Afiza’s Principles of Good Health Care Management

I promised in my previous post that ALL my criticism would be constructive. Here is the post that will deliver that promise.

I name this post as Afiza’s Principles of Good Health Care Management

1)Principle Number 1:The concept of Favor.

You do someone a favour when your action benefits her.

And whether or not something is beneficial is not defined by YOU; it is defined by HER.

In the first place, we housemen don’t care whatever it is you want to call the system that we are working in; be it the shift system or the flexi hours or WHATEVER.

In the first place, all we want is not to have to do on-calls because it means working for 36 hours straight without rest!!

It doesn’t mean we want to work in shifts! It only means that we don’t want to work for 36 hours straight because it is inhumane; it doesn’t benefit the houseman and it doesn’t benefit the patient.

And I have always believed that the best plan is the simplest plan. If I have the authority to put a decree on this, I would simply say, “Berkuatkuasa pada hari ini, semua jenis ON-CALL adalah haram sama sekali. Kamu bekerja seperti biasa sewaktu office hours. Manakala  sesiapa yang diperlukan untuk berada di hospital pada waktu malam, tidak perlu bekerja pada waktu office hours. Mereka hanya perlu datang dari pukul 5.00 hingga 6.30 pagi keesokannya dan dibenarkan pulang setelah orang pagi tiba bekerja seperti biasa. This goes to the MO as well.”

Simple kan! Apa yang susah sangat?? I know I don’t like on-calls…but the shift/flexi-hours that we are implementing is not so great either even though I am willing to give it a try.

I admit, the system that I suggest above would still reduce the number of housemen working during office hours (whereas the on-call system means you have more housemen; who cares if 6 of them are sleepy and exhausted, right?). However, MY system would have a lot more housemen around during office hours compared to if we are implementing the shift system.

If with the on-call system, you get 40 housemen working during office hours; then with MY system, there’ll be 34 housemen working during office hrs (minus the 6 that will come post-office hours). Whereas with the shift system, a lot more of them will be working out of office hours…which is NOT WHAT WE WANT!!  We want more housemen during office hours because that’s when all the referrals, and all the requests for radiological investigations need to be done.

MY system is a balance between two extremes! So, get it done!

Remember the concept! If you want to do housemen a favour; you give them what they want. Essentially, all they want is to NOT have to work 36 hours straight while at the same time maintaining the harmony of enough housemen during office hours.. Not wanting to work 36 hours straight  is not equivalent to wanting the shift system. Because even though the shift system means there’s no more on-calls, it is also disruptive to the normal office hours where the majority of the work need to be done.

Is someone up there listening??? Please.

2)Principle Number 2: The Concept of doing it ‘All or Nothing at all’ / ‘Not doing things in halves.’

“O those who believe, enter Islam COMPLETELY,… -“

Once upon a time, I was given a perfect lecture by my ustaz. My ustaz told me about the wisdom of a particular mufti.

“The mufti was asked by the media, what is Islam’s solution to AIDS. The mufti then answered, had you implemented the Islamic system from the very beginning, AIDS won’t even exist in the first place and you won’t be asking this question from Islam.”

If there had been no rampant sexual promiscuity, no homosexuality, no IV drug abuse, no alcoholism (and hence, no all the previous evils mentioned) AIDS won’t spread. You subscribe to a hedonistic system of life, but when something bad happens, you sought solution from another system altogether. How is that not plain stupid, you tell me!

If something is wrong with your iPhone, do you ask SAMSUNG what is THEIR solution to the problem your facing with your iPhone? Of course not!

Apple won’t claim that there won’t be any problems with their product. No companies can make that claim. But any self-respecting companies would claim that they will have the solution to whatever problems that may arise in the system that they create! It’s only fair to expect THAT of any system!

See the western system of economy. They legalize riba (usury), and now their economic system is collapsing around their ears with a loud crash. And now they are spending more money to find out why they had lost money in the first place. The system does not have the answer…will not have it…EVER. They engage in riba, they engage in currency speculation….and they have gotten away with making money out of nothing for years and now the terrible consequences of such endeavors are catching up with them fast and furious. I dare them to ask what is the Islamic solution to this!

Now, I hope I have made it clear that you cannot mix and match different parts of different systems and not expect things to become plain insane.

Now you have to choose. What kind of system do you really want us to work in? Do you want us to work in shifts or do you want us to work as we used to?

You have to understand that if you want us to work in shift, you have to design a proper system for it. Not simply mix and match.

