In three years working as IHI faculty in both Scotland and Qatar, I’ve heard one theme (expressed in different ways) over and over: No, it won’t work here. We can’t do that. We’re different.
You’ve heard it, too, haven’t you?
Our patients are sicker.
That’s not how it works here.
Our population is different.
That’s not to say that these statements don’t sometimes have some truth to them. There are vast differences between Scotland, in the northernmost part of the United Kingdom, and Qatar, in the Middle East.
But as it turns out, working in two very different countries has taught me that some strategies for promoting patient safety are universal.
Lots of health care providers say they treat a unique population with distinct challenges to patient safety. In Qatar, this is actually true.
In Qatar, the building boom for the 2022 FIFA World Cup has drawn hundreds of thousands of immigrant construction workers to the country. Among a population of 2.5 million people, only about 10 percent are Qatari citizens. The rest is made up of non-Arab immigrants that include Indians, Nepalis, Filipinos, and other Asians.
As a result, health care professionals and their patients come from a variety of different ethnic backgrounds, all with different languages and cultures. How does this diversity affect patient safety?
One way is through the use of physical restraints in the intensive care units (ICUs). When I first visited Qatar, I was shocked to see that health professionals physically restrained the vast majority of ICU patients. In the UK, restraints aren’t even allowed. Diversity was part of the reason given.
In such a multicultural society, clinicians and patients don’t always share a common language. This makes communication challenging. The care providers told me that they restrained patients because they feared that they may harm themselves by extubating themselves or removing their own tracheostomy tubes.
I respectfully challenged them to go back to basics and do a small test of change: ask one nurse to remove one restraint, from one patient, on one shift.
The care teams politely told me I was mad. “It can’t be done,” they said. “We’re different,” they said.
I asked them to humor me. To their credit, they did. Now, across all of the ICUs within Hamad Medical Corporation (HMC), teams have either abolished or drastically reduced the use of physical restraints. On the rare occasion when teams use restraints, a team fully investigates why it happened. And pharmacological restraint hasn’t become a substitute, which is a common risk when ICUs stop using physical restraints.
This is a significant change. Some of the HMC ICUs have around 60 beds with complex patient needs and an almost 100 percent ventilation rate. It’s also gratifying to see that teams are now helping patients get up and move during their ICU stay, reducing lengths of stay, delirium, and time on a ventilator.
Fighting Patient Safety Fatigue with Results
In addition to their differences, Scotland and Qatar have more in common than one might at first assume. Qatar, much like Scotland, is small and mostly surrounded by water. Both are attached to even larger neighboring countries. We both have oil.
In recent years, care providers in both Scotland and Qatar have also been at great risk of patient safety initiative fatigue. In the Middle East, consultancy work has historically been a big business. Experts fly in and out of the region, often advising local health care staff to start several new initiatives a year. The experts come and go — as do the initiatives.
Thankfully, though, frontline health care professionals in Qatar have seen the benefits of the Hamad Medical Corporation (HMC) Best Care Always program. Much like the Scottish Patient Safety Program (SPSP), Best Care Always is a large-scale collaborative campaign led, designed, and driven by local leadership. Their aim is to achieve 95 percent reliability for the implementation of central line, ventilator, and sepsis bundles, and to eliminate subsequent preventable patient harm in the pilot wards by November 2016.
From what I’ve seen, both SPSP and Best Care Always have been successful because they’ve tapped into what matters most to care providers in both European and Qatari cultures: patients and families, the importance of joy in the workplace, leadership, and good team work. In all of the high-performing clinical teams I have seen in Qatar — and, in fact, anywhere else I’ve traveled in the world — all of these ingredients played a role.
Focusing on the Patient
One of the ingredients that’s helped us be successful in these collaboratives is a focus on what matters to patients and families. I’ve been impressed at how much family means in Middle Eastern culture, and it shows in the way health care is patient- and family-centered in Qatar.
Patient stories have been a very effective tool in getting the message across about the need for change. When I talked about people harmed by hospital-acquired infections and pressure ulcers, I could see the social movement grow in front of my eyes.
On one occasion, I told a story about a patient in Scotland who suffered a surgical site infection and died from unrecognized sepsis. I described how the care team missed several opportunities to rescue this patient, and it brought the whole room together. We felt a common bond of sadness and regret as the providers shared their own stories about patients who were harmed by or died of sepsis because clinicians didn’t recognize it or act quickly enough to treat it.
It shouldn’t be surprising that making a difference for patients is what gets health care professionals excited about patient safety — whether they live in Doha, Qatar, or Dundee, Scotland. It’s why we all do what we do, and why I feel privileged to be working to advance patient safety around the world.
Kevin Rooney, MBChB, FRCA, is Professor of Care Improvement, University of the West of Scotland, and a consultant in Intensive Care and Anaesthesia at the Royal Alexandra Hospital in Paisley, Scotland.
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