dying out of medical errors. In Ghana, the statistics are not available for obvious reasons, but you can take a good guess.

You see a checklist ensures that you don’t miss anything important.

An auto mechanic who uses clearly developed checklists to diagnose his cars and solve problems will outperform a very brilliant mechanic who simply relies on his guts. That is why McDonald’s is a globally successful restaurant business, and your neighborhood eatery is struggling to stay afloat.

An “average” doctor who meticulously sticks to proper industry standards and uses checklists judiciously will deliver greater value to his patients than one who relies on his instincts alone. It is time that we fully embrace the use of timesaving and lifesaving standards in the health sector.

January 5, 2019 / by HeiDoctorGhana

THE NEED FOR CHECKLISTS IN HEALTHCARE SYSTEMS IN GHANA

CHECKLISTS SAVE LIVES

Checklists can save you time, money and lives. Just ask Boeing Airlines. Their B-17 prototype crashed simply because the two pilots “forgot” to disengage the Gust Lock. That was in 1935. Both pilots were killed. The prototype was destroyed. Boeing introduced checklists. Nowadays a typical commercial airline pilot would use about six different checklists prior to takeoff. That is usually about 30 different items to inspect, engage, and check off before takeoff. Pilots and crew who have been cavalier about checklists have paid the price.

In 2014, a business jet registered to SK Travel, LLC, and operated by Arizin Ventures LLC, overrun the runway, and collided with approach lights and a communication antenna, killing the crew of three and four passengers. The National Transportation Safety Board found out the following as a result of their investigations as the probable cause of the crash: “During the engine start process, the flight crew neglected to disengage the airplane’s gust lock system, which locks the elevator, ailerons, and rudder while the airplane is parked to protect them against wind gust loads. Further, before initiating takeoff, the pilots neglected to perform a flight control check that would have alerted them of the locked flight controls. A review of data from the airplane’s quick access recorder revealed that the pilots had neglected to perform complete flight control checks before 98% of their previous 175 takeoffs in the airplane, indicating that this oversight was habitual and not an anomaly. Check the number of times the word “neglected” was used in that paragraph alone. In effect, the particular crew was in the habit of disregarding the standard checklists prior to flying. They did this one hundred and seventy-one times without incident on that particular airplane, but when it finally caused a problem, it led to a loss of lives. The interesting fact is that the pilots were not novices. The Captain had flown more than 11, 250 hours. The First Officer had flown more than 18,200 hours of flight time as pilot-in-command and 2,800 hours in Gulfstream-IV airplanes. But despite their vast experience, they were negligent when it came to observing protocols. A team is only as strong as its checklist.

The airline industry uses checklists to ensure that critical things are actually carried out and recorded.

The field of medicine has greatly evolved over the past 200 years, and many aspects of patient treatment have been standardized and automated. Surgery has greatly benefited from standardization and has used it to effectively improve patient outcomes. A simple thing like an instrument count has gone a long way to ensuring that various instruments are not left inside a patient’s abdomen after a procedure. Those hospitals that have ignored the Instrument count have suffered negative outcomes and negative publicity as a result of catastrophic outcomes. The loss of lives and morbidity that have resulted from such incidents are almost innumerable globally.

The fact is that no matter how skilled a team is if they would not pay attention to standardization, they would eventually get into trouble. A team is just as strong as its checklist. The use of a checklist has many benefits.

Firstly a checklist helps us become better organized. It is simpler to do steps 1 to 10 in that order repetitively than to simply attempt to tackle 10 tasks simultaneously.

A checklist actually enhances creativity too, because it becomes easier to master a set of repetitive steps. As we instinctively begin to perform these tasks with mastery, our imagination is free to take on other tasks. Instead of trying to remember what to do next, a checklist takes care of that, and we can use our minds for more creative tasks.

A checklist enhances productivity because it is easier to accelerate the performance of repetitive tasks individually, leading to more efficient use of the time.

It is easier to delegate specific tasks when we use checklists because there is a way to verify that they are accomplished.

Most importantly, checklists are a lifesaver. Since the introduction of checklists, surgical infections have reduced significantly, leading to a significant reduction (more than 40 percent) in mortality from various procedures.

The use of checklists must be embraced by all health practitioners and hospitals, in order to deliver a predictable level of high-quality care to patients.

