Patient Safety in Private Hospitals of
Uganda
Introduction
Uganda National Association of Private Hospitals
(UNAPH) is the umbrella body of independent private hospitals and private
health clinics in Uganda. Private hospitals and private health clinics are
regulated by Ministry of Health through the respective medical councils. UNAPH’s role among others includes the
promotion, protection, representation and development of professional conduct
of members and fostering ethical practice within the independent private health
industry in Uganda.
Patient
safety is the prevention of avoidable errors and adverse effects to patients associated with healthcare.
It emphasizes the reporting, analysis, and prevention of medical errors that
often leads to adverse healthcare events.
Patients are harmed while
receiving care which result in prolonged hospitalization, loss of income,
disability and litigation. Many patients acquire infections, suffer risks while
in hospitals, are wrongly diagnosed, given wrong treatment and medication dose,
and are affected by other types of healthcare related incidents. Policy makers
must make efforts to improve patient safety to ensure private health patients
are safe from accidental injuries during medical care, avoid, prevent and
correct healthcare related incidents and problems leading to patient harm.
The
role played by private hospitals in Uganda’s healthcare system has increased
drastically but there is less information of how services are performed in the
private sector and an inability to compare to data in the public health sector.
There is increased reliance on private hospitals to provide surgical care and
treatment with increasing number of admissions to private hospitals for
surgical procedures each year.
Little
is known about the quality and safety of care provided to these patients, due
to a shortage of independently verifiable performance data. The lack of
reliable data means that regulators are unable to assess the risk of harm posed
to patients in these hospitals, and patients are unable to make informed
choices about where to receive their care.
Through
a review of care quality reports into private hospitals, data from clinical
reports, health consumer complaints and concerns, the following was found:
Admissions
from Private Hospitals to the Public Referral Hospitals
·
Some Private hospitals now receive a
percentage of their income from treating public patients. They also rely on
public hospitals to treat many of those who develop complications whilst being
treated in private hospitals. A sizeable number of patients a year are admitted
to the Government hospitals from private hospitals, although we have not been
able to establish the reasons behind these admissions, nor the cost to the
Government hospitals.
Unexpected Deaths and
Serious Injuries in Private Hospitals
·
A number of cases of unexpected deaths
and injuries are reported from private hospitals. Because of the limited
reporting requirements for private hospitals it is hard to state whether these
deaths and injuries should be a cause for concern. We do know that compared to Government
hospitals, private hospitals mainly treat patients who are ‘low risk’ patients
- those who are less likely to develop complications following surgery.
Size and Facilities of
Private Hospitals
·
Most private hospitals are significantly
smaller than Government hospitals and do not have intensive care beds to treat
patients if complications arise. Less
than half of the hospitals providing surgery have a fully equipped operating
department. UNAPH reports on private
hospitals often identify problems with facilities or equipment which pose risks
to patient safety.
Staffing Arrangements
in Private Hospitals
·
The consultant surgeons and
anaesthetists who work at private hospitals tend to operate in isolation from
other medically qualified colleagues.
Unlike the situation in Government hospitals there are no trainee
surgeons present to observe their work and assist them, and they cannot rely on
the potential support of any senior colleagues on the site. Post-operative care is normally the immediate
responsibility of relatively junior Resident Medical Officers. Further investigation of the resuscitation of
patients following in hospital cardio-respiratory arrest found that a sizeable
of private hospitals have no dedicated resuscitation team.
Record-Keeping
·
There is also evidence from UNAPH observation reports that some patient records are
not always kept in the hospital where they are being treated but instead
off-site with the consultant. This has been identified as poor practice and
risk to patients if something goes wrong. This has also been exacerbated by
poor or weak data capturing in the independent private hospitals sector.
Clinical Governance
·
Because private hospitals do not employ
the surgeons and anesthetists who operate at them a different type of clinical
governance exists from that which operates in the Government hospitals. Medical Councils and Health advisory
Committee - whose members are drawn from, and usually elected by, the consultants
who operate at the hospital - are responsible for ensuring that only surgeons
who meet the required standards are granted ‘practicing privileges’ to operate
at the hospital. The constitution and
responsibilities of Medical Councils are not clearly set out in law, but they
can remove the practicing privileges of consultants if issues of concern come
to light.
·
Performing this role can be difficult
given that there can be a number of different consultants who have practicing
privileges in a small 10 to 30 bed private hospital, and conflicts of interest
can arise. The recent case of fertility
doctor who performed dangerous surgery on a patient in a private hospital
raises serious questions about the efficacy of these clinical governance
arrangements.
