Afaal’s Column

It’s been over an year since we started to work on getting the Hospital Laboratory internationally accredited. It is important that as many of our services are certified to internationally accepted standards in order to gain and maintain confidence of the public.

One of the major endeavours for me in managing ADK Hospital is to get such standards in place and get international recognition. So I decided that we should start slow and improve our services to achieve such recognition.

Last year we established a new laboratory and acquired some more machinery and expert staff. With this development I thought that it would only be fitting that we get this lab accredited. On proposing this, my staff was very enthusiastic and they gave me a commitment to make this happen.

Laboratories get two types of accreditation from the International Standards Organization. The ISO 9001:2000 is the Quality Management System Standard and the ISO 15189 is specific to medical laboratories and is a unique standard that takes into consideration the specific requirements of the medical environment and the importance of the medical laboratory to patient care. We decided to initially go to the Quality Management Standard and later go for the more detailed one. In reality, the initial Management Accreditation sets the standard for the other one and hence it will be much easier to get it with this in hand.

In fact, it was a lot of hard work to get all the major core conformities in place. We had to get all protocols, goals, targets, outputs and much more first on paper to ISO requirements. But that is not enough. We had to implement the standards and get the staff trained to apply the standards. This took us a lot of effort and a lot of support from the laboratory staff specially. I do acknowledge and congratulate them for their achievement. We achieved this working as team together. After all this work, on July 20, 2009, the Laboratory was audited for conformities of ISO 9001:2000 with the certification scope of Diagnostic Laboratory Testing and Reporting.

It was a bit of a tense day since the laboratory staff and the management were eagerly and anxiously looking forward to the outcome of the audit. When the final verdict came it was a time of relief and a time for celebration. Yes! Laboratory has successfully completed the requirements and passed the audit for ISO certification. It is indeed a milestone in the endeavour to provide reliable and quality health services to the Maldivian public. The Laboratory is now accredited for the period 30 July 2009 to 29th July 2012. By the end of this period the lab will have to undergo another audit for renewal of its accredited standard.

With this certification, the Laboratory will now operated all its procedures strictly adhering to ISO approved standard operating procedures. These procedures will be continuously reviewed and assessed so that the standards are maintained and the conformities are met in future audit processes.

The partners of ADK Hospital in the certification process were Assistance Maldives Pvt. Ltd, Maldives, affiliated with Nexus Business Solutions Pvt. Ltd, of Sri Lanka. Auditors of the SGS GROUP, Switzerland, conducted the certification audit. SGS is the world’s leading Inspection, Verification, Testing and Certification Company established in 1878.

Achievement of this certification is only a beginning for improvement and maintenance of quality in the laboratory. We will start to further enhance the processes and also put efforts towards certification for the ISO 15189 standards as well. This achievement also paves avenue for the motivation and initiation of certification processes for other departments of the Hospital as well.

“Patients as consumers have the right to make their own choices and the ability to act upon them” (Wikipedia – The free encyclopedia)

The outcome of successful service depends on empowering the patient. The patient shall be considered an equal member of the health care team. It is a responsibility of the care providers to provide complete information and communicate with the patient regarding diagnoses, treatment and procedures. Such relations would help towards smooth and successful outcomes. It is generally believed in the management community that consumers (patients) are very powerful in defining relationships and too often such relationships favour the provision of services and the provider.

There are two important and key processes for empowering patients. First, provision of information and then communication, consultation and partnership. In order to do so we as healthcare providers need to first understand and acknowledge that patients do have some rights and of course, some responsibilities too. It is equally important to ensure that patients understand the same as well. Once the patient and the provider are in harmony on these issues, health care provision will have very good outcomes with the best of satisfaction. Such harmony is the hardest to achieve.

