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Treat me right

By: Dr. Faisal Saeed, Medico-legal and Quality Improvement Executive

“In the absence of patient’s rights, the health care setting can become a jungle” – Prof. George J Annas

Doctors have always worked for the welfare of their patients, and patients trust doctors to work towards their best interests at all times. The Hippocratic injunction “primum non nocere –first (or above all), do no harm” is the prevailing ethos of the practice of medicine. Doctors are there for the benefit of their patients and they must do them good to the best of their abilities and do nothing which they know will cause them harm. This forms the basis for the patient’s willingness to let doctors get near things she values and even harm them; the heart is trustingly placed in the cardiac surgeon’s hands, the decision on whether a loved one is dead or alive is left to the doctors, or a pill with dangerous side-effects is swallowed without a second thought. In these instances, the doctor is seen as a friend who takes care of you, with good will, fairness and integrity. And because doctors belong to a profession that is regulated and will therefore play by the rules, patients are willing to bare themselves naked, both physically and emotionally.
Based on this trust, and the underlying assumption that the “doctor knows best”, patients for the most part, are willing to submit to the vagaries of uncomfortable and painful procedures and harmful medications. And up until a few decades ago, medicine was unquestionably paternalistic with the doctor acting and deciding for the patient’s benefit, but without the specific consent of the patient being treated. Patients are seen as ‘cases’ that was done something to, rather than something with. Few patients questioned the authority of the doctor, while automatically presuming that doctors will work for their benefit. To trust was to have blind faith in the competence and the good will of the doctor. Furthermore, with the patient being not in a position of having medical knowledge, there was little alternative for the patients but to trust the doctor. Trust is required where there is ignorance.
The potential for medicine to benefit patients is, however, no greater than the potential to harm patients, sometimes with disastrous consequences such as death or lifelong disability. In the face of the possibility for such outcomes, “Trust me, I am a doctor” is no longer justifiable. And with the easy access to medical information, medical knowledge is no more the sole preserve of the medical profession, and informed patients are in a position to reduce that knowledge gap. The ignorance that necessitated trust (faith) in the doctors is lesser. This is not to say that patients need not trust their doctors any more, but that this trust should be based more on confidence than on faith. The ultimate aim of medicine is to do what is good for the patient, and patients need to be able to trust their doctors to do what is good for them, not out of good will, but because it is what is expected of them. Such trust is justified only when patients are empowered through the awareness and protection of their rights.
One fundamental right is the right for patient autonomy­ – patients must be respected as independent moral agents with the right to make decisions on all aspects of their care, based on the information that is provided to them. Doctors are now encouraged to view the decision-making process as a partnership, while embracing a more equal sharing of the medical knowledge. The patient has the right to be informed of the nature of his/her condition, the treatment options, and any complications that may arise as a result of treatment procedures. Based on this information, it is the patient who has to decide and grant the doctor the authority to treat him or her. This is the basis for the process of obtaining consent. The Constitution ensures that each person has the right to life and security of the person and touching a patient without consent is unlawful and violates his or her bodily integrity and amounts to battery, and can also result in a negligent action. The right to patient autonomy is strong enough to entitle patients to refuse treatment, even if the refusal may result in his or her death.
One other fundamental right is that of privacy and confidentiality. This is one set of rights that are ensured even in our Constitution. Article 24 states that “everyone has the right to respect for his private and family life, his home and his private communications”.  Patients have the right to expect that private information about them disclosed to the doctor will be held in confidence.  Confidentiality is central to the trust between doctors and patients because where this right is not protected, patients will be reluctant to seek care in certain circumstances or fail to disclose key information that may have direct impact on their care.
The right to a good standard of healthcare is another right that is derived from our Constitution. It states that “a good standard of health care, physical and mental” is necessary for the realization of all other rights pursuant to the Constitution. The Constitution further states that citizens must seek to achieve a “good standard of health care”. Seeking this right therefore becomes an constitutional obligation on the patient’s part and the state must ensure that citizens have access to quality healthcare. In addition to these rights that can be directly derived from our Constitution, patients have the right to be treated with dignity and respect, the right to complain about the care provided, and the right to redress when harm arises during their care.
One question that always follows from any discussion on patient rights is on the rights of health care providers. The question may seem relevant; but what list of rights can be produced? How would such a list look like?  Doctors can and will continue to enjoy the unique power that is afforded to them through their knowledge and skill in medicine. And doctors will continue to demand exceptional amounts of respect, authority, power and income. There will always remain a natural inequality in the doctor patient relationship. It is precisely because of this inequality that the rights language needs to be used, even though patients cannot be now expected to accept with resignation whatever doctors say or do to them. But society still trusts them and has granted them professional autonomy by allowing self-regulation. It is up to the medical profession to determine the standards of the profession, to ensure competency of their doctors and to discipline doctors when these standards are not met.
Thus, a contract is made between the public and the medical profession for mutual benefit, where the patient is provided a satisfactory treatment in exchange for very concrete and material professional gain from the privileges granted by the society. Doctors and providers therefore have duties and responsibilities rather than specific rights. And if they are to maintain the trust that allows them these special privileges, they have to act in a trustworthy manner. When Hippocrates formulated his infamous oath, the traditional healers could refer to it to know how to act in a way their patients would trust them. It was this that transformed the traditional healers into professionals. Hippocrates recognized the potential for doctors to harm and exploit their patients when he penned the oath that has governed the relationship between the doctor and the patient for millennia. It was acknowledged that doctors were in a position to exploit their patients and prescribes the doctor to restrain himself; prescribe only for the benefit instead of harm; not to disclose the patient’s private details obtained during the consultations; act within one’s competencies; enter homes only for the good of the patients, and to keep away from all intentional ill-doing and all seduction, especially from the pleasures of love with women or with men.  The clinical encounter was one that tempted the doctor to “manipulate, control, or otherwise take advantage of the ineluctably vulnerable person.”
It is thus, the duty and responsibility of healthcare providers and the state to ensure that the rights of patients are protected and respected. Patients come to their doctor in a state of anxiety and vulnerability, with the outcome dependent on the nature of care provided. This vulnerability and the potential for harm and abuse it permits require that the patient be kept at the center of care. Treating a patients right becomes treatment that protects the patient’s rights.
Categories: Issue 26: May 12

