Sunday, January 20, 2013
Address by the Hon. Dr. Fuad Khan
Minister of Health
University of the West Indies Faculty of Medical Sciences
Conference on “Improvement in Health Care Quality and Delivery: Making a Difference”
Hyatt Regency Trinidad, Wrightson Road, Port of Spain
Friday 18th January, 2013, 8:30am
Campus Principal and Pro Vice Chancellor, UWI, St Augustine, Professor Clement Sankat
Dean, Faulty of Medical Sciences UWI, St Augustine, Conference Chairman, Professor Samuel Ramsewak
Sir Andrew Cash, Chief Executive, Sheffield Teaching Hospital Trust, United Kingdom
Management and Staff at the University of the West Indies, Ministry of Health and Regional Health Authorities
Other Conference attendees and specially invited guests
Members of the media
I want to say a pleasant good morning to everyone here. When I was invited, and thank you for the invitation to this conference, it brought home a point from last year when one of my good friends emailed a brochure to me on the internet saying, “I think you should go to this meeting”. This meeting was being held in Paris and that was my friend Dr. Harold Cham. That conference was the International Health Quality Conference in Paris with international speakers and international papers, visits, etc. It was almost a week long. I took the decision to carry myself there to see what it was like, as well as to take all the chairmen of the Regional Health Authorities. I looked around this morning and I didn’t see any of them here which is a bit surprising. We spent a week in Paris learning about Health Quality and I’m very thankful that Professor Ramsewak has decided to embark on this process. What we learned there was making a mistake was human but the mistakes that you do make can cost somebody their life and cost you your specialty and your career.
You see ladies and gentlemen, we have a habit in Trinidad and Tobago to do two things;
1. Break red lights,
2. Break major roads.
Now you could get away with it a hundred times while doing it to the extent that you reach a comfort zone. A certain comfort zone and comfort level, where you are accustomed breaking major roads and breaking red lights, so it becomes part of your norm. The reason I have started with that was because I wanted to indicate something about human behavior. You do something wrong the first time, you’re worried. The second time, you get away, but the tenth time it becomes part and parcel of your human behavior, until one day a truck breaks the other red light while you are on the green and then you are no longer in existence. The reason why that other vehicle struck that other vehicle is because you did not adhere to recognized principles and you did not look at the behavior pattern in what you did.
When I am confronted as Minister of Health with a death in the public sector and on investigation it is seen that at 8:30, 9 o’clock in the morning, there were no senior doctors and junior doctors were doing all the work, it begs the question, were we adhering to recognized principles? When you look into it and you find that there was no adherence to recognized principles, international best practices or international standards, and the end result was a patient who had significant morbidity or mortality in some cases, and you ask the question, that we have come a very long way in medicine but what was the reason for these mistakes? What was the supply chain? How did we manage it and at each level?
Some of the participants at the UWI Conference on Improvement in Health Care Quality & Delivery
I remember speaking to the head of the Accident and Emergency Department in Eric Williams Medical Sciences Complex about a year ago. I was receiving a lot of complaints about the long wait, the amount of patients on the beds, the amount of patients who were ill and who were not moving and we came down to an assessment of what was occurring and it was two things. Waiting for blood results to turn in, that took approximately 34 different touch points to move a blood sample, and also waiting for attendants to move the patient back and forth or move the blood samples back and forth. We found out that it was 34 movements to carry a blood sample from Accident and Emergency to the lab and back. Now, while addressing this we placed a point of care testing machine in accident and emergency and cut the waiting time right down for people with non-emergency conditions. This is a development of looking at a quality supply chain beginning with what we call the end in mind.
This is how quality systems work. Quality systems work where you have to audit yourself. You have to audit what you are doing. You have to audit where you are going and beginning with the end in mind, determines exactly what is going to occur to the most important part of a whole system, which is the patient that comes for your care and attention. By doing that, I work backwards….how best do I treat that patient and how it occurs. I learned that there are things: service marking, relationship marketing, as well as supply chain logistics, and that is how it occurs in all systems.
Professor Ramsewak spoke about these systems. You’re only as good as your system and your system is only good as yesterday’s mistakes because you could do quite a lot and we do a lot in health. And I commend you for it, but what we do get hit with are yesterday’s mistakes, and the mortality or morbidity of one patient. We receive thousands but it is that one patient that determines what we need to do next, to prevent that from reoccurring. You see, the economic well-being in our country, is tied towards healthcare.
Firstly we look at the maternal healthcare and child healthcare and their mortality rates. We have been a bit successful in the infant mortality rate but it is not as good as we want it to be. We have gone down. However our maternal mortality rate still leaves less to be desired. As Minister of Health I have been trying to increase that to zero. We’ve done a very good job with our HIV. HIV mother-to-child transmissions have now reached zero transmissions and that is a laudable fact.
