Managing Patient Safety And Quality Of Care In Public Hospitals In Pakistan

Research Design

The study engaged qualitative research design to carry out a phenomenological inquiry on the subject matter. Phenomenological study focuses on studying the experiences of the participants about a particular phenomenon (Patton, 1990). Moreover, Schwandt (2000) also asserted the importance of phenomenological interpretation of the qualitative research which is superlatively portray as a subjective knowledge of the study from the participants’ perspective. Thus, qualitative research moves away from the numerical facts and extracts the deep meanings of the cooperative understanding to ascertain classic knowledge. In this regard, the qualitative procedures permit the comprehensive analysis of data on the subject matter from different perspectives.

Research Site

The research was carried out at Pakistan Institute of Medical Sciences (PIMS) and Federal Government Polyclinic (FGPC) hospital. Both hospitals are funded by the Health Ministry of Pakistan. The Ministry provides financial resources, as well as formulates guidelines and procedures for the smooth operation of the hospitals. Both hospitals have a separate department for maternal care. Their locations are significant as it helps the provision of health services to everyone from every part of the country, regardless of their socio-economic class.

Study Participants

In-depth interviews were conducted from twenty 20 women patients consuming the outpatients and inpatient healthcare services in PIMS and FGPC hospitals in Islamabad. In order to traingualte the study, six doctors and two nurse superintendents were also interviewed. The doctor included consultants, medical officers, and house job officer who were chosen based on their qualifications and working experiences. Patients who received in-patient and out-patient treatments were approached and asked for their consent to be part of the study. All of the patients interviewed come from a lower income bracket, with no education and are within the age range of 25-40 years. A majority of the women selected for this study has had two to three children and has been receiving health services from the hospitals for an average of two to five years.

Instrument

To gather the relevant information, a pre-designed interview schedule was used to ensure the required topic related to the study objectives was covered. The interview guideline was initially prepared in English before being translated into Urdu by language professionals. The translation was verified through a process of back to back translation from Urdu to English and to Urdu again. Meanwhile, the interviews with doctors contained general non-leading questions which were about patient safety and quality of care at the hospital. Probing was used to get more insight on the given answers. The interviews were conducted in Urdu as all patients can easily speak and understand the language. There were also a few respondents that could only understand and speak the Punjabi language, but as researcher’s own mother tongue was Punjabi which enable to establish the conversation straightforward. The interviews were recorded in Urdu and then translated into English for report writing. Furthermore, six doctors, who were conveniently present in the hospital at the time of research, were selected for interviews.

Data Analysis

Thematic analysis approach was adopted to interpret the data in order to categorize the commonalities and differences in the respondents’ perspective. Verbatim transcription of the recorded interviews was performed which is the universally used method to convert verbal data into the textual form for the elucidation (Halcomb & Davidson, 2006). After transcription of the interview form Urdu into English, the data were organized under different codes by following the immersion process. The ATLAS.ti software was used to produce codes and themes from the data which facilitated in storing, organizing and coding of the conversational and textual data under different themes.

Quality alongside Patients safety

Quality of care and patient safety are two interrelated concepts that are the foundation for the provision of healthcare services for mothers and newborns. The study highlighted the similarities in the provision of healthcare services at the two public hospitals in Islamabad, Pakistan, with respect to standard of quality which is not up to mark. In this light, to provide quality care to the patients, numerous factors have to to be measured, such as the availability of skilled professionals, medicines, equipment, as well as a safe and hygienic environment. In this light, several respondents pointed out that the healthcare services they obtained are of pitiable quality which indicates that the patients’ safety, in terms of receiving abundant care and hygienic environment is threatened due to mismanagement of available resources.

In regards to patient safety, the researcher observed that there are well trained, professional doctors and staff working in the department but they are deficient in the resources to organize for the larger population patronizing the hospital. Hospital administration and staff were observed to put forth their best efforts to provide efficient services to the patients. Undoubtedly, in maternity care, the matter of safety and quality is most important as it deals with two masses; mothers and new borns. In this light, despite the various types of services provided to the patients, the overburden of work and lack of space have made patients feel unsatisfied with the quality of services. Moreover, despite the availability of equipment, drugs, rooms, and furniture they are deemed as insufficient and their quality is lower than the standard requirement. Due to the number of mothers using in-house facilities such as beds in wards and private rooms, there is an insufficient number of beds where the patients and staff reported that the bed against patients ratio is 1:3. The respondents also reported an imbalanced doctor to patients’ ratio at 1:50 per day. As a result, quality of care and patient’s safety is the most important gauge to assess the healthcare delivery services and patients’ contentment with the services.

