Hospitals… The Quality Improvement Ballet – Performance

Op Ed page of The National newspaper in the UAE questioned Quality, Performance and Consistency of Healthcare in the UAE. The unending ballet of hospitals around the world is to continuously improve how they care for patients; patients that are increasingly more health-care savvy in their choices of providers. Many will take a plane when they get sick, others will suffer through misdiagnosis and maltreatment because that is the only thing they can do -their options are limited, and others live in areas where care is adequate.

Quality in health-care depends not only on solidly credentialed doctors, but on the culture of the hospital as well as the culture of the patient. The credentials of a provider are only as good as the background check of said provider -verification of education, training and level of expertise; the culture of the hospital hinges on the vision of the administrators and their capacity to envision and enforce stringent criteria on their providers and support staff; the culture of the patient is the icing on the top that can help or ruin the efficiency of a hospital…because the taboos, the education, the need and the ability to pay for services are part and parcel of what a patient looks for in a doctor or the hospital where they are located.

Take Yemen for example, the one I am most familiar with in the ME…it has a health-care crisis tied to the education of its providers and the education of their patients and their guardians in addition to the culture of health-care in general. In Yemen seeking health-care is a risky business. The pharmaceuticals can or not be the proper ones and their validity is always highly questioned. The doctors come from all over – trained in Russia, Cuba, The ME, Britain, USA, India, etc; but their credentials are always suspect. There isn’t a body of overseers that can tell the difference between a Russian Nurse Practitioner acting as a doctor; or a Yemeni podiatrist serving as an internal medicine doctor. The facilities on their own are much to be desired because precautions such as infection control; patient handling; length of stay are not regulated or watched. A woman who has had a C-Section will be discharged from the hospital a mere two hours after surgery to suffer the roads and unsanitary conditions of the area. The needles used to give medication are dumped in the same trash the family members use to dump their latest communal meal. The compound fracture patient is manhandled by everyone but the doctor before he gets to the Operating Theater; the patient with an unknown disease is housed in the same room as another less sick patient (regardless of age but definitely segregated by sex). The patient is at the mercy of what the guardian wants the doctor to do; not what is in the patients best interest – a cure; pain relief; proper care.

In Dubai and Abu Dhabi the facilities are state of the art; new floors, new offices, waiting rooms, etc -but the credentials of the providers are again questionable. Can a radiologist be an internal medicine doctor? The nurse that takes your vitals is she competent to do so? Will bringing in providers of higher caliber change the fact that without monitoring there is no way of telling, other than the death tolls, if any improvement has been made or not. Can someone not specialized in the administration of health-care centers actually oversee the proper function of the hospital? Is a doctor automatically the best administrator of a hospital?

Is the patient culture in the UAE still adhering to the “Doctor as god” culture that many throughout the world still adhere to but have recently seen a major coup de estat because websites like WebMD have put medical information at the patients finger tips? The question then is how many fingers are doing the walking before they head for the hospital or a doctor’s office? Obviously in an emergency all bets are off and you can only hope the ER doctors know what they are doing. But for planned trips a little information can go a long way. But is the god-complex culture of providers where there is no overseeing body allow for such meddling by the patient. Heavens forbid you ask a doctor if he is sure that what they are spouting is actually what’s wrong or not with the patient.

Then here we go around the block again and land on the level of education of the patient. When you can’t even write your name, don’t even know what a computer looks like less where the Internet is found on it; stating that a patient should get educated on what medicine is doing now a days is sort of ridiculous or impractical. And even those who can read and write may feel they should not hunt for information because- well what do they know?

So then the responsibility lands on the health-care system and its providers and supporting staff. Performance then becomes an internal issue of the facility to enforce on all of its providers and staff be they medical or not. That would entail training, educational reviews, rules and regulations to be imposed on all those who have some connection to the patient. This is a tricky one though, because is the housekeeping, administration, and Medical Records departments patient oriented? YES, everything done within and without the confines of the hospital impinges on proper and efficient health-care.

The very design of the hospital, how it is constructed, how it is managed, how information and the patient get from point a to point b, how and by whom medications are administered and discharge plans for the patient are all integral to quality patient care. Performance of each and every person in a hospital makes the difference between life and death – that is not something we should in any way compromise.

However, we all allow for compromises – the Dermatologist is as good as the Internist; the Surgeon is as good as the Intensivist…and we make the choice to allow one or the other to handle our care- be they competent or not is not something we negotiate or even think about…we take it literally lying down.

So our women and children continue to die in childbirth; the female doctor will continue to know less about the human body and its functions and diseases because the culture doesn’t allow for certain gender examinations; the pharmacist will continue to prescribe what no doctor in his right mind would give without complete labs and examination; providers will continue to treat all patients with body aches and fever as having either Malaria or Typhoid because it is the known cluster disease of the area; and our family members will request or not procedures -wait or hurry up a process that may well kill us while our doctors are powerless to stop it all.