We’ve been speaking to the Ministry of Tourism about medical tourism. For medical tourism to occur in this country, we have to be able to compete with the big players. Nobody is going to come to this country because we say we have achieved or we are better because we say so. We have to show proper accredited standards, proper accredited methods of approach and proper accredited systems.
When the Chancery Lane building was being refurbished to become a hospital, I insisted that we had North American standards and codes in the buildings. Mr. Gosine is here and I have to thank him for that because, the long term thing I am going to do will be developing it for two things: medical tourism and also standards for our people.
I’ve also started to do clinical audit systems. Right now we’re auditing all the work that is being done by doctors, nurses, etc in the logistics of the operating centres of all the regions. We’ve done one audit in the South West Regional Health Authority in the radiology department and believe it or not, it leaves a lot to be desired. When you see that someone goes for a CT scan or MRI in Eric Williams Medical Sciences Complex and six weeks after they don’t get their report, how does that go for quality?
Some of the participants at the UWI Conference on Improvement in Health Care Quality & Delivery
My job as Minister of Health is to make it more user-friendly and to make that system accountable. So the audit system that we are doing is showing certain deficiencies. It is showing that we also need to have two or three CT scans around and we came up with a concept called the diagnostic systems. I will share it with you. One CT scan in Eric Williams Medical Sciences Complex services the hospital, all the wards, all the clinics, even outside clinics, primary health clinics, etc. So it is impossible for it to take that load. I am very glad that Professor Sankat has spoken about the public-private partnership, the P3 approach. That is what Ministry is dealing with and trying to move forward together with the Ministry of Finance. Once we develop the best practices of specific diagnostic centers that CT scan, radiology and MRI, and have all investigations in one building, maybe on a hospital compound, that will take care of all the primary healthcare investigations, freeing CT scans, etc for hospital work. That should take a lot of load off the system. It really came about because of complaints, complaints of long waiting list, and long delays in reports.
We go to pathology. Somebody does an operation in January in one region and eight months after we are still waiting for the pathology report. If that person had cancer, you would need pathology to treat it. So what I have decided to do was a triage system like what they do in Accident and Emergency with one, two, three and four. This determines what is more important, what is less important, and trying to outsource pathology readings both locally and internationally by means of telenets. These are the approaches that we are using to develop a quality system.
Now that I’ve spoken about procedures, let me speak a little bit about staff. You are only as good in your region as your staff. You are only as good as your staff’s behavior. If your staff’s behavior is not in keeping with proper patient care and patient activity, then you have a serious problem because you may deploy your staff to deal with your patients. Let’s take escorts for example. The escorts are supposed to transport patients about the hospital and when they decide not to be found, decide not to go to work although they do get paid for it, and you try to discipline them, the union comes after you. This is something that we have to deal with and we have to deal with it quite soon. All that is part of the quality supply chain. If the supply chain breaks down in any part of the chain, we end up with a poor product. The product will be poor service, poor quality and we will be speaking like this, exactly as we are speaking here today, in the best manner, and with the best intentions. However if you don’t plan an implementation system to get better results, then we will be coming back every year speaking the same thing.
I am hoping that after this conference, that the stakeholders plan implementation procedures for each system in your system and work the plan. Also at the same time, they should have independent people within the system looking at the workings of your plan to see if it is working and criticizing it as well.
We’ve embarked upon developing the infrastructure. The Children’s Hospital in Couva has begun. The Arima Hospital, if UDECOTT ever gets around to determining where it is going to go, I hope one of these days I will get it but I’ve been trying to do that for the last year. The Sangre Grande Hospital is in the making. I hope to do the Mayaro Hospital and the Cedros Hospital. When I say hospital, I don’t mean a massive hospital; I mean things to serve at a local level. Also the health offices are being upgraded for more primary care use.
As you see and you know we have been speaking about non-communicable diseases and the complications of the non-communicable diseases. What I am seeing in the health offices are short management and then no follow-up. So I am trying to get the primary health care system to increase their quality management and do follow-ups of the non-communicable diseases and complications so as to decrease the effect. You’d notice that the Ministry of Health has been promoting healthy lifestyles, healthy eating habits and I am seeing it is taking root. When I see now that all the fast food outlets advertise salads on their billboards instead of just hamburgers and they are promoting calorie content, I think we are reaching the overall aspect of quality management within the Ministry.
As you can see we have launched the Scarborough hospital, etc. So developing an infrastructure is one part of it but developing a cadre of human resources is another part of it. Developing responsibilities for behavior of staff is very vital to quality management. I do hope that the next time that we have a quality conference that I see my chairmen of the Regional Health Authorities taking part in it because they had a lot of input to the ones in Paris.
So ladies and gentlemen, with those few words I would like to thank you and thank the professor for inviting me here. Thank you very much.