A recent opinion piece (1) by Daynia Ballot describes the inadequate response of a private hospital's doctors, management and staff to a tragic and unexpected death. It draws attention to systemic problems in private health care and asks whether the care is excellent.
Is private health care excellent?
Some private hospitals (2,3) publish aggregate outcomes such as infections, falls, medication errors, procedure-related events, and other rates of preventable harm. Despite these published indicators, which are not externally validated, the Health Market Inquiry (HMI) (4) concluded that there is insufficient information about private health system quality.
Personal or family experience of preventable harm or death in private hospitals is usually a private affair but occasionally it attracts attention (1,5). Such adverse outcomes are seldom attributable to a single cause e.g., a doctor, nurse or hospital. If in fact “the system can only deliver the outcomes it's designed for” (6), then some events are accidents waiting to happen, best prevented by focusing on system design and strengthening rather than individual lapses in performance.
Teams and teamwork are required
In the private sector, professional autonomy and independence are prized and protected. This is claimed to be good for patients, but solo practice is intrinsically isolated from the learning and surveillance of peers and can be lonely and stressful. Evidence is growing that teams (7,8) do better, for example in perioperative care, care of complex conditions and primary care. However, among practitioners competing for the same pool of patients there is little incentive to collaborate. The use of common order sets is resisted despite recognised benefits (9). Safety checklists get introduced with good intentions, but without an accompanying culture of learning and become compliance-oriented administrative tasks. Professionals are expected to learn continuously but do so in silos, without nurses or other team members. Private practitioners seldom work with private hospital staff to define local best practices, processes, pathways e.g., responses to emergencies. Successes and mistakes are hidden, denying the opportunity to learn together to deliver safer, more compassionate care.
Challenges are faced by nurses
After 1994, nursing colleges were closed, funding for training was reduced and large staffing shortages have persisted since that time. Hospitals recruit from abroad and depend on agency staff, particularly on weekends and nights. Typically, private hospital wards, even ICUs, have no medical officer permanently on site, thus placing a burden of complex decision making on nurses, creating delays in care and response to emergencies. Despite this dependency, nurses tend to be seen as servicing the needs of doctors and patients rather than being part of an integrated health care team working towards a common aim of quality care. There is no consistent mechanism to include their insights into the care plan, and ward routines are generally set up for the doctors’ convenience. Many doctors looking after a patient often means as many different ways to manage routine postoperative care e.g. pain or blood glucose control, anticoagulation, postoperative feeding, etc. Unnecessary variation is a recipe for error, unreliability (10,11) and “poor nursing” because nurses have to constantly adapt.
Best use of the limited nursing and other professional workforce would come from a more enabling work environment that values all contributions that allows professionals, including nurses, to work closer to the “top of their license” in physician-led teams.
Clinical records are fragmented
It's common practice for private doctors to write only orders in the hospital folder, holding the medical record itself in their personal practice record systems. This would be considered unacceptable in most public hospitals. Without access to the full record, nurses, other hospital staff and other doctors involved in a patient's care are less likely to understand and reliably execute physician orders. A shared record is needed for teamwork, analysis, reporting, and learning. Electronic record systems may in time solve this problem but simple practical solutions, such as requiring a copy in the hospital paper folder and writing a more explicit daily care plan with goals, priorities and rationale are practical, inexpensive options.
Where is accountability?
Healthcare is complex, procedures are inherently risky, and humans are error prone, thus adverse events are almost inevitable. Accountability relies on self-regulation (peer review), the Health Professions Council of South Africa and the courts, but in the absence of a system accountability, individuals delivering care are held wholly responsible for adverse events. Few professionals in private hospitals have their practices reviewed, guided, or sanctioned. They are not held accountable for everyday good care but only for egregious misconduct. The BetterOBS programme (12) under the auspices of the South African Society of Obstetricians and Gynaecologists is an encouraging development although it is still focused on individual behaviour and not system safety. Practice is set and reviewed by peer review committees, doctors collect data and as a result legal claims against practitioners subscribed to the BetterOBS (12) programme have dropped.
