Keeping patients safe: Guidelines for healthcare institutions

We assume that healthcare institutions have their patients’ best interests at heart; here are some of the guidelines and laws that back that assumption up.

MOST of us would probably have heard the stories of emergency patients being turned away from private hospitals because of their critical conditions or lack of financial guarantees, or the overflowing wards in public hospitals leading to patients having to sleep in camp beds along aisles or corridors.

Hospitals were created to treat and nurse the ill back to health, but sometimes it may feel like that original objective has been displaced by the competing interests of being a business, or lack of resources, among others.

So, how do the public know that their welfare and safety are really being put first in these healthcare institutions?

One way, of course, is through government policies.

According to the Association of Private Hospitals of Malaysia (APHM) chief executive officer Dr T. Mahadevan, quality in healthcare was first spelt out in the Fourth Malaysia Plan (1981-1985) as an activity of the Health Ministry (MOH).

This resulted in the launching of the Quality Assurance Programme (QAP), which still serves as a national benchmark for patient safety and quality healthcare in all MOH hospitals, in 1985.

Dr Mahadevan, who was one of two presenters at the Understanding Accreditation and the Relevance of the Patient Safety and Quality Improvement Movements session during the “Overcoming Challenges to Quality Improvement and Patient Safety Strategies” workshop held in Kuala Lumpur recently, notes that, “Surprisingly, we were one of the few countries at that time to do it.”

The QAP covers around 145 public hospitals with a total of about 39,500 beds nationwide.

However, this still leaves out the three university-affiliated hospitals under the Higher Education Ministry, the three military hospitals under the Defence Ministry, health centres under the Housing and Local Government Ministry, Hospital Orang Asli Gombak under the Home Affairs Ministry, and around 220 private hospitals with about 10,500 beds in total around the country.

Practised by all

But there are certain quality assurance and patient safety activities that are practised by most, if not all, public and private hospitals.

These include the Maternal Mortality Review (MMR) and Perinatal Mortality Review (PNMR).

The MMR, also known as Confidential Enquiries into Maternal Deaths, was initiated in the early 1970s and looks at the causes of pregnancy-related deaths within the term of the pregnancy or within 42 days of the end of a pregnancy.

According to Dr Mahadevan, this is one of the strongest and longest-running patient safety activities in the country. This probably accounts for Malaysia’s good maternal mortality ratio of only 29 deaths per 100,000 live births in 2010, decreased from 53 deaths in 1990.

Meanwhile, the PNMR analyses the reasons behind foetal and newborn deaths. Malaysia’s neonatal mortality rate was three deaths in 1,000 live births in 2011, decreased from nine deaths in 1990.

In addition, Dr Mahadevan shares that the Peri-Operative Mortality Review (POMR), looking at deaths associated with surgical and surgery-related procedures done under general or regional anaesthesia, was initiated in 1990.

“But this has remained for public hospitals only; only MMR and PNMR has spread to both public and private hospitals,” he says, adding that the POMR seems to have died a natural death in the private sector.

Aside from these specific inquiries, all hospitals in the country are obliged to do incident reporting.

An incident report is the immediate documentation of any unusual event in the healthcare facility, usually resulting in an injury.

However, in this case, the problem is the large amounts of information flowing in.

“The ministry is overwhelmed; there is a lot of information from the private sector, but it takes time to process it.

“Hopefully, it will be done, so we can all learn and improve,” says Dr Mahadevan.

He adds: “People want to know happens after a report. Hospitals need to ensure that the results get back to the person who wrote the report.”

Accreditation and the law

The other method of quality control is via accreditation through a relevant respected body.

In Malaysia, there are two widely-recognised bodies: the Malaysian Society for Quality in Health (MSQH) and the Joint Commission International (JCI).

The MSQH was set up by the APHM, MOH and the Malaysian Medical Association in 1997, while the JCI, an international American-based quality and patient safety best practices accreditation organisation, came into Malaysia a decade later.

Dr Mahadevan asked the workshop participants if any of them believed in accreditation, and the general murmurs seemed to indicate that it was a chore, more than anything else.

He affirmed the response, saying: “Accreditation is pursued not for improvement, but to put on the (hospital’s) website.”

However, he continues: “But I believe that after going through several rounds of accreditation, something good comes out of it.”

According to him, there are 68 local MSQH-accredited public hospitals and 30 private ones, while the National Heart Institute (popularly known by its Malay acronym, IJN), along with seven private hospitals, have been accredited by the JCI.

“If you have MSQH or JCI, the framework (for quality assurance and patient safety) is there,” he says.

However, Dr Mahadevan notes that, “Quality and patient safety is still very much management-driven, with minimal or nil clinician buy-in.

“It is management-driven because they got to say that we’ve got this programme in place.” (See Triadic tension)

Other methods used to ensure patient safety include the Patient Safety Council of Malaysia, which oversees the implementation of the Malaysian Patient Safety Goals and is chaired by the Health director-general, as well as the following laws:

·Nurses Act 1950 (revised in 2006)

·Registration of Pharmacists Act 1951 (revised in 2004)

·Poisons Act 1971 (revised in 2009)

·Medical Act 1971 (revised in 2012)

·Prevention & Control of Infectious Diseases Act 1998

·Occupational Safety and Health Act 1994 (revised in 2006)

·Private Healthcare Facilities & Services Act 1998 and Regulations 2006

Dr Mahadevan notes that the Medical Act in particular, provides for the establishment of a National Specialist Register, a publicly-accessible database that is compulsory for all medical specialists practising in the country to be registered with.

“Hopefully, we will see this (completed) by the end of the year,” he says.