Availability of
Performance Data
·
Data available on the performance of
private hospitals for patients is ‘poor’ and ‘insufficient to promote
competition between private healthcare facilities.’ UNAPH currently has access to relatively
little information that relates to independent private healthcare. The information which is available is
significantly less comprehensive than that which is available for public
hospitals, and is fragmented.
·
Commitment to Quality of care is a legal
and ethical requirement for all hospitals both public and private. Whilst
government hospitals are required to have their Quality of care Accounts
independently audited, the same does not apply to private hospitals. The report also finds that concerns have been
expressed about private hospital participation in national clinical audits.
Patient
Safety Law
·
There is low awareness of patient safety law in the independent private
healthcare industry. This area of health
law that affects patient safety (e.g.., tort law, professional regulation,
institutional regulation etc.) is not profoundly integrated in the healthcare
industry and general legal framework. Patients also lack information and
guidelines on how to handle complaints before seeking legal redress which is coupled
with weak private health consumer protection.
Recommendations:
In
order to address the above risks and the lack of information the report makes
eight recommendations.
1.
Private providers should be subject to exactly the same requirements to report
patient safety incidents (including mortality data) as government
hospitals. All of the information should
be published in the same way as it is for government hospitals and this should
be a requirement of registration with the medical councils.
2.
Private hospitals should be required to report on their performance in the same
way as government hospitals. The Health
Resource Centre, jointly with the Uganda National Association of Private
Hospitals (UNAPH), should be tasked with making this data available to patients
and commissioners through their respective websites and departments. The
requirements set out for all providers of government supported services to
publish their Quality Accounts to Ministry of Health (MOH) should be properly
enforced by the government and all Quality Accounts should be externally
audited.
3.
The Health Consumer Ombudsman should be extended to cover the whole private
healthcare sector. The UNAPH private
health consumer complaints and protection department should be strengthened to
cover private hospitals in respect of anything related to the treatment of
private health patients and government subsidized patients.
4.
Given the failings detected by numerous inquiries and reviews, the clinical
governance of independent private hospitals need to be subject to a wider
review to determine whether the current arrangements are effective in
protecting patients. The review should
cover the duties and powers of Medical Councils as well as the duties and power
of the hospital director in relation to patient safety. In addition, in order to reduce the potential
for conflicts of interest between clinicians, owners, and patients, Medical
Councils should have externally appointed clinical and lay members with no
connection to the hospitals concerned.
The responsibilities and constitution of Medical Councils should be made
statutory.
5.
Full participation of private hospitals in all national clinical audit and data
collection programs should be a requirement for registration with the Medical
Councils.
6.
It is important that patients are made aware of the different risk factors
between being treated in a small private hospital and a much larger government
hospital. For patient consent to be
informed consent, the consent forms given to patients at private hospitals
should detail not only the risks inherent in the procedure being offered but
also any that stem from the distinctive nature of the facilities, equipment and
staffing of the hospital.
7.
The regulations governing the provision of care in hospitals need to include
some which are private hospital-specific and unambiguous. In particular there should be an on-site
registrar-level surgeon or doctor qualified in each specialty for which patients
are treated, and nurses with qualifications in the same specialties, and
arrangements for an anaesthetist to be on call.
It should also be a requirement that all patient records are kept on the
ward.
8.
Given that there are many admissions to government hospitals from private
hospitals every year a concerted review should be carried out by the Ministry
of Health of the nature and cost of these admissions.
9.
Regulation and monitoring of Clinical issues and administration should be
decentralized to regional referral hospitals and health centers within their
respective catchment areas as the current decentralized district framework is
more of administrative and academic than being practical yet the health
consumer is at risk.
10. There
is need for more increased practical collaboration, networking, inclusiveness,
transparency and partnership among all the medical councils, private health
departments, development partners, professional
associations, health trade associations and health NGO’s. Good healthcare interventions have been made
to benefit the private sector but unfortunately they are sometimes made using
market mechanisms and in isolation of respective stakeholder associations
resulting from the increasing capitalistic nature of handling programs in the
private sector. Health is a public good and ought not to be managed and
administered like a commercial product whereby it requires a higher level of
administration than an individual consultant or Consultancy Company can
arrange.
Most of these recommendations
have been made previously in other review reports, but have not been acted
upon. Given what is now considered good
practice, the lack of any clear picture of the risks to patients in private
hospitals outlined in this report suggests that action on those recommendations
is needed.
Uganda
National Association of Private Hospitals (UNAPH)
P. O. Box 29324 Kampala, Uganda. Tel: +256 772 632211,
www.ugandaprivatehospitals.blogspot.com
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