June 26, 2014 First/Third World Medicine part one

The newly built Ministry of Health Palestine Medical Complex is filled with all the expected contradictions of building a health care system under occupation in what is ironically a third world kind of setting. We are getting the grand tour from a medical student who did his internship here, “Lots of experience, low quality.” The impressively clean, modern, white stone facilities were built in 2010, merging a Ministry of Health hospital and a private hospital (donated by an American) in Ramallah. At the gate there is a sign: “Palestine Medical Complex is Smoking Free Area” (insha’allah as they say here).

I have a particular interest in quality improvement (I understand why things are the way they are, but how does health care move forward, even here), and we are soon meeting with Rebhe Bsharat, a PhD in a white coat, with a short mustache and a warm, friendly manner who is in charge of quality and education for nursing. He reviews the different wings of the hospital, including pediatrics, surgery, emergency, general medicine, the ICUs, dialysis units, triage beds, etc., etc. All the trappings of a twenty-first century medical center. They have 126,000 emergency visits, 200,000 outpatient visits, 27,600 admissions, and 7,000 surgical cases per year.

Quality assurance (which is part of the quality improvement lingo) has been a focus at the hospital for the past three years.

Apparently the World Health Organization has a program for “Patient safety friendly hospitals” with lists of standards to be met.

In the United States over the past few decades, the whole focus on improving the quality of care has been to turn from blaming the “bad doctor who screwed up,” which encourages a culture of secrecy and condemnation, to assuming that most clinicians are doing the best they can under challenging circumstances. Thus the task is to analyze how the system of care makes errors more likely (different medications with similar names and labeling sitting next to each other on the shelf), and how to make systematic changes to reduce error (make the labels different colors and put the medications on different shelves.) This obviously has the potential to encourage a culture of joint cooperation and more creative thinking and has the potential to actually make care safer.

Rebhe admits that there are a lot of challenges because this approach involves changing the culture and attitudes of the providers.

I am so excited to learn that one of their quality improvement programs is focused on hand washing. As a point of explanation, one of my major concerns having worked and observed in clinics and hospitals all over the West Bank, is the fact that almost no one washes their hands before or after seeing patients. As you may imagine, this drives me crazy. This is a preventable risk factor. As a firm believer in the germ theory, it seems to me that even under occupation, clinicians could and should wash their hands, and if there is no water, I have been known to leave bottles of Purell on doctors’ desks as a personal contribution to fighting infection.

So you can imagine my delight on seeing a poster in a ward headed with a logo and “Palestine Medical Complex” with a circle filled with bugs and a slash across it, followed by large letters: no germs allowed, WASH YOUR HANDS and some official signature.

It really doesn’t take much to make me happy. As expected, the initial surveys revealed that 20% of doctors and 50% of nurses washed their hands, so now there are weekly lectures, monthly meetings, and patient safety protocols, all good things. Older doctors (like doctors everywhere) pushed back but the trends are good.

Rebhe explores some of the challenges nurses face. He lives in a small village, and because it takes between thirty minutes and three hours to get to work (depending on the checkpoints), the previous shift just has to continue working until the next shift shows up.

There are three hundred nurses; half have a two year diploma, half have a B.A., 55% are women, and 20% are over forty. Many work here for ten years or so and then return to their cities or villages.

They all need continuing education programs, want better patient education publications and discharge planning, and these are in the pipelines. Rebhe was trained in Baghdad and Turkey, as high-level degrees are not available in the occupied territories, and his thesis was on effective planning for cardiac surgery. Meanwhile, he is trying to get folks to wash their hands.

We tour the wards and I am impressed with their order and cleanliness (an incredible contrast to older Ministry of Health hospitals I have seen). The pediatric unit has forty beds, but only thirty are used due to lack of staff. They receive referrals from all over the West Bank. There is supposed to be one nurse for five patients, but the reality is one nurse for twelve patients (safe staffing anyone?) Bears, ducks, Disney-like princesses, and Winnie the Pooh (how did he get here?) cheerfully decorate the walls. There are no psychiatrists or social workers and frequent shortages of medications.

Today the Ministry of Health doctors are on strike, the outpatient unit is closed, and only emergencies are being seen. The month long strike is over salaries and no resolution is in sight. (Jolt of reality.) Politics and medicine, the challenges continue on so many levels and the patients and staff pay the price. It seems they keep on hoping, keep on praying, keep on showing up for work (sometimes) and for care (always). Alhamdulillah. What else is there to do?