Journal of the Academy of Hospital Administration

S. Satpathy

Key Messages

• Another 2.4 million health professionals needed, says WHO
• Adverse incidents in NHS are still under-reported
• Can patients assess the quality of health care?
• Soft paternalism and the ethics of shared electronic patient records in NHS
• A research agenda for patient safety
• Towards patients-centered health services in India – a scale to measure patient perceptions of quality

1. Another 2.4 million health professionals needed, says WHO

Zosia Kmietowicz reports that the World Health Organization has Called for a 10 year global action plan to expand medical training and stem the “haemorrhaging that threatens {health-care} workforce, stability,” thus enabling health systems to tackle disease and achieve global goals on health. It says that an extra 2.4 million doctors, nurses, and midwives are needed in the world, with critical staff shortages in sub-saharan Africa and South East Asia.

Although the organization acknowledges that some nations have introduced strategies that increase training capacity and limit the migration of healthware workers from the world’s poorest countries, the world Health Report 2006 says that on their own these are “insufficient to deal with the realities of health work-force challenges today and in the future.”

Migration of healthcare staff from poor countries to richer nations remains a critical issue, says the report. On average, a fifth of the doctors trained in 10 sub-saharan countries leave to work in rich countries including Australia, Canada, the United Kingdom, France, Germany, Portugal, Finland and the United States.

The report proposes a three pronged approach to tackle the workforce crisis by building training capacity; enhancing the performance of the existing workforce; and managing migration, premature sickness, and retirement.

National leaders need to accelerate local action in the next few years and develop plans to deal with the skills shortage. They must then share their skills and expertise with a global network of interested parties, such as other governments, non-governmental organizations, financial institutions, UN agencies, academic departments and donors who will work together with local, national, and global alliances to create a more fairly distributed workforece

(Full text of report – Working Together for Health: the World Health Report 2006 is available at www.who.int/whr/en.) (BMJ Vol. 332,8 April 2006)

2. Adverse incidents in NHS are still underreported

Adrian O’Dowd reports from London that underreporting of adverse incidents and near misses is still a problem in the NHS and a barrier to improving patient safety, according to a parliamentary committee report. Almost a million patient safety incidents and near misses happened last year in England’s NHS, but a fifth of incidents and two fifths of near misses are estimated to go unreported, it says. The report, from the parliamentary public accounts committee, claims that the National Patient Safety Agency has failed so far in its five year existence to secure accurate information on serious incidents and deaths and to help the NHS learn from previous experience. There were 9,74,000 patient safety incidents and near misses in 2004-05 recorded on NHS trusts’ reporting systems. Trusts estimate that an average of 22% of incidents and 39% of near misses go unreportedmainly medication errors and incidents leading to serious harm.

The MPs investigating the issue found that doctors are less likely to report an incident that other groups of staff and recommend that trusts evaluate their own levels of under-reporting and target specific training at those groups of staff that are less likely to report.

The Department of Health established the National Patient Safety Agency in July 2001 to collect the analyse information; assimilate other safety related information from a variety of existing reporting systems; learn lessons; and produce solutions. In addition, the parallel, anonymous, electronic reporting system was only available from September 2004.

Edward Leigh, a Conservative MP and chairman of the committee, said of the recorded incidents, “These statistics would be terrifying enough without our learning that there is undoubtedly substantial under reporting of serious incidents and deaths. To top it all, the NHS simply has no idea how many people die each year from patient safety incidents. “What this points to are two related and deep seated failures, One is the failure of the NHS to secure accurate information on serious incidents and dealth. The other is the failure on a staggering scale to learn from previous experience.” Insufficient progress has been made to achieve the department’s plans to guarantee a safer NHS for patients, the report concludes.

(The full report – A Safer Place for Patients: Learning to Improve Patient Safety is available at www. parliament.uk/parliamentary_accounts.cfm.) BMJ Vol. 333. 8th July 2006

3. Can patients assess the quality of health care?

Angela Coulter, member of BMJ Editorial Advisory Board states that patients surveys should ask about real experiences of medical care and raises the question as to whether patients can assess the quality of health care. Patient feedback surveys are increasingly seen as a key component of monitoring and improving the quality of health care. Since 2002, all NHS trusts in England have been required to survey a sample of their patients on an annual basis and report the results to their regulator, the Healthcare Commission. General practitioners throughout the Unite Kingdom can earn extra contractual points and more money if they implement patient surveys. Patients’ feedback on individual doctors has been advocated for practice accreditation, clinical governance, assessment of trainees, appraisal and revalidation.

Studies by Rao and colleagues point to some potential problems, particularly with regard to patients’ assessment of the technical quality of care. Using a British adaptation of a US patient questionnaire {the general practice assessment survey (GPAS)}, they found no correlation between patients’ evaluations of the quality of technical care and evidence based indicators drawn from a separate review of case records. They conclude that patients’ assessments are not a reliable basis for assessing the technical quality of care. The question to be addressed is whether they are right?