Professional Development

By: Shahula and Athifa (trainers)

A short-term training on managerial excellence and client oriented service delivery was conducted for the staff of ADK hospital from January to April 2012. This program was conducted in four batches over a period of four months with the broader aim of improving the quality of care provided to the patients accessing health care services from the hospital. Among the four training batches, there were two batches of support staff and two batches of managerial and supervisory staff selected from various departments of the hospital. Each batch comprised of 21 contact hours of training, and was spread across three weeks. An average of 15 staff participated in each batch.

Some of the key topics covered in this training include, communication, interpersonal skills, team dynamics and positive attitude, customer service, diversity, professional etiquette, techniques for dealing with unsatisfied and angry customer, conflict resolution, time management, management skills and coaching, leadership. As the training was based on experiential learning methodology, the participants discussed and learned through role-plays, group work, and other team based activities in addition to the information provided by the facilitators. A special emphasis was given to improve the self-awareness of the participants, and ways of applying the learning’s from the training into the work environment. As such at the end of the training, every participant had to commit himself/herself through a three-month action plan with personal goals for improving and applying the learning’s from the training into their work environment.

One interesting thing that was noted was the team dynamics that changed as the training progressed. At the beginning of every batch, most staff would interact with the few colleagues that they already know. As the training developed, so did socialization of the group. At the end, it was observed that the training created a forum for exchanges of experiences across departments that allowed the group to understand each others’ work. Moreover, the sharing also encouraged learning’s from each other, such as the techniques that one applied that others could benefit from, or a new change that has taken place.

An enriching factor was the sharing of experiences after applying the skills learnt which linked the training room to the real world. An example is SOGET – smile, being open, greeting, eye contact and thanking the patient while serving. Another example reflected an attitudinal change – treating patients with diverse cultural backgrounds the same, and not being prejudiced while we serve. Participants also learnt steps to deal effectively with dissatisfied customers and upset customers. Perhaps one vital factor was the emphasis that it is the staff that is central to customer satisfaction. Three questions that were highlighted at the end of every topic to promote this kind of application were: What (content)? So What (how relevant is to my work)? Now What (How will I apply it at work in the coming days)? Further, the pre-training, post-training evaluation reveals that 85% of the participants who filled the questionnaire had a significant level of positive change.

Another noteworthy observation is the increased level of participation of participants. The active participation yielded a higher level of learning that will help translate the knowledge to practice in their daily work. Trainings are important to maintain quality of service and staff motivation. What is more important is to apply the skills learnt on a continuous basis.

Excerpts and quotes from evaluation sheet

I learnt the importance of my overall attitude and behavior while dealing with others at work and during my daily life

Thanks for the last 3 weeks of invaluable gems of learning and wisdom you have given us. We learnt so much about the importance of our attitude and behavior and how to improve ourselves for the better

 This training helped us a lot to improve in our work. And also this helped out to build friendship between our co-workers

 I learnt a lot and it is a very useful thing which will absolutely help me to improve and give a perfect service to the customers

 These types of training really help us out to deal with different kinds of customers. I hope more of these trainings will be conducted in the coming future. Thanks for this class. It really works

Categories: Issue 26: May 12

Closing the gap: from evidence to action International nurses day – 12 May 2012

By: Department of Nursing

Every year, May 12th is marked as the international nurses day in conjunction with the birth date of Florence Nightingale and significance of this day to the nursing profession in immense. It gives the profession an assurance for their continued service and also a commitment to the continuous improvement in nursing care.