Patients should have easy access to information kept about them in the hospital and be helped to understand it. In addition hospital staff shall be empowered to share such information and help the patients and family understand them. Patients should also be given information about the treatment planed for them and the possible side-effects and/or other risks that may result from such treatment. The choice of a patient to decline or refuse any treatment shall also be respected without prejudice and the patient shall not be deprived of their access to any other service offered by the institution as a result. Thus, provision of proper and complete information gives the patient a sense of their participation in care and increases their confidence in the professionals as well as the institution.

The first step to developing such harmony is to start informing the patients of their rights and responsibilities when seeking care. In addition an environment conducive to hear their views and use them is most critical for improved outcome in service.

Following on from the write up on mishaps and mistakes, I would now reflect on complaints and compliments in the hospital. Every time a customer is unhappy about something in the hospital, they make a complaint. Be it waiting a while in queue for the doctor up to issues of food served while admitted to the hospital. How easy is it to lodge a complaint though? Most of the time even at ADK Hospital, customers will complain because they were not able to lodge a complaint easily. So what can be done to hear people out and make it easy for people to lodge a complaint? Simple, make it easy for anyone to lodge a complaint. Establish a complaint management system and let people know about it. If we do this, we get complimented for handling a complaint. Isn’t that nice? But again we need to change a culture of many years to do that.

In the short period that I have been managing ADK Hospital, customers have told me that the front office is very reluctant to let them meet the management. Why? Is it fear that they may be reprimanded? Or is it because they want to hide a possible mistake from the management? Well, I asked around my staff about this. Talked directly with them and the answer is none of what I have just mentioned. The answer usually is “no reason” or “it’s the way it has been always.” This doesn’t surprise me at all. What I am finding hard is to change such cultures. It is not necessarily their fault too. Even at home if we do try to hide anything that might get us into trouble, don’t we? I guess that’s where we all come from.

Well my challenge now is to design a proper complaint handling mechanism and implement it. What do I get in return? Compliments! I hear a lot of complaints and what I do is listen. Try to explain but not to show excuses. If genuine, accept and see what we can improve on. Showing the way from the top is also helping a bit but we will have a long way to go to perfect it. One of the biggest satisfactions that I got so far in my short career managing a hospital started from a complaint. A customer called me and complained of an issue about his wife’s condition. She was not having any progress neither was the doctor able to determine what is happening. I offered to help the customer by getting a second opinion. Facilitated an appointment to another doctor and guess what? Two days later, the customer calls me back to thank me. It was even better; he said that he canceled the air ticket to Colombo to show his wife to the doctor because of the service that he got, a compliment from a complaint. This could have been done by anyone in the hospital. It’s just a matter of listening and courtesy. There is no restriction for anyone in the hospital in the way I acted in this case.

Very few people measure compliments. I feel that measuring the compliments is also a good way to assess our performance. Every time when I walk around the hospital, there is one spot that I stop for while. Just to see whether my staff got a new compliment. At the nurses’ station, there are heaps of written compliments from patients. Laminated with colours and pictures too. Many doctors’ also have such tokens of compliments they receive from patients kept in their consultation rooms. I feel happy to see these. That is a positive sign that the staff is putting an effort to uphold our motto – caring about you when you need it most. I make a point to congratulate and appreciate their work too. When I ask the staff about these compliments they show emotions and comfort. Those compliments help drive them to perform. It gives them satisfaction and touches their hearts. It is mutual isn’t it? We touched the patients’ hearts when they needed it and in return they touch ours.

When someone goes to a hospital to seek services they expect the best. Anything less is unacceptable. This is a common phenomenon irrespective of where ever you are in the world. Sure enough, no one wants to go to hospital unless absolutely necessary and of course they want to get better as quickly as possible.

But how perfect are hospitals? How perfect are the people who work there?