The answer is both yes and no. They are right to dismiss the notion that patients’ questionnaires could be used as the sole measure of quality of clinical practice, but has anyone seriously suggested this? They are probably also correct to point to the limitations of the technical quality domain of the GPAS questionnaire, which uses a rating scale to assess patients’ perceptions of doctors’ medical knowledge, thoroughness of physical examination, and diagnostic and prescribing skills. Most patients prefer doctors who have excellent communication skills, but they also want to be assured that their doctor has sound, up to date, technical skills.

A recent public survey carried out for the General Medical Council found that giving good advice and treatment was the factor that most influenced people’s confidence in doctors (rated as very important by nine out of 10 respondents), followed closely by good communication skills. Other factors that were highly rated included maintaining confidentiality, respecting patients’ dignity, and involving them in treatment decisions.

Well designed questionnaires for patients could contribute usefully to an assessment of both the technical competence and interpersonal skills of doctors. If these surveys are to play a role in quality improvement, they should provide clear factual results that prompt follow-up actions. Knowing that, say 20% of your patients gave you a clear view of what you need to do to improve things, but receiving feedback on the proportion of your elderly patients who, for example, would have liked a flu vaccination but were not offered one gives a much more useful guide to deficiencies in performance. Rao and colleagues had to search clinical records manually for this information where patient records were not computerized, but could just as easily have used a patient survey.

Simply giving doctors the results of patients’ feedback does not seem to be effective for instigating change. However, in some parts of the US integrating patients’ feedback into educational programmes with the results made available to the public has yielded improvements in doctors’ performance.

(Full text of article (editorial) is available at BMJ Vol. 333, 1st July 2006)

4. Soft paternalism and the ethics of shared electronic patient records in NHS

Prof. O.F. Norheim states in a BMJ editorial on ethical issues of shared electronic patient records that it is ethically sound for patients to opt out, rather than “opting in” as recommended by the Royal College of General Practitioners. The NHS is planning to make patients’ health records more easily accessible using a network of integrated databases. This will, we may reasonably expect, improve quality of care and efficiency, reduce paperwork, and sometimes even save lives. The ultimate aim is to benefit patient health and welfare. Easier access to medical data from a “single resource shared by everyone” also make patients vulnerable. Patient records contain sensitive private information that can, if not handled correctly, harm the patient. Should all citizens by default be included in the new electronic records service with the possibility to “opt out” if they prefer, or should people be asked to opt in” only if they want to?

To impose electronic records on members for the population against their will may be unduly paternalistic even if we assume that all the technical, legal and organizational safeguards are in place and that the system, on balance, promotes health and welfare. A policy counts as paternalistic if it “attempts to influence the choices of affected parties in a way that will make choosers better off. Should we not all accept a policy that makes everyone better off? Defenders of liberty and autonomy disagree. One of the lessons learnt from the history of medical ethics is that efforts to promote the common good must be constrained by liberty and informed consent: Those affected have the right to accept or reject a programme which will have a direct impact on their legitimate interests. Patients have a legitimate interest in privacy and preventing third parties gaining access to sensitive material – this is a concern in legislation everywhere. Standard medical ethics suggests that when people disagree about whether a programme is acceptable, the public should be fully informed about its implications and included only if they give explicit consent.” Those affected know best whether it is good for them. For shared, electronic patient records “opt in” with explicit informed consent is therefore the only acceptable solution.

Recent advances in ethics, law and behavioral economics on the understanding of “bounded rationality” suggest an alternative way of protecting freedom: “soft paternalism.” Consider an example. Suppose the director of the cafeteria in your hospital knows that customers, including doctors and nurses, have a tendency to choose more of the foods placed at the beginning of the counter. If the director offers the healthy food first, she maximizes the chance of customers making healthy choices. If she places the less healthy food first, the opposite will happen. What is the right thing to do? People do not always make the choice that are best for them. Employees offered a wide range of pension saving plans (including plans that are good for them in the long run) on average make poorer choices than employees who are offered a good plan as a default but who are free to opt out.

The choice of the default rule in organizational systems powerfully affects people’s choice for two reasons. Firstly, people are not always rational. Inertia prevents people from making the best choices, collecting all the information is costly and takes time, weakness of will affects all of us, and people do not always have stable and well formed preferences within the range of choices open to them. Secondly, as the cafeteria example shows there is, in many cases, no mental freedom of choice. Soft paternalism recommends mildly steering choices in a direction that makes people better off, while preserving freedom of choice. The same kind of reasoning can form the basis of the suggested NHS information technology programme, using “opt out.”

I have three caveats to this conclusion, however, the NHS must convincingly show that technical, organizational and legal safeguards will be implemented in its information technology programme. These safeguards must include strict and transparent rules of access to health records, mechanisms of complaint and open understandable information about the programme and its implications.

(Full text of editorial can be accessed at BMJ, Vol. 333, I July 2006)

5. A research agenda for patient safety

T.V. Perneger in an editorial published in International Journal for Quality in Health Care makes a strong case for patient safety the core research agenda. He states that patient safety is a global problem that calls for global solutions. Six action areas are presented, one of which is research on patient safety. The necessary of patient safety research is echoed by another wide-reaching organization, the Council of Europe, in a recommendation on the management of quality and safety in health care soon to be issued to its member states. Everyone seems to agree on the principle, but what type of research should we be doing? Let us consider some of the options.

