Exchanging common experiences from Malawian and Scottish hospitals is helping improve patient safety, as Rose Kumwenda-Ng'oma and Pat O'Connor explain
Malawi is one of the 10 poorest countries in the world. For every 100,000 live births, 984 mothers die. This is staggeringly high, even when compared with other developing countries. The most recent world estimate of the overall maternal mortality ratio is around 400 per 100,000 live births, compared with 12 per 100,000 for the UK.
On the surface of it, what could the UK and Malawi, as fundamentally different healthcare settings, have in common, or indeed hope to teach each other? Quite a lot,.as the two teams found out during a recent visit..
Over the past two and a half years, NHS Tayside has brought down its hospital-wide adverse event rate by a dramatic 79 per cent through its pioneering involvement in the Health Foundation's Safer Patients Initiative. The Health Foundation Consortium based in Malawi is working to reduce.maternal and neo-natal mortality and morbidity over a three-year period. Both teams are working with the US-based Institute for Healthcare Improvement, among others, to learn new skills in improvement methodology so patient harm can be minimised.
The IHI's philosophy is 'all teach, all learn'. In April this year, members of the Health Foundation's Malawi team and the patient safety team at NHS Tayside met to exchange experiences and ideas about how to tackle patient safety issues in hospitals. By the end of the visit, each team left with new ideas to test in their local contexts. They also left with a sense of common purpose.
Leading by example
Both teams have found that obstacles arise when senior members of the team are not actively involved.in improvement work and that this can hinder progress in terms of achieving results, spreading the work and sustaining it. It is vital that the senior team prioritises safety issues and sees the value in testing changes to working practices and styles. Both teams acknowledge there is as much to be gained from.learning from the things that go wrong as from those that produce successful results.
Two approaches have worked well for NHS Tayside and the Malawi team is now considering testing these. The first is patient safety 'walkrounds', involving a member of the executive team. These are not the same as the management 'walking the shop floor', rather they are used for staff to raise safety issues directly with the top team, with the guarantee that any agreed actions will be acted on by the senior team within 72 hours. The other is safety 'huddles', or pre-procedural briefings. Again, these are to discuss safety issues only and act as an effective communications tool to focus on safety, enhance effective team-working and lay out clear demarcations of responsibility.
Patient safety is at the top of the agenda at NHS Tayside. It is included on every meeting agenda in the hospital as item zero. Safety is.discussed first before moving on to the core business of the meeting. The board is also presented with data on safety and occasionally presented with patient stories.
From the Malawi team's point of view, the challenge of getting leadership on board to support improvement ideas and changes may be greater due to cultural and historical factors. Many decisions are often deferred to a very high level. It is usual for Ministry of Health officials, policy-makers or local district managers to make decisions about local budgets, staffing, protocols and guidelines. This makes it hard for frontline staff to come forward and suggest innovative ways of improving safety or suggest changes to working practices. As such, improvement decisions may take a long time to be accepted and implemented.
But practices in the hospital are changing, and not because of top-down diktat. One of the first steps taken in Malawi was to engage the hospital leadership to work on national protocols that were summarised on one side of A4, laminated and posted on ward notice boards. Staff find these A4 sheets much easier to read, digest and follow.
Another change that has lead to significant improvements in the care that mothers receive is the involvement of women volunteers. Often, women arrive at hospital in labour but do not reach the labour ward in time. The volunteers have been given the responsibility of spotting these women as they arrive, taking down their critical administrative details and getting them to the ward within three minutes. They also provide the women with comfort and support during their labour and delivery.
As at NHS Tayside, the team tests every improvement or change using a 'plan, do, study, act' cycle, first on one patient with one member of staff, and then if successful with three and five, and finally with all staff and patients.
Both teams are encouraging staff to test their own ideas for improving safety and have embraced the concept of care 'bundles' on their maternity units. Very simply, bundles are a number of evidence-based interventions that when packaged together produce a greater effect than when conducted on their own. The induction bundle helps staff decide.whether or not to induce a labour. NHS Tayside has printed stickers to help staff go through the checklist of items in the bundle. The Malawi team is now considering producing their own stickers as they think this simple step could be helpful for their staff.
Interestingly, the Safer Patients Initiative does not explicitly focus on maternity services and the induction bundle is in use on the maternity ward at NHS Tayside thanks to innovative staff who have spread the changes from one corner of the hospital to the other. This transferability is something that interests the Malawi team. By working with innovators or those defined as 'early adopters', staff have been involved in devising their own solutions, which helps to internalise and spread the safety culture.
Resource poor, ideas rich
For NHS Tayside, the exchange demonstrated that acute shortages of human and financial resources need not be.barriers to.innovation and adaptation.
The Malawi team shared many examples of how they have adapted hi-tech approaches to fit their resource constraints. For example, safety is compromised when staff have to gather together everything they need for a particular situation, such as a post-partum haemorrhage, obstructed labour or even a caesarean section. Pre-designed instrument packs are not available in Malawi, so the teams have created cardboard boxes with everything they need for specific emergencies. Rather than worrying about where things are, they just have to reach for the correct box and then concentrate on treating the mother and/or baby, reducing the delays that can make such a difference to life and death. Alongside the boxes, staff keep inventories to ensure the labour ward never runs short of critical drugs and supplies needed for emergency obstetric complications.
This is likely to be the first of many more important exchanges. It is vital that we continue to share experiences and best practice with each other so care can be delivered as safely as possible to patients across the globe. .
Rose Kumwenda-Ng'omais programme manager for the Health Foundation Consortium inMalawi. Pat O'Connor is head of safety, governance and risk at NHS Tayside.