A mistake or a mishap in a hospital is a big thing. It points a lot of fingers, becomes a major media headline and lead to accusations of intentionally disabling someone or even worse killing someone. Healthcare providers are always on the alert, continuously conscious trying to avoid any such incidence in the hospital they work in. The irony is that something happens when you least expect it. Such incidences are detrimental to the hospital and the professionals since people loose confidence and trust in them. It is always said that Maldivians go abroad for treatment because they do not have confidence in the services. I see that the Maldivian health care system has a major challenge to achieve their trust and confidence.

What is alarming but true are the statistics from the world’s most advanced health systems. The following are some statistics that I collected from expert presentations from the UK, US, Australia and so forth. In the UK about 10% of patients admitted to hospitals face some adverse event. In Canada almost 13% and in Australia almost 17% of all patients admitted to hospitals face and adverse event. Every year almost 19,000 babies are dropped by doctors while taking deliveries, over 20,000 wrong prescriptions are given and over 5,000 surgeries are done on the wrong side in some of the world’s most advanced health systems. It was shown that in the US alone some 98,000 people die in hospital due to medical errors per year. Over all more than 80% of all mishaps in hospitals are due to human error.

However, unlike any other business health professionals will not be able to call back the patient. Nokia could recall faulty batteries and replace them, but an ovary that was taken out by mistake cannot be recalled back and replaced. Is it possible for health care settings to achieve the expectation of 100% perfection?

So how do health care providers compensate for this?

Continuously improving the quality of care delivery is the most important thing. Thriving to achieve perfection should be their goal. But even then when and if such a mistake or mishap occurs, a good investigation and full disclosure to the concerned patient and family would perhaps help. Showing empathy and a sincere apology would at least gain respect and a bit of confidence from the patients. Unfortunately this is the hardest to do. Not only in the Maldives but all across the world. However, in fact in some countries such practices have shown very positive outcomes for hospitals. In the US, adverse events in hospitals are such an issue that there is now a Coalition of doctors, insurers, patients, lawyers, administrators and researchers called “The Sorry Works Coalition” joined together to provide a solution for medical mistakes, mishaps and also malpractice (www.sorryworks.net). Though the sorry works, the efforts should not stop there. Health care providers shall keep thriving. Thriving to reach that level of expectation.

What can patients do and what are their roles? Well the best thing is to empower themselves to what their rights and responsibilities are while in a hospital. Making sure that you question the professionals till you are satisfied and understand your treatments, investigations and procedures. If you need a second opinion let the professional who is treating you know that and you can even refuse treatment till you are convinced that you should go ahead with it. This may offend some professionals but it is your right. Get professionals to accept you as an equal partner in determining the treatment you get.

Though hard to achieve, once the patient and the provider are in harmony on these issues, healthcare provision will have very good outcomes with the best of satisfaction. It will help build the confidence and trust between the patient and the provider.

After all to err is just human!

“You are feeling better today,” announced the Doctor, as he sat down by patient’s hospital bed.

Patient:  “Really? What’s better?”

“Well,” doctor sputtered, his face flushing, “in my professional opinion, you are better!”
Patient: sighed “ I don’t think so, I still feel the same, and tired “

Doctor:  “Your lymphocytes are better and you should feel better,”
Patient stops reacting, unhappiness visible on his face.

Can you hear the tension in this encounter? Why are doctors and patients so often at odds? Why are both expressing more frustration and less satisfaction? To answer these questions, more and more researchers are putting the doctor-patient relationship under the microscope. What they are finding is fascinating.
Tug of war is because doctors and patients are on different ends of the rope.

• To the doctor, illness is a disease process that can be measured and understood through laboratory tests and clinical observations. To the patient, illness is a disrupted life.

• The doctor’s focus is more on keeping up with the rapid advances in medical science than on trying to understand the patient’s feelings and concerns. Yet patient satisfaction comes primarily from a sense of being heard and understood.

• Many doctors do not see the role of physician as listener, but instead view their function more as a human car mechanic: Find it and fix it. Yet patients often feel devalued when their illness is reduced to mechanical process.

