Global Healthcare Access and Safety: Today, Tomorrow, & Roadmap  DLS

Today’s failure to achieve accessible and safe healthcare globally has human and economic costs. 1.2 Both are significant and those paying can afford it the least.3 Deficiencies in healthcare access and safety result in additional deaths and disabilities, as well as increased medical costs and lost income. Today, healthcare is massively undersized. 4,5 Half of the people on earth cannot afford or do not have timely access to safe emergency, surgical, obstetric, and anesthetic care. 6 And, even when people do have access to healthcare - if it is not coupled to safety - there are extra human costs. In fact, unsafe healthcare is a leading cause of avoidable deaths worldwide.7 Since the human costs of access and safety deficits in healthcare cause the economic costs, both have the same payer. The clients paying for these healthcare deficits with extra deaths and disabilities also pay for extra medical expenses and lost wages. The client is not the global community. The clients are people who live in low-and-middle-income countries. They are challenged with most of the access and safety deficits in healthcare and pay most of the human and economic costs of this as well.

Tomorrow, all of this will be worse if healthcare becomes less safe, like it did with the last pandemic, or if population growth is greater than, or in different places than capacity growth8-10. This issue is particularly significant in regions where half of the population consists of children who will reach reproductive age within the next decade. Because the population is growing and the access and safety deficits in healthcare are not only huge but also concentrated in countries that cannot afford to fix them, just maintaining status quo is an immense challenge that needs global support. Recently governments, and global organizations, assembly’s, donors, and more- or the global community - have significantly ramped up their efforts to improve global healthcare access and safety and are doing so with policy, global funding, donations, assistance, relief, and more. Their efforts are sometimes coordinated and sometimes in connected spaces, thus there are holes and limitations in these efforts.

Roughly twenty years ago, patient-safety in US hospitals reached most safety standards. 11,12 To get there it took many people - often massively skilled - doing specific tasks, non-compliance penalties, and more, yet it still needs work. Today, hospitals, that often have less than this and a fragile infrastructure and ongoing critical shortages of many things including staff, providers, and money, face a larger challenge. In the setting of a rapidly changing healthcare industry and massively growing needs and costs, these hospitals must reach safety standards, add efficiencies and quality, produce a competitive product, and be resilient. Anything less puts the hospital’s future at risk, reducing healthcare access. Also, this needs to be a top priority, done yesterday, even in already fragile and stretched hospitals. Uncorrected healthcare deficits do not go away, they fester, like an infected wound, and during this time, all human and economic costs are paid.

Achieving safety standards - or getting as close to these as possible - everywhere in the hospital, and supporting them with good healthcare, governance and policy, is entirely the hospital’s duty. This task is too big and complex for outside partners or the global community. The precision in this task is enormous, and only the local team, who work on the front lines, is qualified for this job. They alone have shared values, practices, unique knowledge of the environment and social structures, relationships, and more that is needed to do this. They can make processes safe, sustainable, and locally relevant. Every member of the local team must know the hospital’s safety goals and those related to his or her job and achieve them. One miscommunication or unclear policy, weak governance, or gap in safety anywhere in the hospital, can upend safety and make even the best provider’s care unsafe. The local team is uniquely qualified and has a duty to achieve safety standards everywhere in the hospital, without gaps.

The global community has the duty to actively help hospitals achieve safety standards. For humanitarian reasons, it is the right thing to do, and for self-interest reasons, the world is healthier when everyone is healthy. This too must be a top priority and done - not yesterday - but a long time ago. Safety deficits need fixed before and perhaps with access deficits, but not after them. Hospitals, that have not achieved safety standards and attempt to add efficiencies, grow, and advance care, will pay greatly for this. Larger human and economic costs will be paid, and bigger safety corrections in a more complex setting will be needed. Additionally, there may be other costs, not defined here, and the risk of less support if global attentions shift. Global support of hospitals reaching safety standards is a timely priority, thus it needs to be done now.

Resources are limited. The global community has the duty to be good stewards of resources and make good investments. Is there a way for this to be done without appropriate oversite and data? Global hands are not washed of responsibilities when the money is spent. To support good investments going forward, unbiased, and appropriate data needs to be collected and analyzed quickly and efficiently. With data the global community can identify cost-effective healthcare corrections and hospitals that are good investments of global money and that do much with little and learn from them. Standardized data collected at project milestones can also be used to quickly identify corruption and waste so that projects can be put right or stopped. Oversite and - not dictatorial - but coaching and mentoring guidance can help health systems navigate the expected unfamiliar territory and interfaces and promote collaboration and success.

Ideally, emerging hospitals - even though they are often facing resource constraints and substantial demands on many levels - can identify and request what it needs to achieve quality healthcare. Ideally, the global community - even though it faces various degrees of connectivity and cohesiveness challenges – is positioned to provide the requested support and tools that enable cost-effective and sustainable improvements in healthcare. The global community has substantial talent and resources. The ideas, published guidelines, and other tools and support provided by the global community are sometimes perfect but often there are gaps. Sometimes there are many ~copies of the same perfect tools and none to address other needs. Some tools are brilliant but perhaps cryptic, massively complex, concealed in the “web,” or unavailable in another way. There are also excellent tools that are of limited use because they include non-workaround steps or requirement. Testing and using personal protection equipment, PPE, were first steps in many early Covid-19 plans - but at this time - there were few to none of these items available in most of the world. Is it reasonable to expect every hospital or healthcare system to clearly identify its specific needs and prioritize them effectively to sustainably build quality and minimize waste, especially when the global community faces challenges in achieving this level of coordination?

