Hospitals should not be in the news except for celebratory reasons. However, in India, hospitals are in the news for all the wrong reasons. Either it is for violence against health care workers (HCWs) or a mishap where patients are at the receiving end of the health system. Both indicate a failure of the system and not individuals.
While the Kolkata rape incident is a one-off case, violence against HCWs is a cause for serious concern. I strongly feel that violence against HCWs is inherently linked to patient-care systems. A system that does not care for its workers will also not care for its patients and vice versa. Ultimately, these reflect how humane our health system is. HCWs face attacks from both sides — patients and relatives and from the administration.
For example, in any case of health service failure — be it the non-admission of a patient or an avoidable death of a patient, one of the first actions of people in power to counter public outrage is to suspend the doctor(s) concerned and order an enquiry. This knee-jerk reaction to the suspension of doctors, sends the message that justice has prevailed, and the inquiry is forgotten. Except, of course, for the fall guy doctor(s). Even hospitals are happy with this, as it deflects responsibility from them to individuals. While people are right to be outraged, preventing such occurrences requires a systemic response. If any patient is referred to another hospital because of the lack of an appropriate specialist or equipment or service, individual doctor(s) should not be held responsible.
So, how do we make our hospitals humane and safe for both health care workers and patients? We can learn from the “safe-systems” approach, which underpins an effective road safety management system and is built on the premise that humans will make mistakes, but no one should be seriously injured on the roads. This shifts the blame from the driver to the transport system. Neither the driver nor the pedestrian should suffer. The safety of both is the priority. Similarly, keeping the safety of both HCWs and patients should be the responsibility of the health system.
In the safe-systems approach for traffic injuries, we treat traffic injuries as not only a behavioural problem but also an engineering problem. The “engineering” elements of the system — vehicles and roads — should be designed to be compatible with the human element to minimise harm, particularly by making roads forgiving of human error. The five elements of a safe transportation system are — safe roads, safe road users, safe vehicles, safe speeds, and post-crash care. A safe system ensures that all five elements work in synergy and that an error or weakness in one element is compensated for within other areas. It also emphasises that responsibility is shared, safety is proactive, and redundancy is crucial. Road crashes should be investigated as a system failure rather than as an individual crime. The same logic also applies to health systems.
Human errors occur simply because of being human, and factors such as anxiety, stress, and fatigue (doing a 24-36 hours duty) increase the risk of errors. Systemic errors occur when something in the environment/system contributes to the occurrence of errors, such as crowded hospitals, inadequate staffing, or non-functional technology. No one chooses to make errors; rather, human error is inevitable, unpredictable, and unintentional. Being human, a doctor can miss a diagnosis, or a surgeon can operate wrongly. Rather than blaming them for carelessness, we should find out why necessary steps of prevention were not taken, and once the incident happened, why the steps for mitigation and future prevention were not taken. A system-centred approach recognises that any such incident is a symptom of a deeper systemic problem.
Akin to road crashes, health service failures are a continuum of an infinite number of mistakes of different degrees, ranging from catastrophes (which make newspaper headlines) to minor slipups (which patients never come to know about). Health service failures include both clinical errors (inadequate or inappropriate treatment or diagnosis) and system errors like delay in treatment, poor attitude of care providers, or inappropriate referral. Most of these occur at highly crowded places like emergencies or high-pressure areas like operating theatres or intensive care units (ICUs), often due to the need exceeding the capacity to provide safe care.
One of the main reasons that hospitals and health systems in India don’t learn from failure is because the work environment inhibits speaking up or questioning, fears of retribution due to a clear hierarchy, and lack of effective teamwork. Secondly, the culture of most hospitals makes cover-ups, workarounds, and quick fixes the predominant response to failures rather than root-cause analysis and systematic problem-solving. To address these, we need to adopt a ‘safe-health-systems’ approach, which should include the five elements:
Safe patients: Since they know themselves best, patients need to be more proactively engaged in their management. For this, they need to be educated and empowered, and our health system must be willing to engage them more.
Safe health care teams and processes: Health service delivery is a teamwork of doctors, nurses, and others who attend to different aspects of care. Avoiding errors requires good communication between them and acceptance of collective responsibility. The use of updated disease management guidelines, standard processes, and use of checklists to ensure that these are followed and documented is also critical.
Safe medicines and technologies: The health system must procure safer and better quality medicines. All health care technologies should be well maintained, and have fail-safe and early warning systems which get deployed if something goes wrong (like airbags). Ensuring the availability of medicines, technologies, and human resources at the correct time and place is critical.
Safe hospital culture/management: A culture which rewards people for reporting errors rather than punishing them ensures that every error is reported and investigated. Ensuring the safety of HCWs is a part of this aspect. Most public hospitals do not have clean, safe spaces for sleeping and toilets for junior doctors, especially for women. That we continue to fail to provide these basic services and yet expect them to deliver quality care shows our utter disregard for them.
Post-incident management or response: Timeliness of response to a failure is critical to ensure that it does not spiral out of control. The response includes calming the situation, correcting the wrong, or providing alternative solutions. For example, if a patient is to be referred, advance information can be provided to the referred facility, and transport arrangements can be made. This needs a round-the-clock team of social workers and hospital administrators. Doctors and nurses are frontline care providers and should not be given this task. This ring-fencing of HCWs is most important. The media should also frame such stories as system failures rather than individual errors.
While these may not prevent all adverse incidents, these would go a long way in addressing the day-to-day grievances of both patients and health care workers and create a more conducive and pleasant hospital environment. However, the implementation of this approach requires a strong politico-administrative commitment and a rethinking among the hospital administrators and health care providers. May the Kolkata incident spark the first step in this regard.
Anand Krishnan is a professor at the Centre for Community Medicine at All India Institutes of Medical Sciences New Delhi. The views expressed are personal
