JESICA Santillan was smuggled into the US by her Mexican parents in search for treatment to cure her rare and life-threatening heart disease. Their plight caught the attention of the local community and funds were raised to cover the cost of a heart and double lung transplant at Duke University Hospital, one of the leading transplant centres in the world.
Within three years of arriving, Jesica received exciting news — she was about to receive the transplant she was anxiously waiting for (it is worth bearing in mind that donors for heart and lung transplants are extremely rare and most patients die while on the waiting list). The surgery was proceeding without complications but five hours into it, the team received devastating news: the organs transplanted into Jesica were of the wrong blood type. This meant that her body will reject the incompatible organs, with death as the inevitable outcome.
It is difficult to overstate the sheer amount of waste that was brought about by a simple lab error. The years of anxious waiting, the logistics behind transplanting organs, the community mobilised to solicit funds, organs that could have been used to save another life, and the financial and reputational damage — all these pale in comparison to that ultimate cost of a human life.
There are few circumstances that highlight the fallibility of man as vividly as a doctor who makes a mistake. However, the vast majority of mistakes in healthcare do not occur as a result of individual incompetence. Mistakes are usually a manifestation of systemic issues — there were dozens of individuals who had the opportunity to check Jesica’s blood type but did not do so because they were not prompted to or had assumed that it was done by someone else.
In 1999, the US Institute of Medicine (IOM) published the seminal report To Err is Human: Building a Safer Health System. It estimated that up to 98,000 deaths occur every year purely as a result of medical errors, equivalent to a jumbo jet a day.
Healthcare provision is complex — dealing with complicated issues under intense time pressures and complex communication patterns. A highly dynamic system to identify and minimise the risk of errors is therefore essential to maintain the highest level of quality.
Readers are likely to be familiar with the concept of corporate governance. Clinical governance is philosophically similar but differs in that it is heavily weighted towards the main stakeholders in healthcare — the patients. It has more to do with a healthcare institution’s ability and commitment to continuously improve the quality of patient care.
Peter Drucker’s maxim, “if you can’t measure it, you can’t manage it”, is applicable in this context. One of the key features of clinical governance is continuous audit cycles to identify mistakes and near misses, with a view to implementing systemic changes that will decrease the risk of such occurrences in the future.
In the case of Duke University Hospital, it overhauled the transplant protocol, with a focus on improving communication. Blood and organ compatibility is now double-checked to prevent similar tragedies from occurring. The hospital is unique in that it publicly admitted to a mistake and has been transparent with efforts to improve its quality of care. A similar approach should be adopted by all healthcare institutions including those in Malaysia.
Investors and users of healthcare institutions should be privy to information about the standards of service that a centre provides. At present, there is a lack of transparency and it is unsurprising that many patients choose a particular hospital on the basis of recommendations that may or may not be tethered to facts.
Malaysia’s healthcare industry has been deemed a key economic area under the government’s Economic Transformation Programme, with the Performance Management Delivery Unit expecting healthcare tourism to bring in revenues of US$3.5 billion by 2020. More importantly, the industry is mostly driven by domestic consumption, and demographic trends indicate that by 2020, 10% of the country’s population will be above the age of 60. This will lead to significant economic and social challenges but also opportunities for healthcare providers.
As the industry grows, it becomes trickier to sieve the best institutions from the rest. Measuring the performance and value of companies that deal with human lives should be done beyond the usual metrics such as share prices and return on invested capital. Organisational culture that prioritises clinical governance is particularly important for short and long-term returns. The domestic and international markets play a moderating role in the behaviour and performance of corporate entities. Such pressures should also be brought to bear on healthcare institutions.
The IOM report concluded that to improve patient safety, “the external environment [must] create sufficient pressure to make errors so costly in terms of ability to conduct business in the marketplace, market share and reputation that the organisation must take action”. Combining a culture that values clinical governance with external pressures from key stakeholders will help ensure that patients receive the care that they deserve.
Dr Helmy Haja Mydin is an associate of the Institute for Democracy and Economic Affairs and an associate professor at Universiti Malaya
This article first appeared in The Edge Malaysia Weekly, on March 16-22, 2015.
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