True accountability starts with a declared and shared commitment to measure and provide the best possible care. Seeing everyone working with their own data is more convincing than “Top 20” hospital listing (13) and perhaps more immediately productive than public reporting and new reimbursement mechanisms. In some countries, like Brazil, private hospitals compete with one another but are also brought together by their hospital association to learn and improve (14). They share performance data linked to common goals, such as hospital safety, tracking and comparing institutional performance over time.
The influence of lawyers
When things go wrong in the private system, physicians are held to account through litigation. Enormous malpractice awards threaten to completely derail the public sector and are also a big problem in the private sector, though the total size of awards is undisclosed. In a world where a perfect result is expected, uncertain outcomes can occur despite excellent care. If responsibility was shared for creating a safer system that was more transparent and able to admit failure, the medical litigation industry might shrink.
Better responses to adverse events
Recently, a surgeon and anaesthesiologist were arrested and charged with culpable homicide after the death of their 11-year-old patient (15), generating outrage from the profession and worsening levels of fear and defensiveness. The family claim that they are following the legal route “in pursuit of the truth” about the death of their son. While harm can and does clearly result from overt disregard for accepted standards of care, most adverse events are not the result of recklessness or negligence deserving criminal charges. They often happen because the systems that doctors and nurses work in are weak. Blame and fear drive hospitals and professionals behind a wall of silence. When a patient dies unexpectedly a nurse may be fired, a doctor taken to court, a hospital manager forced to leave, but the system remains unsafe.
More compassionate, effective, structured responses to adverse events exist. Using principles of transparency, compassion, and learning, Michigan developed the Communication and Optimal Resolution (CANDOR) program (16) which has 3 elements: (1) response and disclosure to patients and/or family, (2) investigation and analysis, with review of the organization's current processes to make improvements and changes, and (3) resolution and organisational learning, with a process involving legal counsel, claims, and risk management staff. CANDOR includes Care for Caregivers because staff also need support and compassion as professionals who continue to care for patients may be under enormous stress, placing other patients at risk. Similar programs have been able to contain liability costs while adhering to a commitment to offer compensation proactively (17).
Looking back to make care safer going forward
Morbidity and Mortality (M&M) reviews are a cornerstone of surgical quality-improvement programs (18) where past mistakes and failure can be openly discussed. While this process is limited in scope by its reactive design, M&Ms help to identify system factors that contribute to bad outcomes, e.g., revealing untoward outcome involving agency nurses who may be new to the hospital and its routines, or communication issues, such as staff reluctance to unnecessarily “bother the doctor” after hours. But where they do exist, few doctors attend these meetings. Attempts to reconstruct events are therefore difficult and follow-on processes for addressing identified systemic factors are weak and ineffective. A distinguishing feature of good hospitals is better “rescue” (19) i.e. early recognition and action (i.e. resuscitation) in response to clinical deterioration. Systematic mortality audits (20) of recent deaths in hospital are a proactive way to gain insights into each hospital's context and processes that may generate adverse events and give hospital leaders and staff new tools for understanding and preventing adverse events.
Advocacy or co-creation?
The experience of a high status health professional who was unable to get the information and attention needed to safeguard a family member led to a call for stronger patient advocacy (1). Patients are entitled to information and participation in decision making, and are invaluable in co-design and co-production of care. Thus, progressive health systems include patients and families in these processes (21). Systems that reduce reliance on the insights and decision-making of any single person create more safety.
Reimbursement and markets are not delivering safety or quality
Fee for service reimbursement creates incentives for hospital occupancy and revenue-generating procedures. Safety, effectiveness or health outcomes are not valued, perhaps partly explaining world-beating private sector rates of caesarean section (22), tonsillectomy (23) and other interventions. Local funders are attempting to introduce different payment mechanisms in response to unsustainable cost increases and perhaps awareness of quality gaps. Improvement in quality and safety may result but also increases in administrative burden. Is it not time to shift energy and attention from payment, market and inspection mechanisms to a commitment to, and reward for, better patient safety and experience?