For example, in HSB medical department, the system works like this: The morning shift is from 7.00 am to 5.00 pm;  afternoon shift is from 11am to 11 pm; and the night shift is from 10 pm to 10 am.

The amount of housemen who work during office hours are reducing…so we are covering more patients than we are used to. But our superiors still expect us to know all the cases well; the bloods are still expected to be ready especially if the night people were unable to complete them, we still have to do the housemen round first, before the MO/specialist round.

We end up starting our morning shifts at 5.00 am!  To make matters worse, in certain wards, we rotate like the hurricane. On Sunday I was covering ICU, on Monday I was covering CCU/CRW (because the person who covered this ward on Sunday was rostered to do night shift on Monday) and then on Tuesday I was rostered to cover 1st class ward (because the previous houseman who covered the 1st class ward on Sunday and Monday is now rostered to do night shift on Tuesday). I don’t know any of my patients because I am changing wards everyday! How can you REASONABLY expect me to know all the cases well when YOU can’t do it too if you were in my shoes unless you come at 4.00 am to study all the cases you have never seen before in your entire life until that day itself? You tell me!

You see, you can’t implement system in halves. You said the objective of implementing the shift system is so  that we will have less working hours and a better lifestyle. So, you said that the morning shift starts at 7.00….but then you also expect me to be able to do all the things that I am expected to do during the old system. (you want one thing from one system, but you also want another thing from another system….so you end up not reaching the objective you set out to achieve in the first place which you CLAIMED as for us to work less)

You want us to cover more patients per shift. But you still expect us to be the phlebotomist, the attendants, the ones who do the procedures, the ones who arrange patient’s future appointments, the ones to fill up all the STROKE Registry forms and Cardio Registry forms, the ones who refer inter-departmental cases. We used to do all these while caring for 6 patients only and we still went home later than 5.00 everyday.

See? I am not averse to the shift system. But I am averse to the discrepancy in how it is implemented and your expectation of us when the system is implemented.

3)Primciple Number 3: The concept of technology as a means of solving/easing daily problems.

By rights, when we use technology, it is with the aim of making our lives a lot easier.

So we have to recognize…what is our problem….and solve it with technology.

But in HSB, with the e-HIS system, it is the other way around. We end up using the technology because it’s there; regardless of whether or not it is helping our work.

Hospital Sultanah Bahiyah is number ONE when it comes to creating daily nuisance in the disguise of the e-HIS system and all sorts of computerized technology. Take the OBS CENTRAL in the ObsNGyn Dept for example…using continuous CTG monitoring in healthy pregnant women is one perfect example of how we have no idea how to use technology PROPERLY.

I will list the problem in order!

1)      The nursing reports are done in the computers… for the online ‘ghost’ to read, perhaps?

2)      In certain wards like ICU, CCU and 3C, it is so-called paperless….meaning even our daily reviews are made in the computer.

3)      We need to order blood investigations and radiological investigations through the computer first before it can be made available online. (I will tell you why it’s bad, later).

When I was a student in Australia, I actually enjoyed reading the nursing reports that were handwritten in the patients’ files. I thought it was important to read the small paragraph of what the nurses had written…I really did think it was vital for me to know if the patient was sleeping well, was the patient taking orally well, and had the patient pass motion etc etc. I actually read their reports because it was there, written in the same place that I was going to write MY reviews on.

In HSB, all the nursing reports are done in the computers! While my reviews are done in the patient’s files! As the consequence, none of us housemen actually read the nursing reports. We end up asking the patient the very same thing that the nursing reports would have told us in a glance.

It’s not efficient!

We should be using the E-HIS system in things that are absolutely vital for us to be able to trace it back a few years down the track when the patient  represent himself in the future. For example, the discharge summary SHOULD be done in the system…because when the patient gets admitted in the future, we would want to know the patient’s previous history and admissions. Also the blood and radiological Ix SHOULD be made permanent by having them online; we need to be able to trace them back for the patients’ future admissions.

But what is the use of the nursing reports being made ‘permanent’ online? Is it going to matter a few years down the track, that during the patient’s last admission he has passed motion well for one day, and then vomit the next day and then got constipated the day after that…and then got diarrhea the next day.

No, right?

A few years down the track, those things are online rubbish. What’s not rubbish is knowing (from the discharge summary) that during last admission, the patient had suffered from irritable bowel syndrome or gastroenteritis or rectal carcinoma etc etc (not the details of what happened everyday).

Do you get me or not when I say we don’t use technology properly…but we use it just because it happens to be there, so we better make the nurses use it to their heart content! Heh!