• Doctors feel frustrated, even betrayed, when patients withhold pertinent information. Yet patients who use alternative medicine, for example, may not tell their doctors for fear of ridicule or being labeled as “silly” or uneducated.

Changes in our culture and in the practice of medicine have also added tension to the doctor-patient relationship.

In some ways we have become more doctor dependent, because we see doctors sooner than people did 50 years ago, yet we are less dependent on the doctor for information and decision making.
All these changes are unsettling for both doctors and patients. Then there’s the blame factor. Doctors often blame patients when communication breaks down. But researchers have found that many doctors have shaky interviewing skills. For example

• Doctors do more talking than listening. A new study published this year in Journal of the American Medical Association (JAMA) found that 72% of the doctors interrupted the patient’s opening statement after an average of 23 seconds. Patients who were allowed to state their concerns without interruption used only an average of 6 more seconds.

• Doctors often ignore the patient’s emotional health.

• Doctors underestimate the amount of information patients want, and overestimate how much they actually give. In one study of 20-minute office visits, doctors spent about 1 minute per visit informing patients but believed they were spending 9 minutes per visit doing so.

So what about the patients?

Patients aren’t perfect either. In one survey doctors rated 15% of their patients as “difficult.” Disagreements involve everything from expecting an instant cure to demanding prescriptions.
While one doctor’s difficult patient may be another doctor’s favorite, researchers have identified common characteristics of patients that everyone agrees are hard to manage. Patients described as “frustrating” by some doctors have the following characteristics.

• Do not trust or agree with the doctor.
• Present too many problems for one visit.
• Do not follow instructions.
• Are demanding or controlling.

Patients who use the doctor as a scapegoat for their anger at the illness are less likely to get good care. “Doctors are profoundly influenced by the demeanor, comments, and attitudes of their patients.” A patient who is consistently rude and irritable will almost certainly not receive the same medical care as a patient who conveys more positive attitudes.

In spite of all these problems, there is reason for hope. Yes, doctors and patients will always be on opposite ends of the health care system, but that doesn’t mean they can’t pull in the same direction. In fact they can be partners in care. After all the goal for both the patient and the doctor is to get a cure!

Both the doctors and patients can contribute making this relationship better. For instance doctors can try and cultivate a patient-centered partnership. “The patient desires to be known as a human being, not merely to be recognized as the outer wrappings for a disease. In a video-taped study of 171 office visits, doctors who encouraged patients to talk about psychosocial issues such as family and job had more satisfied patients and the visits were only an average of two minutes longer. Incidentally, doctors also benefit from the patient-centered approach, researchers note, because they feel more job satisfaction and are less likely to burn out.

To improve patient compliance, doctors can work on mutual trust. Research confirms that the health of the doctor-patient relationship is the best predictor of whether the patient will follow the doctor’s instructions and advice. Respect patients as experts in the experience of illness. Patient-centered relationship that accepts the patient’s unique knowledge as just as important to outcome as the doctor’s scientific knowledge. “The medical visit is truly a meeting between experts.”

Similarly patients have some obligations too! Patients can contribute building this relationship as much as the doctors can.

Patients are obliged to provide complete and accurate information about their health and the condition they are in at the time of contact with the doctor. Its not only the duty of the doctor to ask all information from the patient. There is an obligation to ask questions as well. Especially if the doctors’ instructions or explanations are not clear, patients have a right to ask questions and make a dialogue with the doctor till they fully understand.

Participating actively in care is also an obligation of the patient. Especially if in pain, patients can costribute to care by reiterating the effectiveness and/or the ineffectiveness of the interventions given to them. Also patients are obliged to treat caregivers with respect and courtesy and also to keep to appointment times as well.

In short, the best outcome of care will be in those instances where there is a good relationship between the caregivers and the care seekers. A partnership where both benefit by reaching the same goal.

(This article is a combined work of Dr. Jayashankar, Senior Registrar Urology at ADK Hospital and myself)