Patient Safety in Africa: A Culture Shift?

Patient safety has received increased attention in African countries in the last decade, yet little is known about African patient safety challenges and quality improvement opportunities. Most of the patient safety and quality improvement efforts have been made at the international level, particularly by the World Health Organization (WHO). Recently there are more local organizations in the region with the aim of galvanizing actions to improve patient care including accreditation efforts connected to the United States-based Joint Commission International and the COHSASA (Council for Health Service Accreditation of Southern Africa) organization in South Africa (Safe Care, 2011).

Sustaining the momentum created during the period is indeed of critical importance in delivering focused, culturally relevant improvements in patient care in the region. This will require a platform on which to discuss and engage healthcare professionals, government, patients, and the public in the development and implementation of local solutions. Making any measurable progress in patient safety in the region will also require actions to be taken simultaneously at different levels of the healthcare system, actions that could lead to developing and implementing appropriate patient safety policies, standards, and regulations.

We Don’t Know What We Don’t Know

In terms of progress, research shows that patient safety and quality of care information from the region is still “infrequent and limited in scope” (Carpenter, et al., 2010). For instance, it is not known whether a safety intervention such as the WHO Guidelines on Hand Hygiene in Healthcare designed to prevent healthcare-associated infections at the point of care or the Surgical Safety Checklist, which is designed to improve the safety in surgery, have been implemented. There is also scant evidence of local initiatives put in place in healthcare organizations to ensure patient care is effective, appropriate, and safe (WHO, 2011). Therefore, an information gap in practice remains related to the implementation of best practice, safety culture, quality improvement, and patient safety and quality of care measures in the region. Moreover, patient safety and quality improvement initiatives in parts of Africa are being stifled by factors including unfocused stakeholder agendas, infrastructure constraints, lack of improvement capacity, and other resource limitations; the biggest threat or bottleneck may be a lack of accurate data to inform improvement priorities.

Ente and colleagues found that 75% of African healthcare professionals believed that adverse events were mistakes made by individual practitioners leading to personal guilt, depression, and remorse (Ente, Oyewumi, & Mpora, 2010). Fear of blame, prosecution, and even imprisonment for medical errors may impede the reporting of patient harm in African healthcare settings as in other countries (Barach & Small, 2002). This fear of reporting further complicates the ability to collect incident reports or obtain open and transparent information concerning suspected adverse events. Additionally, in many developing African healthcare settings, medical records are not organized well or completed properly, leading to frustration, debate, and clinical misjudgments. Over 53% of survey participants reported frequent or occasional rates of medical errors in their healthcare facilities (Ente, et al., 2010). Any clinical setting that lacks reliable data to recreate the occurrence of medical errors and adverse events, which is critical in identifying the underlying problems and the potential solutions, is bound to face enormous and daunting challenges to improve patient safety.

Creating a Foundation for Patient Safety and Quality Improvement in Sub-Saharan Africa

Understanding the depth and breadth of preventable patient harm within the African care-delivery system may be the first step to establishing sufficient urgency for change. Establishing targeted goals for quality and patient safety improvement will require large-scale collaboration within and across borders, boundaries, and national cultures (Aspden, et al., 2004). Due mostly to other patient safety and quality organizations/agencies such as the National Patient Safety Agency in the U.K.; the Institute for Healthcare Improvement, the Agency for Healthcare Research and Quality, and National Patient Safety Foundation in the United States; and the World Health Organization, many early adopter African countries are eager to leverage evidence-based methods and strategies for healthcare improvement in their countries to reduce incidences of patient harm.

One such African improvement organization is the Society for Quality Healthcare in Nigeria (SQHN). Nigeria is located in sub-Saharan Africa with a population of nearly 150 million over an area roughly the twice the size of California. The SQHN was formed in May 2006 with a mission to lead, advocate, and facilitate the continuous improvement of quality and safety in healthcare in Nigeria through education, collaboration, training, and accreditation. The Society has also articulated its objectives with the Nigeria healthcare industry as a starting point:

• To promote the principles and practice of quality improvement and risk management in healthcare.
• To provide a national voice on quality improvement and risk management initiatives in healthcare.
• To facilitate opportunities for communication, cooperation, and exchange of ideas and experiences in healthcare quality.
• To facilitate training and continuing education in healthcare quality.
• To establish and maintain a support network for those actively involved in healthcare quality improvement and risk management.
• To promote professional ethics as they relate to practice of healthcare quality improvement and risk management.
• To develop and foster alliance with related national and international bodies towards healthcare quality improvement.

