Systems harm patients more than doctors

Hospital Association of South Africa

A culture of “name, blame and shame,” in medicine drastically reduces the potential for system changes to improve patient safety, the Hospital Association of South Africa’s (HASA’s), annual conference was told by a global expert in public health on Tuesday, 27 August.

Professor Michael Marx, of the Heidelberg Institute of Global Health at the University of Heidelberg said it was deeply disturbing for clinicians to realise how much their performance was shaped by the equipment, tasks, environment and organization around them. “They base their professional confidence and their business model on their individual abilities and confronting these other factors can be rather disturbing,” he said.

Speaking on the “Flaws of Quality Improvement and Patient Safety” on the second day of the HASA’s conference on Cape Town’s Foreshore, Prof Marx singled out research naming the ‘human factor’ as causative in about 80% of avoidable adverse events and patient accidents. He said this labelling unfortunately reduced patient safety to the mere avoidance of human error.

Professor Marx’s presentation comes as South Africa’s National Health Department begins forensically auditing a R98 billion medico-legal bill, driven by a combination of healthcare system dysfunction/failure, clinical error, fraud, corruption, ghost claims and rogue lawyers tipped off by unethical health facility managers. Deputy Director General of Health, Dr Anban Pillay, who took part in an NHI panel discussion at the conference on Monday, revealed that an alternative dispute resolution mechanism consisting mainly of clinicians was being set up to deal with patient complaints and adverse events. He said a national fund would be set up to reimburse legitimate claims, the aim being to avoid protracted legal disputes and side-step vexatious claims.

“Many countries have done this. It will be written into law, so we can avoid the courts. Our judges are fed up with vexatious cases being brought to court,” he added.

Professor Marx said human factors embraced physical, psychological and social characteristics of human beings – in so far as they were influenced by socio-technical systems, adding, “it’s about individuals, groups and organizations.”

He said that in addition to having strong foundations and functional funding, health systems need to develop the capacity to measure and use data to learn. Powerful measures for improving healthcare existed, and methods for improving patient safety were tried and tested. These included work processes in hospital design, introducing meaningful standards, and ongoing training. Workplaces should be designed according to human factor aspects, he said.

The strongest interventions he cited included eliminating technical obstacles and solutions, simplifying and standardising processes and equipment, and making vital equipment and apparatus available. This included perfusors, ventilators, infusion equipment and blood pressure monitors, (many of which a significant number of district hospital in South Africa do not have).

A management that participated “noticeably,” and supported staff also made a big difference, he said. Research as long ago as 1940 by quality management pioneer, Dr Joseph Juran, recognised a universal principle of the “vital few and the trivial many,” when it came to healthcare staffing.

This was why a framework of sound quality of care indicators, “might help us focus on that 20% which influence 80% of the effects,” he added.

The foundation of quality improvement, which always took time, included precise measurement, participation and ownership, choosing the most relevant intervention for any particular facility or setting, and “making friends with your implementation researcher”.