High Expectations

 

My first week at the hospital was both exactly and nothing that I expected. The hospital is a lot smaller than I had thought and seems to only have 1 permanent medical doctor and 1 permeant surgeon. The local government has placed 4 locum doctors there, on contracts of various short durations, in order to cover the gaps. The low number of doctors means that when the doctors are on call they cover the entire hospital. Peads, surgery, the labour ward, everything. Regardless of your speciality, you cover the lot. So you could end up with a GP doing a midnight c-section, or a surgeon trying to treat status epilepticus (unstoppable seizure activity). 

Our first task on arrival was to be paraded around the hospital and made to formally greet every single member of staff, in every single department, even ones that I am sure I will have nothing to do with. On our visit to the wellness clinic I was surprised to learn it offers foot massages and cleansing rituals. Some departments seemed busier than others, the HIV department was over 30 people strong, whereas when we arrived at the paediatric ward, I notice it was suspiciously quiet. I found out this was because there were no children there at all. After asking I was told that the hospital currently didn’t have any paediatrician, the locals knew this and so were not bringing their children to the hospital unless they really had to.

As our royal tour of the hospital progressed, it was clear that formalities are a big deal here. Entire departments were made to down tools, leave colleagues mid convocation and abandon patients to great us in order of their ranking. ‘I want to talk to you, but I can’t until Sister has.’ one nurse told us as we passed through. One thing that I was not expecting, and which was a recurrent theme, was how difficult everyone found my name. No body had ever heard the name Yasmin before. Watching them sound out the word and fumble over it was quite funny. The other thing I noticed was that all the heads of departments here are female nurses, as too are the majority of the management team. This means that there is a very large female presence in roles of authority, quiet an alien concept to me. The head of the hospital however is a man, so its not quite a female empowered utopia of my dreams.

After our day of endless introductions, we began work on our projects. For those of you that don’t know, the idea of Quality Improvement (QI) in healthcare is to focus on very specific small areas where a change can be made and easily assessed, measured and sustained. A standard QI project might be something like ‘Reducing time for CT scan, for patients presenting to the A&E with renal stones, to under 48 hours’. To achieve this you might come up with multiple different strategies. I’m not sure the QI lead for the hospital had fully grasped this concept as we were given huge nebulous topics with lofty targets without any real direction. I have been given the grand topic of trying to reduce the hospitals’ over all mortality by 5% by December. 5% might not sound like a lot but let me tell you, it is! Some of the largest medical studies in the world, run over years, with huge international teams behind them, are delighted when they are able to prove that they have reduced mortality by 1%. 5% is the surely the stuff of dreams, unless it’s a project to put a doctor into an area previously without any health care provisions at all. Sadly I don’t know any paediatricians in Lesotho that might achieve this goal. And in which area are they expecting me to achieve this mega goal in? Oh, just the entire hospital. And to all patients regardless of their illness. In a hospital which I currently have no idea how it operates, what its services are, which medicines they have and don’t have, what their supply chain is like, what their labs are capable of, what the turn around time is for investigations, the morphology of conditions that normally present to the hospital, the capabilities of the team in the hospital or what attempts have been made and most importantly have failed previously in order to achieve this. Right, yeah, sounds easy. I should be able to figure this out in 6 months no problem. Right after I learnt how to actually do a QI project as I have never actually fully completed one before.

Learning how to QI

The QI office

I couldn’t bring myself to tell our overly enthusiastic QI lead that what she had actually given me doesn’t actually classify as a QI project and is more of an institutional goal and directive. Especially as she was telling us how excited she is to learn how to do a proper and correct QI project from us. Instead, I quickly googles ‘How to run a QI project and read through the website ‘QI project plan for dummies’.