Two Steps Forward, Eight Steps Back...

Alright guys, brace yourself—you're about to be taken to the very edge-of-your-seats, on a thrilling, electrifying, heart pounding, rollercoaster ride that is… quality improvement. I can already hear your enthusiasm. 

I cant tell you how sad this
 obs chart makes me

As you might be able to recall, my modest task was to try and reduce the hospitals over all mortality rates by 5% in just 10 months. I knew I had to try and somehow find an actual project shaped focus for this problem. In my first meeting with management everyone seemed very keen for me to introduce an Early Warning Scores (EWS) system into the hospital. This is basic practice in the UK, and something that as an A&E and ICU Reg I’m highly trained in, so I so I thought it might be an easy project for me. After speaking with people, it turns out this was a project that the hospital had been trying to do for 12 years now, and has failed each time. Its not a concept practice anywhere in Lesotho, so the idea is very foreign to both doctors and nurses. When I visited the wards, I soon learn that staff didn’t have access to enough observation machines to carry out the observations at the frequency for them to act as an early warning system. I can see why its failed so many times.

 

With that idea dead I decided to read over all the notes from patients who had died in both January and December to see if I could find any patterns as to why they were dying. The notes were quiet enlightening. It turns out some truly mad things are occurring in the hospital. I read through plans that not only made no sense, but to my mind would have hastened death, significant investigations that were seemingly ignored with disastrous consequences, and noticed that a lot of patients seemed to be, not so silently, aspirating themselves to death (choking on their own saliva) but it was somehow not being picked up by the medical team. Having worked in a low-income African country before I knew there must be more to this. The doctors and nurses here are not stupid or neglectful. They are all highly intelligent, trained, devoted individuals. Given the right (or wrong) circumstances, everyone is liable to making bad or dangerous decisions. As I read through the notes I kept telling myself ‘We listen, but we don’t judge’…but it was hard if I’m being honest. 

So, I decided to go out onto the wards and speak with the staff about what it is actually going on. I had wondered why none of the doctors had requested a renal function on patients who clearly had signs of renal injury, but apparently for the entire month of December the lab had run out of reagent for Creatinine so was unable carry out the test, and nurses were not used to measuring urine output to act as a clinical marker. They were currently facing the same problem with full blood counts (a basic yet extremely essential test, without which, practising medicine becomes less of an evidence-based science, and is more akin to a medieval pursuit of removing the bad humours from the body). When I asked if I could look at some of the chest Xrays for the patients who’s notes I had reviewed, I was told that there wasn’t any hard copies of them. A few years ago, the government had bought the hospital a lovely new digital Siemens Xray machine, higher quality images, less radiation, beautiful. Unfortunately, this machine did not come with a server to store the high quality, large image files on. So, staff would take a grainy picture of the Xray on their mobiles and WhatsApp it to the Dr’s WhatsApp group before the original image was lost forever. The same system was used for reporting urgent blood test or tests from other hospitals. Unfortunately, with the ever-rotating pool or locums, not everyone is on this WhatsApp group, meaning new Drs have no way of seeing old investigations for patients when they start. But without doubt everyone told me that the biggest problem the wards faced was the locum doctors. With only 1 permanent medical doctor, the remaining 4 posts were filled with locums, who would come to work at Maluti during their annual leave from their full-time jobs elsewhere in the country to make a bit of extra money. The locums might only stay a week, they have no idea how the hospital ran, what they were supposed to be doing, or who was supposed to be supporting them. 

After chatting with the staff on the wards my head was buzzing with possible ideas on projects to improve things. Later that week I had a meeting with the Chief Medical Officer (CMO), I had already discovered that any project I wanted to do would need his approval. I presented my findings and listed a few ideas of projects which I thought could reduce mortality, and thankfully he was very receptive to all of them. It finally felt like I was making progress on turning this huge goal into a manageable QI size project. One of my ideas was to improve the situation around the locum doctors, but the CMO quickly told me that although he was very much in favour of this idea, management wouldn’t want me to focus on them. The hospital had plans to bring in specialist and so soon would not be in need the locums (although they had been saying this for over a year now and the specialist were no closer to arriving). I asked the CMO who’s job it was to oversee the locums, check if their plans were sensible and offer advice if they were stuck. It was him, although he admitted to me, that as he is a surgeon by background, he felt out of his depth consulting on medical problems, and technically he was still waiting for his licence to practice in the country and so was supposed to be doing strictly non-clinical admin work. 

Eventually we settled on a project. I would focus on trying to improve the use and review of investigations to try and avoid the common situation of extremely significant investigations (such as bloods and Xray sect) not being seen for days, if at all. Under this pretence I would also create a locum induction booklet which would at least put down in writing what was expected of the locums and detail how to do various essential functions around the hospital, as well as hospital protocols. Whether or not these locums would follow the rules of my induction booklet was another problem for another day, but at least I finally had a project. Or so I thought. 

Out of nowhere the hospital was invaded by 22 Americans from a NGO called Adventist Medical. One day, when I arrived at work I was met with a barrage of American accents flooding the corridors—loud, overenthusiastic, and declaring even the most mundane observations like they were breaking news. For one week only they had brough personnel to help in every single area of the hospital, from technical support in the labs to assistance in the sterilisation process of theatres. They even had a team dedicated to improving water purification in the villages. QI was not left out of the onslaught, and so a special last-minute meeting was set up with us to speak to them. 

They could not have been less interested in what mine and Sarah’s project where. Fair enough I guess, they want to upskill the local staff, not us. Unfortunately, they also didn’t seem that interested in what the staff had to say either. It appears as though they had there own agender, and finally, by the end of the meeting it became apparent what that agender was. They wanted to upgrade the hospitals data filling system. To be honest the current system was about as efficient as exchanging CPR for a motivation TED talk, so its not a bad idea. At the moment patients are not given a unique patient identification number on admission, so there is no way to track down old notes or past investigation results. Once discharged notes are filed based on date of discharge and nothing else. Walking into the filing rooms is the stuff of nightmares, single handedly run by one very short man who any day now will disappear under a landslide of poorly filed notes. The Americans asked if we would be interested in exchanging our projects for this one, defiantly a worthy endeavour I thought, but that would put me right back at square one…