Physician leadership is needed
Most private hospitals have advisory boards, to which doctors are elected by their peers, which may be vocal about some issues such as equipment or nursing quality but have few leadership responsibilities. Clinician leaders should advocate for better equipment and staffing but should also take responsibility for creating a safer environment where every practitioner holds themselves accountable for the safest and most compassionate care possible. Doctors have played an important part in hospital committees that have enabled rapid and effective responses to the Covid-19 pandemic. Clinicians’ creativity and problem-solving skills are underutilized resources for improving care at a system level and developments during the pandemic could be models for future transformation.
A challenge to the private sector
Excellent care happens every day but preventable death and harm may be more common in private hospitals than we think. We have a design at odds with the increasing complexity of health care which demands greater teamwork and collaboration. Doctors work largely in isolation, are expected to be all knowing, and responsible for their actions and for outcomes, without system guardrails to help them do the right thing. More policing and regulation may make no difference while the market fails to bring quality and safety into the picture. Hospital groups have, or claim, little authority over medical practice. The legal system generates defensive behaviours, driving problem behind walls of silence. Doctors cannot work their way out of errors in their own solo practices, and errors cannot be litigated away by censure and large settlements. HMI recommendations are untested and may never take effect (4).
Getting to better and safer care
There are better, more proactive ways to make our health care systems safe. For example, the Institute for Healthcare Improvement framework for safe, reliable and effective care (Figure 1) (24) speaks to two themes: (1) a learning system and (2) “culture”. Mechanisms should be in place for clinicians to anticipate and learn from their mistakes. A learning system needs transparency, including when things go wrong, so we can understand and commit to the changes needed for greater process reliability; continuous processes of measurement and improvement to identify care that is slipping; places of psychological safety in which to learn and be accountable to one another, to patients and others. Leadership must take charge of efforts to create a just culture that promotes teamwork, communication, negotiation, and trust. The Best Care Always campaign (2009-2015) (25) was a successful local initiative based on these principles that showed that a model of shared learning is possible in the private and public sectors.
Going forward, practical measures that might head off preventable harm include: (a) synchronising the daily rhythm of work for doctors and nurses, for example doing rounds together at a mutually convenient time; (b) ensuring all members of the team have access to the full medical record, with all relevant findings and conclusions; (c) meeting at least daily to co-create daily goals of care for each patient and a shared written plan; (d) standardising more care so it is easier for nurses to deliver it reliably; (e) communicating better, especially in situations that are urgent or emergent, in a climate of psychological safety and (f) upskilling all nurses via an enlarged cadre of intermediate level professionals.
To reduce the role of lawyers in health care we must make it less likely that accidents happen. We should operate more transparently, especially around the time of a mistake, accept culpability and communicate, especially to our patients, an intention to fix system failures that cause the damage. In a blame-free, but accountable culture, near misses are seen and used as learning opportunities (e.g. in M&Ms) and the ability to rescue is improved by learning and practicing together.
An independent, non-profit, networked, patient safety foundation allied with universities and professional societies could be the catalyst, based on existing models (26,27). Small levies on hospital groups and medical administrators and a re-allocation of legal fees and malpractice premiums could support this endeavour. Imagine the benefits, if just a small proportion of the R200m HMI budget, or of hospital revenues, was spent in this way. By avoiding harm, savings can come from fewer hospital days, which not only benefits patients but also hospitals, by increasing their capacity to care for more patients.
Conclusions
Although excellent health care, delivered by skilled practitioners with supportive nursing teams does exist in the South African private sector, private hospitals can become better and safer places for patients to receive care, and for staff to experience joy in work. It would require a fundamental change in the current mind-set of the all-knowing practitioner, disconnected from opportunities to learn with peers and deprived of opportunities to work safely in multidisciplinary teams. All parties, including patients, hospital administrators, doctors, nurses and funders should work together, starting with a leadership coalition of stakeholders committing to a re-design of delivery of care. Through co-created care pathways for most common health conditions and transparent internal continuous monitoring systems would ensure reliability as well as better nursing care and improved patient outcomes. In addition, it would break down the divide between clinicians, nurses and administrators, bringing all sides together around what matters most to patients and staff i.e., best care for every patient, as well as a transparent, fair and compassionate response to adverse events when they do occur.