Checklists should be used even for the most basic of functions. For example, there are clear recommendations that have been put forward when it comes to the components of a general wellness visit for various age groups and based on gender. Using a checklist ensures that it is possible to conduct a more thorough exam every single time, rather than leaving it to the discretion of the practitioner. Of course, where it is necessary, changes can be made that would suit the specific patient. This simplifies the life of both the doctor and the patient. It is simpler to simply check off a list of things to be done than to laboriously try to list them from memory every single time.

It is not enough to have a checklist in place, however. It must be enforced. There is no team of one, which is why the nurse has a duty to cross-check that the items are actually executed according to plan. There is a nurse who stopped a cardiothoracic surgeon after an open heart surgery from closing up. She insisted that an instrument had been left inside the patient’s chest. The surgeon was adamant. He insisted on closing. He was sure he had accounted for all his instruments. The nurse stood her ground and said: “I will not allow you to close.” The surgeon was angry. They did the instrument count again. That instrument was missing. When the doctor removed his initial clips, there was the instrument in the chest of the patient. These incidents have happened time and again. A good team leader knows the value of his team members, and rather than try to shout them down, will instead empower them to make the team more effective.

Using checklists will greatly enhance the work of the Ghanaian doctor. Not only will the doctor become more efficient, but the patients will also be better satisfied. Time will be saved as well. Instead of writing copious notes, simply checking off items that should be done or that have been done will save a lot of time.

Checklists do not get in the way. They actually make the way clearer and simpler for everyone. Would you like your pilot to say to his First Assistant during taxiing “I wonder if the Gust Lock is off or on?” or you’d rather rest knowing that every single item on the checklist had been meticulously checked and cross-checked. A single “sheet of paper” can save you from a lot of trouble. Literally.

January 5, 2019 / by HeiDoctorGhana

LONG WAITING TIMES – THE BANE OF HEALTHCARE SYSTEMS

 

The length of the waiting period is inversely proportional to the patients’ perception of the quality of healthcare delivered, and the patient’s satisfaction. The longer your patients wait to see the doctor, the less satisfied they will be. It is really that simple.

 

No one likes to wait for long periods for a service, and healthcare is no different in that regard. Healthcare is quite different in other regards though in the sense that the people who come to the hospital are generally not too eager to be there in the first place. Most people would usually not go to the hospital or clinic unless they absolutely had to. Queuing up at Disneyworld is not the same as queuing up in a hospital OPD. The former has the promise of certain fun. The latter generally holds no promise of any kind of fun for the patient. Prolonging their waiting times for longer than necessary just complicates matters.

 

Patients have been known to get angry and walk off after waiting for great lengths of time. Others have lost their calm and assaulted health personnel. The loss in revenue and reputation to health facilities cannot be overemphasized. This is one area many hospitals have not paid attention to. They used to get by with the nonchalance because patients did not have too many options to choose from. One particular study of the waiting times at a major health facility in Nigeria showed that the patients waited anytime between 60 to 180 minutes just to see the doctor. They spent on average about 5 minutes with the doctor. As scandalous as that sounds, it is quite representative of what pertains in many health facilities, especially public health facilities, which are generally overwhelmed by attendants and understaffed at the same time. In order to change the status quo, there must be a strong political will to overhaul the healthcare system.

 

The situation in the private sector is quite varied. On one end of the spectrum are some facilities that are battling for survival, with low patronage. Those are not the subject of this post. The other end of the spectrum is made up of facilities which are just like the busy public facilities, with congested waiting areas and short consulting times. For the hospital owner who didn’t use to care about the length of the waiting period, it is time to wake up. This is because patients are becoming aware that they have options. Those that cannot afford the options would simply pray for the day they acquire enough money so they can seek better experiences elsewhere.

There are a few factors that are responsible for the long waiting times in the hospitals.
First is the inadequate staff numbers that are deployed to tackle the disproportionately high numbers of patients. It is not uncommon to see one receptionist attending to dozens of patients at a time. This scenario plays up because for some owners of health facilities, especially people without any medical training, healthcare it is simply a game of numbers, where they are interested in making the barest minimum amount of investment and yet reap high returns.

