No one should be treated badly, then die unheard

By JENNY LUESBY

Once upon a time, in Western TV programming history, there was a comedy series that challenged a whole society’s perceptions, under the name of Monty Python, shocking us all with iconic shows such as a skit that looked at words and how we react to them emotionally — in a side-splitting scene on how to use ‘tinny’ words and ‘woody’ words.

Since then, using words that produce a positive emotional reaction in us has become a marketing science. Every phrase is structured to touch the parts of our brain that wants to believe, that falls in love, that is searching for ‘the dream’.

One such hit me square this morning as I passed a building somewhere around Juja Road in Nairobi with a slogan painted across its entire side saying: ‘We are here to change the game’.

Feels good. Makes me curious. Is bold.  Whereas phrases like ‘improved systems and processes’ leave us all bored, disinterested – no touching the ‘in love’ spot there.

Yet the reality is that it takes a lot of words that are a great deal less than shiny to deliver true change, and ‘systems’ is not only one of them, but perhaps the most vital of all.

Just lately, we at The Standard Group have been challenging the Establishment to achieve greater monitoring and accountability in Kenyan hospitals. Yet it seems that based on current ‘systems’, it’s a task our country is still too busy for.

Take the medical board. Having not heard a single case all year, the one and only board charged with hearing and judging cases of medical negligence finally sat last week. The case No 1 for 2013, relating to a death 11 years ago, was never heard: the doctors involved went to court the Friday before and got a court injunction to stop the board hearing the case. So no Case No 1.

By Thursday, the board had got to Case No 2 for 2013, involving a case of a woman who died five years ago following a botched fibroids operation at Nairobi Women’s Hospital. The ruling was thorough, solution-oriented, and charged the hospital with now proving that it had the correct internal systems and staff licensing in place to stop the same ever happening again.

Medical ombudsman

The board heard just two more cases last week, including one of a doctor who was drunk as he carried out a Caesarean section — he was de-registered.

But now the board has no more time to hear any more cases. It won’t sit again for three months. Its part-time members are too busy, which is how it becomes possible that files can remain provisional for five years, cases unheard for 11 years.

The fact is that the failure in having an effective medical ombudsman is systemic and structural.

It is not a problem, per se, of the quality of the board itself, but that it is a board that is so under-resourced, so part-time, so unsupported in law that it barely gets to address the problem it exists for.

For sure, the Nairobi Women’s Hospital will now be forced to introduce checks that will save future wrongful deaths. As one doctor wrote, all humans err. But we don’t normally put professionals in a position where one tired mistake costs lives — we create an error-proof system.

As it is, the woman who died was operated on when her blood count was so low she should never have been sent to theatre. A system that requires top-level sign-off for operations below a set count would, at a stroke, prevent any repeat of that. But the system wasn’t in place, and her operation proceeded.

But worse than that, for all the hospitals that are still running without best-practice systems, where the doctors are overtired, over-worked, and effectively working in chaos, doing what they can, without drugs, without equipment, inside awful hospital administrations: now all must wait until the board can find time again — slated for August — to even look at one more hospital.

Changing the game isn’t just, as it happens, about beautiful phrases, about love, about commitment, or about a dream. Real game changing means diagnosing the real problem, even in its many fragments and forces, and fixing it, one strand after the other, with better systems.

We call it good management.

It is about staffing rotas, and equipment maintenance, it’s about work supplies, and accounting systems, it’s about job definitions and information systems.

Systems, in reality, should be a word that truly turns us on, because it makes everything better. It CAN change games, save lives, improve the future. But it takes time. The right systems don’t come without information gathering, analysis, and conclusion.

Systems gaps

And right now, we’re short-cutting the resourcing to even undertake the probes for solutions. No one murdered the doctors who made the mistakes. No one prosecuted the hospitals. The board only moved, with measure and ruling, to get the skills and systems gaps addressed.

Hats off to them for that one real step forward. But do we really think three cases so far in 2013 is enough — up against lives lost? Is it really OK, even, that everyone can bandy around statistics on the scale of this problem and no authority, not even our Government, can put in place a system to even collect the data?

Give us systems, and our doctors will cheer as loud as any of us. For negligence is only negligence, and a problem that no one wins from.

Some things merit time and attention to getting right.

 

The writer is Consulting Editor at The Standard Group.

[email protected]