And you know what the funny thing is?! The funny thing is, even the nurses hate it! It complicates their works. Their roles as nurses are not to spend time doing reports online. Their role is to look at their patients. Not to glue their eyes on the computer screen and let the student nurses do all the observations/ sponging/ suctioning/ procedural-assisting.

It is for the same reason that I am VERY MAD when it comes to doing my reviews in ICU/CCU/ and 3C. Because I do not get WHY, oh WHY, do I have to do it online? Doing reviews online takes time because you have to open a few windows (to check the Ix results as well as the reviews in other previous entries). Doing my reviews online takes a lot of time because I have to compete the use of the computer with the nurses! Now, I am not lacking in competitive spirit…but not for something that will become an online rubbish. Like I said, a few years down the track, my DAILY reviews online is not important anymore. The patient will only have a few diagnoses that I have to recognize in the discharge summary for the benefit of the patient’s next admission. So only the discharge summary should be online.

You know, in Australia they know when to use the computer; and when not to use it.  Daily reviews are done in the patient’s files. Only the discharge summary is done in the system.

Furthermore they are also smart in the sense that they get all the blood results to appear online. But they can order the investigation through paper, which takes less time than having to order it in the computer.

The size of the paper that they use to order the blood IX is about 1/3 of the A4 size paper. All they have to do is get the patient’s sticker (which is already pre-printed in bulk with the patients names, age, MRN; in other words, they don’t need to go online to get the stickers printed) and stick it on the form; then write down FBC/RP/LFT….and then put the patient’s blood sample together with the forms in the specimen bag.

Like I said, they know how to make technology works for them. They know they need the result online, but ordering it online will take time (especially, if you have to compete the use of the computer with the nurses who are busy passing reports to one another). So they design a system that enables them to order investigations in the easiest way possible while also making it appear online.

Look at us! It’s true in one sense; our work is easier because we can get to see the investigation results in the computer stat when it’s ready. But we make the ordering of it to be so hard and time consuming. What a fool we are.

Do you see what I meant in my previous post when I said that we are HORRIBLY inefficient in using our resources; human resource as well as our technologies.

I spent time writing very long post on this because I think it’s important that we recognize our mistakes in our healthcare. It’s not that we don’t have enough doctors….we just use them for doing non-doctor things….and thus they will always be busy NOT BEING DOCTORS. We have the nurses doing reports online for Allah only knows which ghost to read! As a result, the nurses are not doing nursing stuff….so we then come up with the inspired idea that we don’t have enough staff.

We have good technologies….even at par with other developed countries. But it’s time we recognize that non-proper use of ANYTHING will not get us ANYWHERE. It’s like what the Malay means when they say bagaikan kera mendapat bunga!

4)Principle Number 4: The Concept of Useless PaperWorks (useless to the ones who actually do the patient nursing care in the wards)

We set up stroke team, infectious disease team ….and the jobs of the team consists of sending us FORMS for us in the ward to fill up. The jobs of those teams are not to fill up their own forms…but to distribute the forms to other wards with the related cases.  It’s US who have to fill it all up, like we don’t have enough to do.

Oh yes….if the patient happens to have all AIDS, Hep B/Hep C ….then the forms should have two copies, too…because they will go to separate divisions.

So what the heck is the job of those teams??  If we have to fill up one form to notify that the patient has all AIDS, Hep B and Hep C….shouldn’t it be THEIR job to double up the forms since it has to go to separate divisions…THEIR divisions! We do our nursing/doctoring jobs in the ward…..and then we also have to do your team’s administrative job. You guys memang pandai unburden yourselves…..and put the paperworks on us who do the actual care that actually benefits the patient.

You and your paper work can do nothing to a simple thing like a patient’s spiking temperature.

I know it’s important to notify these things. But since we have already done our part in caring for patients in the ward, which is something that YOU didn’t do….why can’t YOU do your paper-works job, for a change, and leave us alone!!

Thank you!

**That ends the online-lecture of Afiza’s Principles of Good Health Care Management.**

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THE RATIO!

THE RATIO!

Insya Allah on the 16th of October, the medical department in HSB will be starting the renowned shift system.

I am glad.

I expect things will go haywire, topsy-turvy for awhile as we adjust to the increased number of patient that we need to take care of. We are so used  to having 4 housemen in the ward, and that means the ratio of housemen to patients is roughly 1:6 . With the implementation of the shift system, AT MOST, we will have only 3 housemen in the ward (so the ratio will be 1 houseman to 8-9 patients). Sometimes, there may be only two housemen. In that case, it would mean that 1 houseman will be taking care of 14 patients.