This Roadmap provides a straightforward framework to guide the hospital in achieving safety standards, enhancing quality, and subsequently improving efficiency, competitiveness, and resilience. It lowers whole-hospital safety risk methodically. Safety issues everywhere in the hospital are collected, ranked from highest to lowest risk, then corrected in that order, following the steps in the Roadmap. Corrections, as well as starting points and more, are confirmed by data produced by the Roadmap tools. When one safety issue is corrected, there is a celebration, an Ebenezer stone is placed, and a new targeted correction is selected. All the while, there are ongoing skill and educational workshops and lectures. The Roadmap’s simplicity, ongoing education - especially during the gap between data collection and the corrections when many projects deflate - and early successes fuel the enthusiasm to continue. Top-down support and a whole-hospital commitment to safety facilitates corrections. It can also be used, with less support, for isolated albeit dampened improvements in specific areas of care or as a part of a continuous improvement plan.

The design axioms in this Roadmap are strategic and intentionally build skills in the local human infrastructure as international safety standards - the goals here - are achieved. By following the Roadmap at each point of care in the hospital, item preparedness goals, then action goals are achieved. An example of these goals is that a pulse oximeter monitor is present in the operating theatre, and a "time-out" procedure is performed before each surgery begins.

The sustainability of goals is jeopardized if the local human infrastructure lacks consistent and timely application of critical skills. Even minor operational challenges such as medication shortages often require innovative solutions - for instance sourcing supplies from sister hospitals. By following the design rules of the Roadmap, root-case-analysis, problem-solving, and other investigative and decision-making skills develop in the local team. Their approach to issues grows in consistency, efficiency, becomes gap-free and dependable. This critical strengthening and standardization are vital to hospitals achieving safety standards sustainably because it is the local team - who build suitable processes with suitable items – that make this possible.

Successful hospitals of the 21st century need to be efficient, provide competitive healthcare products, identify market changes early then navigate them, capitalize on innovation, and be resilient. The skills needed for these objectives often overlap and tolerate an occasional blunder, except when it comes to resilience. Resilience challenges to hospitals are unyielding and may result in catastrophic losses even with thorough planning, effective contingency measures, multilayered financial plans, prompt decision-making, well-coordinated responses, robust communication systems, clearly defined chains of command, and accountability within an established safety framework. Medicine, equipment, technology, and education are globally interconnected, and their associated cost reflects international prices that many hospitals in emerging markets cannot afford; thus, various international groups often contribute to these expenses. They also supply staff and provide various management services because during the first ~ decade of this support there may not be enough local staff with the skills needed. Despite this support - even when it is ongoing and healthy - the local human infrastructure must acquire mature and practiced resilience skills because situations change. Connections break down when leadership changes, funding ends, or workers are recalled due to contagions, violence, or other risks. While this may never happen, hospitals should be prepared with independent and robust resilience skills to continue local healthcare services during stress.

During repeated Roadmap cycles the local team is strengthened and the hospital becomes more resilient. As Roadmap experience increases, responses become more suitable and quicker. Strengthened teams find something in new problems that is like something they dealt with in an old problem. For example, the care of Covid-19 patients is like the care of Ebola patients. By attaching something known to a new problem, there is a history of what worked in the past and a starting point. To this, the features of the new problem are added, like the respiratory component of covid-19. This makes new problems more familiar and more approachable. The team then, using a well-known and practiced method, respond to the new challenge quickly and appropriately. Roadmap experience builds hospital resilience.

A colleague was tasked with identifying and prioritizing needs to improve anesthetic care and patient safety in a resource limited country, then to develop a plan to address them, basically creating a roadmap for grant funding. I offered to help. Initially, the goal of this roadmap was to improve anesthetic care by identifying and planning the improvements needed to enable anesthetic care to reach safety and quality standards. It soon became clear that this - in isolation - is nearly impossible and if it is achieved, it will produce limited, and often threatened, improvements.

The roadmap needed to maintain patient safety as a key focus and include all perioperative care. As this still limited and isolated roadmap developed, it became evident that progress would remain at risk without a comprehensive governance framework that included safety for staff, patients, and operational processes as a top priority everywhere, guiding decisions even in areas without established standards. Even minor lapses in protocols and provider safety measures - such as ambiguous policies regarding staff with Covid-19 reporting for duty - can upend years of healthcare advances or even derail it forever.

Ultimately, hospital survival - and by extension, healthcare access, and anesthetic care - depends on process efficiency to produce a competitive healthcare product, and institutional resilience. The Roadmap was transformed into a risk-reducing improvement plan across the whole hospital. This standardizes everyone in their approach to improvements and prevents overdevelopment in some areas and insufficient progress in others. In the Roadmap safety risks from every part of the hospital are identified, prioritized, and strategically reduced. First corrections at many hospitals include perioperative care. The strategic skills to build efficiency and hospital resilience are developed by following the design axioms of the Roadmap, repeatedly through several Roadmap cycles. Completing the final version of the Roadmap proved challenging, taking several years beyond the grant deadline to complete.