More or less all government-run public hospitals are testimonies to face the similar situation. This resulted in the occurrence of cross infections among newborns, and this presents the discernible indication on the lack of budgeting and monitoring to improve the standard of quality health care. Health policies and programs were claimed to have excellent standards and protocols with an exceptional level of care, however, the reality is too hard to swallow. Be deficient in of accountability and transparency, the mismanagement of assets, as well as unsatisfactory human and financial resources are considerable barriers in the stipulation of proficient and quality care for mothers and newborns. In this regard, the State is accountable for this failure to provide desirable quality care as it is the accountability of the stakeholders, including health service workforces such as doctors, staff, and nurses to deliver public services honestly and competently. In this regard, patients’ need is one of the most dominant aspects in the provision of care, however, despite the adoption of WHO standards and safe motherhood programs to promote safety and the quality of care for mothers and newborns, it is still not progressing at an expected pace as it needs consistent supports and monitoring by the government.

Chin and Muramatsu (2003) painted the facilitating factor of quality of care from providers’ perspective such as proper training on case management, proficient record system and prearranged programs for quality improvements. On the other hand, the lack of resources, grave workload, intermittent patients and providers’ communication, lack of experts and negligence of resources are contributing barrier against quality care. Various perspectives on quality of care are also supported by previous research (Crilly & Le Grand, 2004; Meadows, Levenson, & Baeza, 2000; Newman & Maylor, 2002; Kirkham, Morgan, & Davies, 2006) where doctors related quality of care with the efficient delivery of services over the number of patients treated, nurses talked about the relationship between training and quality of care, while managers exemplified the relationship between policy/planning and priories with provision of quality care.

Relating the impression and findings on quality of care, Hulton, Mathews, and Stones (2000) construction for assessing the quality of maternal health services in developing countries posited that quality care upgrading is required at public hospitals. Patients relate the notion of quality of care with the availability of physical and human resources, as well as the nature of services provided to them by the hospital. One of the doctors asserted:

Doctors-patients’ ratio is far above the ground. One doctor has to look at almost 80 to 100 patients daily, due to which abundant time is not possible to give to one patient.

Patients’ experience in getting maternal healthcare services can be measured through competence of human and physical resources as quality is also linked with the utilization of services. In this regard, Pakistan has shown considerable improvement in its health system and is now providing one of the best public health infrastructures in Asia, however, there is still a delicate assessment on the quality of care. In addition to the weak implementation of policies and standard quality principles, the scarcity of competent workforce is a major factor that has diminished its quality performance (Bhutta, et al., 2004).

Hygiene and Patients’ Safety

Hygienic clause is another significant indicator of the quality of care in the hospitals besides the availability of physical resources and the provision of sufficient care by professionals. Regrettably, the respondents’ remarks and the researcher’s observation have shown the substandard hygiene situation in Pakistani public hospitals. This lack of satisfactory hygiene training is due to the overload of patients, lack of sanitary staff, as well as the lack of awareness among patients in utilizing public goods. In this light, the patients are not aware of their contributions to the cleanliness of the hospitals and put the responsibility on the service providers as a majority of the respondents’ criticized the staff for not cleaning the toilets. One patient mentioned:

“Cleanliness is just okay, not good but not bad at all. As it is gynecology department so there are lots of uncleanness because of bleeding and discharge from after delivery, but I will again say that lower staff is very authoritative and illegally powerful. Sometimes I asked them to clean my bed and change the bed covers as it becomes dirty but they never listen to me and never change the bed sheet other than their decided time and willingness”

In accumulation, in regards to patients’ safety, there are some loopholes with respect to the provision of treatment. Some of the patients mentioned that staff, mainly the nurses and midwives do not care about the patient illness and behave very badly, as expressed by one of the respondents:

After the operation, while shifting me from OT to the room, staff very badly treated me. Their attitude increased my pain but they don’t care about that. While transferring me from one bed to another, I feel they are just like throwing me and getting rid of their duty.

The researcher also observed the awfully underprivileged situation in regard to patients’ safety and quality such as no germ control mechanism was used and toilets are left dirty and redolent. This portrays the lack of quality care. At the same time, a well again provision is given to the patient placed in private and semi-private rooms as they pay extra fees for similar services.

The analysis illustrated that human resources are lacking in both hospitals, as highlighted by the respondents including the staff, doctors, and patients. In this light, each hospital has recruited sufficient staff according to the accessible financial resources but the lack of quality care to the patient is due to the higher doctor to patient ratio (1: 1127) (Wasif, 2013). During the regular duty, which spans up to eight hours, a doctor has to examine 40 to 50 patients in the OPD, wards and in the labor room, while the number is reduced to 20 to 25 patients in the Operation Theater and in the Emergency Department. The doctors themselves admitted that work overload affects their ability to provide efficient and quality care to entire patients. In this regard, although the doctors and staff are well qualified and have expertise in their fields, however, work overload hinders their ability to meet the quality standards and protocols for the patients. One of the doctors stated:

Quality of care is impacted by doctor’s knowledge and skills which we enhance taking workshops, and refresher courses. Regarding safety, we perform our duties for the betterment of the patients and provide them with relief to get rid them from their pain.