In this regard, each nurses day is celebrated with a theme of significance for continuous improvement. This year, the theme was “closing the gap: from evidence to action.” Of course, information and evidence has always been the major catalyst for positive change in any profession. Processes and standards based on evidence are more robust and ensure a consistent quality in the provided services.

The main gist of this year’s theme is to make nurse understand the role they play in the continuum of evidence to action. It is about asking good questions, improving skills, working closely with colleagues and also to use research and evidence for the benefit of patient care.

Similarly nurses are a source of good information and evidence. Nurses can provide important information about patients, their needs and systems required to provide a better and effective service. Nurses can also generate a lot of information on the operations of the health system and feed that information to research.

Hence, this year, the theme looks to shift the nursing environment to on that is conducive to evidence based practices while developing the standards of care provided through out the profession.

In the Maldives, there is a long way to go in developing a nursing care system that is in line with the theme of this nurses day. While recognising the achievements of the nursing system in the Maldives, nurses have to take a new initiative to build the culture of learning and using lessons from practice to improve care.

This year, in conjunction with the nurses day, the nurses of ADK also conducted some activities. In this regard they conducted a school health programme fort he children of Ameer Ahmed School and also held a function to have a bit of a break from their routine heavy and hectic workload.

The day ended with all smiles on the faces. Those who got deserved recognition for their hard work and those who showed their talents besides nursing, on the stage.

Categories: Issue 26: May 12

Clinical Incidence Management

By: Afaal, MD

In the healthcare setting more and more people are treated safely and successfully everyday and there is no exception here in the Maldives.  However, despite the dedication and hard work of the teams of healthcare professionals, in the complex health system things can and do go wrong placing patients at risk or harm. According to international studies, about 10% of patients will suffer an incident during their episode of care at a healthcare setting. In the Maldives, there are no such statistics available to understand the extent of the matter. It is though evident that there are such incidences in the entire healthcare setting here in Maldives as well.

One question that comes to mind is that why don’t we have such statistics? And the answer is very simple. We simply don’t have the mechanisms and the facilitations to identify and manage such incidences. There are many reasons for this. The first and the obvious reason is that, in Maldives any incidence puts the healthcare professional into situation of blame and accusation from the public. The culture is that the health professional intentionally does harm to the patient, which, of course is not the case.

Secondly, there is no protection to the health professionals and health providers through regulation and or Laws. Hence, the motivation for development and implementation of incident management systems are bleak due to the fear of litigation. Especially, the experience in Maldives is that healthcare mishaps are tried as criminal cases, whereas in the established systems, healthcare mishaps are tried as civil cases unless a criminal intent is established.

Established statistics in the world indicate that patient safety incidents are almost always unintentional. The

key to establishing an incident management system in the healthcare setting is to identify and manage such incidences and minimizing all risks to the patient. It is imperative for the creation of a learning culture where the professionals and the institute learn form incidents and near misses. It is used to review practice, train staff and improve their competency, assess equipment and communication gaps and make continuous improvements to the system of healthcare delivery.

There is a need for the Maldives to establish a proper legal and regulatory framework to facilitate risk management strategies such as incident management in healthcare settings. This will be a key factor to improve the quality of services and care provided in the country. There is a need to shift the mind set of the regulatory bodies and the public, as well as those within the health system to do away with the blame culture and move towards a learning culture.

Given the above reasons, we are having a challenge to implement an incident management system and standard here at ADK Hospital. There is apprehension and reluctance among clinical staff to champion a change in the paradigm in which we have been working. Establishing such a system and testing it out can only overcome this challenge. We have to start to gain our confidence by doing it and facing it.

Hence, the ADK Hospital’s clinical incidence management system is now ready for implementation. In the recent past we have used the aspects of this tool to assess some incidents and so far has proven to be satisfactory. With the implementation of this mechanism, we hope to see positive improvement in quality as well as care processes.

The main purpose of implementing this mechanism is to minimize patient harm through identifying and treat hazard before they lead to patient harm, identify when patients are harmed and promptly intervene to minimize the harm caused to a patient as a result of the incident and to ensure that lessons are learned from the clinical incidents and applied through taking corrective actions.

Categories: Issue 26: May 12