Ali Yawar Alam  ( Department of Quality Management, King Fahad Hospital Hofuf, Al Ahsa, Kingdom of Saudi Arabia. )

The modern day health care has become far more sophisticated, technologically advanced, super specialized, yet it has also become far more risky in terms of potential harm to the patients. The Institute for Healthcare Improvement estimates there are 15 million incidents of medical harm each year in the United States of America.¹ Researchers at the Harvard School of Medicine have found that even today, about 18 percent of patients in hospitals are injured during the course of their care and that many of those injuries are life-threatening, or even fatal.²
Quality of care is the extent to which the care provided achieves the most favourable balance of risks and benefits. Institute of Medicine (IOM) defined Quality of care as, "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."³ Patient safety was defined by IOM, as, "The prevention of harm to patients."³
In Pakistan efforts to quantify the quality of health care and patient safety have been constrained because of a variety of reasons. What has not been done in the past should not be accepted as an excuse for not taking bold steps in the future. With health now being a provincial subject (post 18th amendment) the need for standardizing the quality of care is all the more required.
The patient is potentially at risk, when he/she comes to receive care. Acknowledging this fact is the first step in building a system of care where patient safety is ensured and quality of care and patient outcomes are monitored. Subsequently, building the processes and systems with methods that have been tested and practices that have produced better patient outcomes Internationally, need to be learned and adopted.
Quality and safety is everybody's business in any health care setting, from top leaders to managers and including all cadres of the staff. The purpose of developing policies and procedures is to reach at a certain desired level or standard of health care. These set of standards can either be developed, by a National level team of experts in healthcare or adopted from external quality assurance organizations. One such leading accreditation International organization is Joint commission International (JCI).4 The choice of the type of standards chosen would depend on multiple factors ranging from priority being given to health, political will and commitment, allocation of resources and readiness for accountability, fairness and change.
Provision of safe and quality care is not equivalent to high tech care. Provision of safe care very often does not demand high tech care. For example directly asking the patient his/her complete name (usually three names) and father's name (in case patient has only two names) each and every time; during taking history and physical examination, taking blood samples for lab testing, before undergoing radiological investigations, before giving medications to the patients, before invasive or non-invasive procedures, before transferring the patient to another unit or hospital and before sending the patient to the operation Room. The practice of identifying the patient just by bed number or room number is a potential cause of medical errors. The health care providers should always use two unique identifiers for the patient; patient full name and medical record number. This method of identifying the patients is 'International Patient Safety Goal (IPSG 1); Identify patients correctly'.⁴
Listed below are some examples of practices,^4-9 evidence based, to improve quality of care and patient safety, do not require high tech or excessive cost, rather these are cost-cutting measures with improved patient outcomes:
1. At admission as an inpatient, patients and families receive information on the proposed care, the expected outcomes of that care, and any expected cost to the patient for the care
2. Involving the patient in planning of care and determining discharge planning needs.
3. Single, integrated plan of care by the primary treating physician/surgeon incorporating the goals of all relevant disciplines giving care to the patient.
4. Adherence to hand hygiene guidelines (5 moments of hand hygiene)
5. Non-acceptance of physician prescription with cutting or over-writing
6. Physiologic criteria for admission to specialized units such as ICU
7. Mentioning date and time of care at each point where care was provided to ensure continuity of care.
8. Patients and their families are given understandable follow-up instructions at discharge
9. Complete restriction on use of prohibited abbreviations such as O.D, Q.D, µg
10. Using 'Lean' principles for eliminating wastes in health care, such as; waiting (example waiting for discharge), inventories (patients waiting for clinic), defects (wrong information communicated), excessive processing (multiple bed moves, re-sticks), overproduction (unnecessary tests), movement (working across multiple sites), transportation (patients attending different departments) and underutilization of some staff.
11. Implementing clinical protocols, clinical pathways and clinical guidelines for priority (high risk , high volume, problem prone) medical and surgical conditions
12. Identification, prioritization and mitigation of clinical risks (such as infectious out-break, severe medication errors) including risky interventions and non-clinical risks (such as fire hazard chemical spill), with input from all the departments in the hospital in a pro-active manner
13. Time out before all invasive medical procedures
14. Surgical site marking
15. Surgical safety checklist for all procedures
16. Sign-in, time-out and sign-out in operation room
17. Procedure for prompt reporting of panic values from lab and radiology
18. Incident reporting system in the hospital; to learn from incidents, near miss or sentinel events.
The overall purpose of all these measures is to improve the processes and systems, improve patient safety and ensure quality of care, ensure continuity of care, minimize waste, improve patient outcomes and enhance patient satisfaction with the care provided to them. The benefits of such endeavors will have large impact on the patient population, if these initiatives are carried out at a higher level by the ministries of health and encompass public as well as private sector health care organizations.

 
References

1. Institute for Healthcare Improvement, available from; http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm? TabId=6, accessed 17th May 2013.
2. Landrigan CP, Barry GI, Bones CB, Hockbarth AD, Goldmann DA, Sharek PJ, et al. Temporal Trends in Rates of Patent Harm Resulting from Medical Care. N Eng J Med 2010; 363: 2124-34.
3. Institute of Medicine of the National Academics, available from; http://www.iom.edu/, accessed 17th May 2013.
4. Joint Commission International, available from; http://www.jointcommissioninternational.org/, accessed 17th May 2013.
5. Best Practices for better care, available from; https://www.uhc.edu/BPBC.htm, accessed 18th May 2013.
6. Association of American Medical colleges, available from; https://www.aamc.org/initiatives/bestpractices/, accessed 18th May 2013.
7. The Joanna Briggs Institute: 800 hospitals, available from; http://www.joannabriggs.edu.au/800%20Hospitals, accessed 18th May 2013.
8. World Health Organization, patient safety, available from; http://www.who.int/patientsafety/en/, accessed 18th May 2013.
9. AHRQ, Agency for Health care Research & Quality, available from; http://www.ahrq.gov/, accessed 18th May 2013.