One of another consultant mentioned that:

Quality of care is supported with the hierarchy of service delivery such as treatment given by the consultant and experts. There is a sequence of services through which patient care is managed from junior to senior doctor. It never happen that only junior handle and treat the patients. All major decision regarding patient care and safety is based on consultant, specialist and senior doctors. In this way, the process of quality and efficient service provision is ensured.

Hospital administrations and staff do their best to provide proficient services to the patients, chiefly in maternity care, where the matter of safety and quality are most important as it deals with two lives; the mother and the new born child. The foremost problem related to patient’s safety was highlighted by the patient was the behavioral concerns of the staff. The doctors and staff are outnumbered by the crowd who visited every day, but still, doctors and staff are doing their best to treat all patients within their duty hours. The overcrowded wards and emergency units also contribute to poor quality of care.

The analyses demonstrated that patients’ safety will increase when there is a quality of care provided by the doctors and nurses. However, disappointingly, the workload for doctors is too high, where one doctor has to examine at least 30 to 40 individual cases within his/her six to eight hours of duty. Consequently, doctors find it difficult to provide one to one attention to a single patient. According to one of the senior doctors, there are only 77 doctors per 100,000 people Pakistan, which is an alarming situation.

On the other hand, the definition and understanding of the quality and patient safety is slightly different from the perspective of administrative staff,

Quality is there that’s why patients survive; all staff and doctors perform their duties well to provide quality care to the patients. We follow proper procedure and medical ethics to deal with patients. We ensure that whatever care that patients’ required, we provide them at our earliest. For safety purpose, not to transfer any germs and infection to patients and doctors, we use antiseptic lotions, hand wash, also provide to patients whatever available here or provided by the government. For floor cleaning, we use anti-germs cleaner also.

Koblinsky (2003) shored up this finding by associating low quality of care with factors such as low salaries, long working hours, heavy workload, difficult working environment, lack of equipment and undefined job descriptions. Throughout the data collection phase, the availability and utilization of human resources were observed. Similar to the respondents’ perspectives, the researcher also observed that the workload of doctors is very high. Moreover, there is a high rate of patients’ turnover due to the lack access to affordable maternal healthcare services, but on the other hand, hospitals lack human and physical resources to fulfill the needs of the entire population. Consequently, doctors need to work hard to manage the patients with limited resources, which affect the quality of care.

Public hospitals are the only affordable source for healthcare for economically challenged patients, are overcrowded all the time and it is difficult for the management to provide quality service to all patients. Limited health care financing in the tertiary healthcare provides limitations in attaining universal coverage for mother and neonatal care. Financial deficiency leads to the underutilization of MCH care causing inadequate training, low staff competence and inefficient use of resources and affecting the quality of service delivery.

This finding is supported by Otieno (2014) which reported the quality of maternal healthcare services at public hospitals in Kenya. The study was conducted to assess the outcome of free services offered to mothers. The study is a mixed method research where both survey and interviews were conducted among patients and midwives to examine their perception and experiences of free maternal healthcare services at public hospitals. The study found interdependence between hospital infrastructure and the implementation of free maternal healthcare services, as well as a positive relationship between knowledge and quality of services with patient’s satisfaction with the services.

Patient’s Safety Protocols

Assessing patient’s safety and quality of care within healthcare structure is one of the biggest challenges for the public health system. To develop safety and quality for maternal healthcare services, World Health Organisation (2004) has developed quality of care and patient safety protocols which need to be integrated into the health system. Public hospitals, such as PIMS are required implement protocols based on the WHO guidelines to ensure better and safer healthcare services for mothers and newborns, as supported by a consultant;

We use WHO safe birth checklist to overcome the maternal and mortality ratio mostly maternal and neonatal death occurs during narrow time period of 24 hours after delivery. This is very common perception that shifting delivery from home to hospital is good to overcome the mortality ratio, but still, hospital is not able to reduce the mortality and morbidity rate. And the reason is that low- quality care provided during childbirth by most of the public institutions. So we adopted WHO designed child birth safety checklist to make sure the proper treatment and care are given to the mother and newborn. The use of the checklist helps us to reduce the mortality.

The checklist is based on the management practices of delivering services designed by WHO in 2008 to deliver simple, low cost, safe intervention for safe child birth practices. There are 29 items in the checklist which comprise of different management procedure practices from admission to discharge. This checklist needs to be filled at the time of admission. The checklist is very easy to fill, and the person in charge can easily fill it by marking ticks in each column, and immediately analyzing the next step of the treatment and subsequently, referring patients to the following stage of care. Meanwhile, the checklists used in both MCH and PIMS need to be filled up before an operation or before the patient is sent to the labor room. The checklists start with the same question; does the woman need antibiotics, and medical personnel has to indicate whether the patient has any allergies, fever or any type of discharges, indicate whether or not antibiotics have been given at the first stage, as well as other required medication.