Now, if you ask the interns who are working overseas, they will probably scoff and said…so what?? I am taking care of 30 patients per day.

Yeah, sure, super-genius! But you don’t have to be the phlebotomist, and the one doing all the procedures. We do pleural tapping…do YOU? We do peritoneal tapping….do YOU? We do bone marrow aspiration….do YOU? We do central venous line….do YOU? We do Lumbar Puncture too….do YOU? We do all the procedures! We also do all the blood taking before the morning rounds….do YOU? Our rounds start at 8…that means we have to come at 6.30 (at the latest) EVERYDAY to make sure all our 6 patients blood result will be ready before the rounds. We also have to do our own reviews before the round with specialist.

So, don’t scoff and expect us to take care of 30 patients when we are the ones who have to take all the bloods and do all the brannulas during office hours, and we are also the ones who have to do all the ordered procedures.

We are also the ones who have to do the inter-deprtmental referrals. If my patient needs an urgent CT scan, it is I who have to speak to the radiologist. If my patient suddenly develops hematemesis, it is I who have to speak to the surgeon to refer the patient for scope.

I do the attendants work as well, would you believe it? When I want the result of ABG stat, I am the one who run to the ICU. Not the attendant/PPK.

And when they are discharged, I do all the clerical work as well, on top of the clerical work that is already expected of me on a day-to-day basis.

While in overseas, you are the clerk daily….and you are the phlebotomist ONLY when you are working out of office hours. In Malaysia….I am the doctor, the clerk, the phlebotomist, the attendants, the registrar (because I do procedures that you don’t and I make referrals!), and sometimes I am even the nurse (when the nurses are slow in getting what I want to be done stat!)

So, you can’t expect me to be ALL THAT while caring for 30 patients!  Even I can be a clerk for 30 patients. But I can’t be ALL THAT I have listed above for all 30, just as you can’t. Caring for 6 patients may sound like very little….but the jobs are non-stop!

It always irritates me to NO END when the older MO boasted “During MY time as housemen, I took care of the whole ward. BY MYSELF”.

G…God!

Sure. But YOU didn’t do the bloods…..the nurses did. YOU didn’t have to set the brannula….the nurses did. YOU are not expected to know all the cases in the ward. YOU didn’t have to prepare your own stuff for procedures. YOU didn’t have to beg the nurse to PLEASE hurry up and prepare the instruments for long line/pleural tapping/peritoneal tapping/BMA/ LP….and when bored of waiting because you knew you had so many more referrals to do, YOU didn’t end up going all over the ward finding the instruments yourself.

In a way, you were luckier. The nurses of the old-generation  actually acted like nurses and they did their work properly and thus helped along your work….they even arranged for the patient’s next TCA upon discharge. Nowadays, it is I who have to arrange it.

But if you really believe that your caring for the whole ward is MUCH harder than our caring of 6 patients, by rights, you should see us go back at 5.00 sharp everyday…and we would even be at the counter gossiping the time away by noon. After all… caring for six patients to caring for the whole ward is such a SHARP contrast, isn’t it?

So what’s wrong with the system? WHY is it that even when the ratio of housemen to patients are dramatically reduced,  do we still go back late everyday? Why are we not so out-of-work that we don’t spend our supposedly free time in the pantry or in the library? If the time occupied caring for the whole ward compared to the time occupied caring for 6 patients are roughly the same….then something MUST be wrong somewhere, isn’t it?

And all my dear readers by now should already know me too well to expect that I shall MOST CERTAINLY spit it all out.

I have even made a list of the muddles that we housemen are in but to keep a long post short, I will just reveal the ONE MAIN THING that we are horrible at…..

….I hereby declare that WE ARE SADLY, HORRIBLY, EXCRUCIATINGLY, TERRIBLY INEFFICIENT IN MANAGING OUR RESOURCES.

Do you know that in John Hunter Hospital in Australia where I did my medical study, they don’t have 30 interns per department?  They don’t! In the WHOLE hospital, it will only be around 50! How come their workload is so much lighter than us?

In HSB….at the very least, there will be 30 housemen for EVERY DEPARTMENT (and tu pun, captain akan merungut susah nak buat roster; we need more!!) Most of the time, we try to maintain 40 housemen per department. That makes 240 housemen AT LEAST in the whole hospital! That is a huge number and if we give that amount of interns to Australian hospitals, they will end up only having to work half day with plenty of holidays in between AND their morbidity/mortality rate won’t be any worse than ours!