(a) In-depth studies of errors, mishaps and patient safety incidents

These studies apply rigorous investigation methods, variants of “root cause analysis”, to a variety of health care incidents. Their purpose is to learn as much as possible about the complex casual chains that lead to incidents. Typically, such studies are qualitative and do not attempt to measure frequencies of events. The validity and reproducibility of such investigations are questionable and the underlying conceptual models of incident occurrence are interpreted inconsistently.

(b) Epidemiologic studies of incidents and errors

Such studies estimate frequencies or incidence rates of patient safety incidents, health care related/ complications and appropriate practices of care, using methods that minimize bias and allow accurate measurement. So far, such studies have been conducted mostly in hospitals but should be done across the spectrum of care – from outpatient care to rehabilitation. Currently, such epidemiological studies are hampered by the lack of consensus taxonomy of patient safety incidents – another priority of the World Alliance – should much improve the situation.

(c) Identification of risk factors for patient safety events

Analytic studies, whether prospective studies, casecontrol studies, or ecologic analyses, should seek to identify risk factors for the occurrence of patient safety events. Such studies have built the foundation of prevention activities for a variety of public health problems.

(d) Research on human factors

The old saying ‘to err is human’ is certainly true but does not tell the whole story. Another defining characteristic of humans is their ability to work reliably in hectic circumstances. We need research to understand in what situations people are most prone to errors or violations. In particular, how do contextual factors, such as a ‘culture of safety’, the physical environment, or regulatory mechanisms, influence people’s behaviour? More research is needed about teamwork, particularly multidisciplinary team work. This line of research should draw on experimental psychology and anthropology, in addition to more traditional epidemiologic studies.

(e) Patient involvement in safety

Involving patients and their families in patient safety activities is another priority of the World Alliance. A potential role for patients is to alert health care staff about possible errors, related to personal identification problems, allergies and comorbid conditions, or basic precautions, such as hand washing.

(f) Development of patient safety indicators

Accurate measurement, regular monitoring and benchmarking are key activities fro progress in patient safety, as for other aspects of quality improvement in health care. Proposals of sets of patient safety indicators have been made by several organizations, yet the ascertainment of the reliability, validity, sensitivity to change and interpretability of indicators remains an important area for research.

(g) Evaluation of interventions to improve safety

Finally, a crucial domain of research on patient safety is the evaluation of interventions that aim to improve safety in real-life health care settings. Remarkable little evidence exists today regarding the impact of several routinely recommended interventions, including incident reporting and analysis.

(h) Of particular interest are studies that assess the effectiveness of educational interventions to increase the awareness of health care staff about patient safety and managerial interventions to heighten the ‘culture of safety’ in hospitals. The impetus to patient safety research that will be given by the World Alliance and other governing bodies is a welcome development.

(Full text of editorial is accessible at International Journal for Quality in Health Care, 2006 Vol. 18, No. I; 1-3.)

6. Towards patients-centered health services in India – a scale to measure patient perceptions of quality

KD Rao, DH Peters & KB Roche in an article published in International Journal for Quality in Health Care 2006; Vol. 18, NO. 6: pp. 414-421 focus upon the development of a reliable and valid scale to measure patients perception of quality in the Indian health care service scenario.

Objectives were to:

1. Develop a reliable and valid scale to measure inpatient and outpatient perceptions of quality in Indian and
2. Identify aspects of perceived quality which have large effects on patient satisfaction. The study was a cross-sectional survey of health facilities and patients at clinics and the study setting was primary health centres, community health centres, district hospitals and female district hospitals in the state of Utter Pradesh in north India.

Main outcome measures:

Internal consistency, validity and factor structure of the scale are evaluated. The association between patient satisfaction and perceived quality dimensions is examined.

Results

A 16 item scale having good reliability and validity is developed. Five dimensions of perceived quality are identified – medicine availability, medical information, staff behavior, doctor behavior and hospital infrastructure. Patient perceptions of quality at public health facilities are slightly better than neutral. Multivariate regression analysis results indicate that for out-patients, doctor behavior has the largest effect on general patient satisfaction followed by medicine availability, hospital infrastructure, staff behavior and medical information. For in-patients, staff behavior has the largest effect followed by doctor behavior, medicine availability, medical information and hospital infrastructure.

Conclusions

The scale developed can be used to measure perceived quality at a range of facility types for outpatients and inpatients. Perceived quality at public facilities is only marginally favorable, leaving much scope for improvements. Better staff and physician interpersonal skills, facility infrastructure and availability of drugs have the largest effect in improving patient satisfaction at public health facilities.

(Full text can be accessed at International Journal for Quality in Health Care 2006; Vol. 18, No. 6: pp. 414-421)

S. Satpathy is Additional Professor, Department of Hospital Administration, AIIMS, New Delhi.