 

The healthcare industry can be successful, even lucrative when run properly. The vast majority of investors in the health sector, I am sure, have noble intentions of actually delivering quality service. Some owners, however, are only interested in making a profit. They sacrifice patient satisfaction for a higher return on investment. Some too can simply not help it because they do not have the funds to hire the right number of staff members. They may have jumped into the healthcare industry believing that it was lucrative, only to have the shock of their lives when they realized that it called for much more than they were able or willing to invest.

 

Another factor that can affect patient satisfaction is the quality of the waiting period. No matter how naturally patient someone is, it is much easier to wait in a beautifully furnished and air-conditioned waiting area than to wait in a crowded, hot and humid “waiting” area with no air – conditioning and no entertainment. The socialist approach to healthcare whereby governments indoctrinate the people to believe that they should expect “free” healthcare has created the situation whereby the government cannot provide decent health facilities for the general population. (Sometimes the government is able to build a beautiful edifice but cannot get it to run efficiently.) Unfortunately, some private health facilities have bought into the dogma of socialist healthcare. They provide the bare minimum at socialist prices. The end result is that they are not able to efficiently run their facilities. A well designed and properly furnished waiting area goes a long way to improve the patient experience. People will appreciate the value you provide, and they will recommend your facility to their family and friends.

 

Whereas there is no specific “right” waiting period, it is generally accepted that most patients will be happier with a health facility if they waited for no longer than thirty minutes to see their doctor.

 

Hiring the right number of staff in the beginning, and scaling up to meet increasing demand is the way to go. If your clinic is just starting off and not so busy yet, instead of hiring a receptionist, assign a nurse to your front desk. You can have the nurses rotate. Once your patient load begins to increase, you need to hire a full-time receptionist well trained in customer care. Or you can simply hire an extra nurse to share the workload. It is important that you have a pleasant person at the front desk. It is easier for patients to wait when the front desk person is patient and pleasant. The person at the front desk must be suited to the kind of clients you seek to attract to your facility. If your goal is to compete with the government health posts for patients, then you should hire accordingly. There is nothing inherently wrong with that. Just know that it will be very difficult for you to beat the government in a price war. The government can offer everything for “free’’ because it doesn’t need to work for the money – it can simply extract more taxes from you to pay for the freebies.

 

If your target is to attract middle and upper-class patients, hire appropriately. You need to respect your patients. Do not put someone at your front desk who is rude, does not communicate well, and always has gum in their mouth. That would just not cut it for your patients. Your business will soon begin to suffer, as your customers discover a facility with a nice receptionist who doesn’t chew gum or frown her face often.
Sometimes the bottleneck is in other parts of the patient flow through the hospital. For instance, you may have very smart receptionists, but your nurses may be inadequate or simply slow. Worse still you may not have the right number of doctors to take care of the patients. A lot of common sense must go into running a health facility. If you have 100 patients in your clinic you cannot have just one or two doctors on duty at the time and be “fine.” You ought to actually sit down and think it through. Does that proposition make sense to you? If you were among the 100 patients waiting would that be acceptable to you to have only one or two doctors?

 

Sometimes the problem is with the cashier, or the laboratory, or the imaging department if you have one. If your “laboratory” takes 4 hours to run a basic test, it might be a good idea to outsource this to a proper laboratory which would give you timely and accurate results. It is inappropriate for your patient to spend 13 minutes with the doctor and yet spend 20 minutes trying to pay their bill to the cashier. You might need to hire a few more cashiers.

 

The thing about fixing these issues is that you cannot correct what you don’t measure. You need to actively measure the average waiting time in your facility, and also find out how long patients spend altogether when they come. You can use a timing chit which you give to the patient at the time they enter the facility, and which will be endorsed at each station as the patient progresses through the system in the facility. When you collect about one hundred chits, you will have sufficient information to make a judgment. Some simple arithmetic will give you the average waiting time.

 

If you are unable to do this, however, you can find a good statistician. If you cannot afford the fees, you can get any high school Math teacher and have him help you. Just make sure you pay a fair price for the help. Paying for the help will help you take it seriously.
Once you have the data, you can begin to look at areas where the patients have been spending the most time. (I can almost bet that is unlikely to be their doctor’s consultation.) You can begin to make changes to your system that will greatly impact on the perception of the quality of care your patients get from your facility.

January 3, 2019 / by HeiDoctorGhana