Morbidity and Mortality
Developing an accountability system in the functioning of our healthcare delivery!!
PROF. M. S. KHUROO
Over 900 infant deaths in year 2011 and another 500 infant deaths till ending July 2012 in our premier children hospital has shattered the incumbent families and sent shock waves across the society. What has followed is media pointing to corrupt clinical and drug practices, fixing individual responsibility& axing the demon, political blame game, legal enquiries, defects in bureaucratic controls and even excessive hospital attendant rush. All these are means in an attempt to heal the wounds. There has been considerable attention towards healthcare in recent past and a definite improvement in infrastructure and manpower development. Has this or will such acts improve healthcare delivery! Answer is unfortunately “No”. I would stress that building infrastructure puts more pressure on healthcare delivery rather improve it. Improvement in healthcare delivery needs development and adherence to a set of “Rules” by Health Dept. and each health delivery unit. These rules are known as “Internal Policy Procedures & Regulations (IPPRs)” and have been extensively researched in the West. We need to apply these to our healthcare keeping our cultural, social and religious beliefs in focus. IPPRs regulate and monitor the nerve roots of the healthcare delivery procedures including clinical practices; nursing practices; infection control policies; drug policy; narcotic control rules; hospital traffic; operation theatre and other intervention policies; blood bank practices; sanitation; clinical research policies; In-service training to medical & para-medical staff; Credential policies etc. IPPRs have inbuilt mechanism for on-going evaluation of health delivery and suggests measures to continuously improve it. Inability of our healthcare to adopt IPPRs model is one of the main reasons for sub-optimum health delivery. One policy in IPPRs, which focuses on the accountability of functioning of the health delivery, is named as Morbidity & Mortality policies (M&M). Had this been in vogue in our State our premier children hospital would pick up infant deaths at its inception and take proper preventive measures? This policy shall also make all other health units accountable and detect any such hidden catastrophes.
M&M is an extremely complicated subject; however at the same time it has been well studied and all modern health Dept. in the West have a well-established multi-level M&M committee. A suggested model for M&M policy for our hospitals is presented (Fig). Policy starts from Medical Record Dept. (MRD) wherein the treating physician/faculty is by law to generate a structured discharge or death summary for all patients under his care and discharged from hospital or died during hospital stay. In addition he records any morbidity (complication) to the patient under his care. Completion of these reports by faculty and/or residents is linked to generation of monthly pay slips in many hospitals. For this, all health units must have an efficient medical record department and this should be transparent and open to external review by the authorities and known to public and society so that the efficiency of each unit can be graded on a scale as is done all over the World.
MRD officer frames a monthly report of all admissions, discharges, deaths and morbidities and sends it to Hospital M&M committee, that is a statutory body headed by Medical Superintendent with representation from senior faculty and nurses and administration. Any complaints by the patient’s family are also addressed and investigated by this committee. This committee reviews each death & complication and records and reasons whether the event was or could be prevented. Death & complication rate of each consultant/health unit/dept. is evaluated and any unusual or excessive events recorded. It recommends administrative (including punitive) action for any unexpected death or complication to Hospital Director for implementation. Most hospitals conduct a weekly M&M meeting in which specific deaths or complications are discussed for education to the hospital staff. However, this meeting is only of educational value and cannot generate punitive reports. Hospital M&M committee is responsible to State M&M committee, a statutory body headed by Head of the Health Dept. (varies from region to region; could be Minister or Health Secretary) with representation from senior faculty (usually with Emeritus status) and other state administrators. This committee reviews M&M reports from all hospitals of the State and makes critical comments on the functioning of each hospital. These comments usually address any unusual deaths or complications; infection rates; drug related complications and occurrence of any unusual disease states or epidemics. Both hospital & State M&M committee can critically evaluate the credentials of any faculty and recommend corrections if there are unusual or excessive deaths or complications occurring through his practices. For example if a surgeon is credentialed to do open heart surgery and outcome of his surgeries is sub-optimum, committee can recommend limiting his practices. In addition to this, hospitals are duty bound to announce to public successes and failures such as death and complication rates of all major surgical procedures and interventions. This helps public to take their own decisions in deciding to attend/undergo any of these interventions in these health units.
All hospitals and health units in the West follow M&M policy to accurately define the possible harm, which may happen to patients and take early and effective measures to prevent a catastrophe. In this policy hospital has an M&M committee and this committee searches through the medical record help all morbidities and mortalities which happen in the hospital and for each event an explanation is sought through an ingenious review process as detailed above. Index cases are discussed in open forum for discussion and education. Periodic publication of infection rate, antibiotic sensitivity, morbidities, mortalities of procedures and other important events are published for information to faculty and through them to the patients and public. I believe it is essential that this should be introduces in our system to prevent major catastrophes.
Author is former Director, Professor & Head Gastroenterology and Chairman Department of Medicine, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar. Feedback at Khuroo@yahoo.com.
Lastupdate on : Wed, 15 Aug 2012 21:30:00 Makkah time
Lastupdate on : Wed, 15 Aug 2012 18:30:00 GMT
Lastupdate on : Thu, 16 Aug 2012 00:00:00 IST
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