WHAT!!!!  is WRONG with our health system that we cannot utilize that much human resource efficiently without making the cliché of ‘HO stands for Hamba Orang’ still sounds relevant to this day?

Yeah, yeah yeah….give me all the usual idiom of “Dimana bumi dipijak di situ langit dijunjung, so tak payah nak compare-compare oversea dengan sini. Kalau banyak merungut, pi balik kerja kat oversea.”

To that, I will just say “Your jealousy is showing! I am at the special position of being able to objectively compare our horrible system and their superior system. I have done both system!You… HAVEN’T! So your opinion doesn’t count. Sorry. I will be more prone to listen to someone who is ALSO oversea grad but find that Malaysian health system is superior…if you can find that person, then we’ll talk. Okay?”

Nak kata I berlagak? I don’t bloody care. Those who know me, they know I am nice. But I am speaking facts….the fact of which, if you haven’t been in any other system other than in Malaysia, you have to at least, consider that what I am saying have merits and not act like you are so very patriotic (and I am not?) and would champion Malaysian health system to your dying breath.

I am patriotic!

I could have worked overseas, you know? It’s not like I got rejected from working in Australia, and therefore I have no choice but to come home. I CHOSE to come home despite the fact that I was MARA scholar. Those who have never been offered the scenario of being able to choose where they could work, cannot say they are more patriotic than I am. I was in the position to choose….and I chose Malaysia.

And it works both ways, you know.

Whenever someone from overseas look down their noses at me and say that their system is superior, I swear I could feel my spine stiffen in indignation. I will be the first to object to such statement.

When my friend who worked in Ireland said “Well, I care for 30 patients.” I will then say, “Yes, but you don’t do procedures, right? You are just a clerk!”

When my friend then said, “How can you stand working for 36 hours straight when you are on-call. How about patient’s safety, being cared by an over-worked and overtired doctor?”

I then said, “Well, it’s not so bad. You get used to it. It makes you a tougher person.” All the while waiting for my Pinocchio nose to increase in length.

Then my friend said, “Why should we use lab-coats? Very unhygienic. You know, infection control and all.”

I was THE advocate of NO LAB COATS all these while but I had said, “Well, we changed lab coats everyday from Faber. So, it’s very hygienic.” (there still leaves those who only change their labcoat once per posting, however).

My point is; YOU don’t work in Malaysia. You are in NO position to say anything about the system that I work in. How dare you come up with disparaging remarks about OUR HEALTHCARE when you have never even entered our system!

So, do you get me? I don’t like the system that we are in. I am the first to declare that our system has such HUGE room for improvement. But I’ll be damned before I let anyone who has never worked in Malaysia get away from looking down their noses at us!

I am part of the system, so I can talk. It’s like, if I say my siblings are a torture to live with, the only thing you should do is listen but NEVER AGREE with me since YOU DON’T KNOW and your agreeing with me will only make me defend them.

The fact is NEITHER system is perfect. If you have worked in both system, you’ll know that. (And if you haven’t worked in BOTH, be very careful lest you annoy either parties).

NO system is perfect.

But in overseas, they make it perfect for the doctors after they make it perfect for the patients.

In Malaysia, it’s not perfect for patients; it’s not perfect for doctors. It’s just perfect for someone higher up who didn’t give squat about how those below are faring!

That’s the whole problem!

I am sorry to those higher up who may be reading this. But what I said is true. Call me sometime, and we’ll talk! See? I am not even anonymous. I talk and I own up to it. If you are annoyed, at least you know who you are annoyed with.

As long as we are bad at managing human resource, it doesn’t matter how good the ratio of housemen to patients will ever be, the life of doctors nor the quality of patient care will never be better. NEVER.

So since nowadays we are all for constructive criticism, do I have any suggestions on how to improve our management of resources (human, or otherwise)?

Of course I do! One of them is; start implementing MY kind of shift (read my previous post H.E.R.E.) And reconstruct the E-HIS system (insya Allah, I’ll go into details in the future).

But that will have to keep until next posting. It’s too long already and I am at heart, an instinctive performer who knows when to make a good exit.  My dictum of a good exit is to keep the audience wanting more. (heh!)

So stay tuned. Until next posting, you guys take care and know that I am sorry for sounding like an arrogant ass if I do, but know that I am actually very humble. I am bad at everything else other than writing (okay, that doesn’t sound so humble).

It’s just that I always find that some things are much easier to understand when the message is delivered with ‘attitude’. So, out of necessity, I have to act arrogant when I really don’t want to.