In tertiary care hospitals, it is important for these interventions to be exercised at all times. Despite the poor infrastructure, lack of equipment and scarcity of staff, efforts are to be made to ensure the quality of care is satisfactory. The different responses from the perspectives of doctors, nurses, and staff illustrated that quality is a joint effort for all of the stakeholders.

As mentioned by the doctors, patients, and staff, hospital structure is important in providing quality care to the patients. In this light, quality standards cannot be met if the structure is deprived of physical resources like building, equipment, and qualified health practitioners. Shortage of beds forces three patients to be placed on a single bed which could jeopardize the safety for the mothers and the newborns. However, they cannot refuse patients access to the services and have to accommodate all of them with the available resources. This situation affects patients’ safety as when three women share one bed it is difficult for them to move or even rest. Furthermore, having a shared bed makes it difficult for new mothers to breastfeed their babies. In this regard, doctors and staff need to manage the situation better.

In regard to patients’ safety and provision of quality care, there are well trained and professional doctors and staff working in MCH but they have limited resources to manage a large population. Furthermore, regrettably, MCH have shown dreadfully alarming insanitary conditions. The lack of accountability and transparency, the mismanagement of assets, as well insufficient human and financial resources are the foremost barriers in the provision of efficient and quality care for mothers and newborns. In this regard, the state is accountable for this failure to provide high quality care and it is the liability of the stakeholders, including health services providers such as doctors, staff, and nurses to make use of public services befittingly and competently. Furthermore, patients’ needs are the most paramount aspect in provision of care.

In addition, mothers need to receive consistent information from their health-care providers. A comprehensive education booklet may promote consistent education from nurse to nurse. Consequently, the focus of this quality improvement project is to provision prenatal and postpartum education during hospitalization. Nurses should collaborate with educators to develop educational materials that provide consistent information throughout the continuum of care. A study by Jafree, Zakar, Fischer and Zakar (2015) highlighted that the healthcare system of Pakistan lacks medical ethics and nursing education, as well as the lack of monitoring of the violations of medical ethics in hospitals.

Medical Errors

Although hospitals strive to ensure for patients’ safety and treatment without having major medical errors conducted by the staff, the disagreeable bureaucratic nature of work and corruption are the biggest challenges in overcoming the problem. In this light, healthcare providers have no fear of losing their jobs if they commit errors as most of them are permanent employees, so they are protected even when they commit acts that jeopardizes the hospital’s reputation. This preconceived notion among workers has hindered the establishment of safety precautions in the hospitals. Medical errors are categorized by Haw, Dickens, and Stubbs (2005) into three, prescribing error, administration error, and dispensing errors. In the present study, the staff mentioned that dispensing errors sometimes occur due the high workloads, as reported by one of the staff nurse:

The mistakes can be like that as you have seen the patient such arrived and I went to take reading of her Blood pressure, she was waiting for long, but the other sister who was on duty was changing her dress because some blood doped on her clothes while injecting blood to patient, so I thought she had taken the B.P of that patient, so patient was waiting from last twenty minutes who came from operation theater and need vitals on urgent basis. So, on delay to give vitals, head nurse scolded us, so like these types of minor errors or mistake happens.

The above finding is supported by a similar study conducted by Stratton, Blegen, Pepper and Vaughn (2004) which highlighted the unjust nurse to patient ratio as the major cause of medical administrative failure in the hospital. Nurses are often fatigued and stressed due to the heavy load of work and organizational factors which causes them to conduct errors (Lin & Ma, 2009). The staff highlighted that there are constant emergency cases and the staff and doctors are always on their feet; making them vulnerable to errors. Moreover, the researcher observed that emergency section in MCH is always overcrowded. This is in line with a study by Trzeciak and Rivers (2003) which stipulated that overcrowding in emergency department is the major contributing factor which threatens patients’ own safety and leads to the increase of medical errors and decrease of patient safety. In this regard, patients do have rights to make a complaint if they believe that the doctors and nurses had conducted any mistakes, and there are patients who launched complain directly to the higher authorities.

Some patients suggested that policymakers should consider the views and concerns of all caregivers from different departments they are directly connected to health matters and resource management. Furthermore, proper monitoring and evaluation should be conducted once a policy or program has been established. Hence, the biggest challenge is to adhere to and be accountable for the policies, plan and rules executed. This might suggest that accountability is needed in public hospitals, thus, the staff and doctor must ensure the safety and quality of the services being delivered to mothers bearing our next generation. Aspects such as cleanliness is a must as sometimes animals like stray cats could enter the hospital room so the floor needs to be kept clean at all times.