The members of SQHN represent diverse healthcare settings including public and private inpatient hospitals and clinics, health professions faculty, and health maintenance organizations. After initiating two annual quality-focused conferences to showcase regional patient safety in 2009 and 2010, as well as several quarterly capacity-building workshops, the SQHN engaged its members in the wider organizational question of the efficacy of patient safety culture in Nigeria as it related to similar constructs in other international health systems.

Prior to conducting a stakeholder workshop in Lagos in the spring of 2011, the SQHN surveyed 40 members concerning patient safety culture using culturally relevant questions as well as targeted questions from the U.S. Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety Culture (HSOPS) (AHRQ, 2011). The survey was sent to registered workshop members before a scheduled educational workshop, and the response rate was 89%. More than 43% of respondents were physicians, 10% nurses and other professionals representing midwives, medical students, hospital engineering, administration, pharmacy, technicians, and quality assurance officers. Nearly 70% of respondents had 11 years or more of healthcare experience, with most having more than 20 years of experience. Ninety percent of survey participants held leadership positions in their facilities.

Early Patient Safety Survey and Its Relevance to Nigerians

When asked if “patient safety” was solely an American or European concept, more than 97% of respondents strongly disagreed. An overwhelming majority viewed patient safety as a global issue, with the following comments representative of the majority of responses:
Patient safety is a universal concept. The degree to which we consciously implement and adhere to its principles varies from place to place depending on the level of healthcare development, regulatory requirements, and especially patient consciousness.

Patient safety is meant for all, irrespective of sect, sex, tribe, country, etc. This concept is a reality, which has to be imbibed at all cost. This is because patient safety is the corner stone of high quality patient care.

It is the responsibility of all healthcare workers to ensure that the patient, public, and environment are not exposed to harm, no matter where in the world we work.

These responses validate the views of Julie Storr, WHO project manager of the African Partnerships for Patient Safety (APPS) Program, in her paper Focused Problems, Broad Solutions that patient safety is about quality of care, hence it affects everyone (Storr, 2010).
When asked, “What are the most common actions (reported by over 70%) being taken within your facility to improve quality and patient safety?” responses included:

1. Incident investigation (92%) and providing feedback on these investigations (82%)
2. Creating standard operating policies and procedures (89%)
3. Assigning specific staff and resources to patient safety and quality improvement (79%)
4. Conducting clinical audits (76%)

 Next, using the AHRQ HSOPS safety culture tool, the SQHN asked three questions related to the culture composite for Management Support for Patient Safety to compare with the 2011 AHRQ benchmark data registry (AHRQ, 2011):

1. Hospital management provides a work climate that promotes patient safety. (82% agreed or strongly agreed, which equals the AHRQ 50th percentile.)
2. Hospital management seems interested in patient safety only after an adverse event happens. (76% disagreed or strongly disagreed, which equals the AHRQ 90th percentile.)
3. The actions of hospital management show that patient safety is a top priority. (84% agreed or strongly agreed, which equals the AHRQ 75th percentile.)
4. Overall Management Support for Patient Safety aggregated result. (81% positive, which equals the AHRQ 75th percentile.)

 Interpreting the Results and Survey Limitations

The demographics of the SQHN survey sample indicate that patient safety and quality improvement are being led mainly by experienced physician leaders. The sample group may have inherent bias since most group members opted-in to attend a patient safety and quality improvement educational workshop, which may predispose them to stronger beliefs in the importance of these topics.

The most commonly reported actions of patient safety and quality improvement indicate a retrospective and rule-based approach to quality improvement (Kuhn & Youngberg, 2002). Although essential components of a safe system, policies, protocols, and procedures-driven practices may neglect the root cause of errors based on a systems approach grounded in a safety culture. Little patient-safety specific training is conducted at the frontline, and learning from error may be difficult due to an existing culture perceived as being punitive (Ente, et al., 2010). Although root cause analysis is being conducted, there is still much to learn about how human error is analyzed and understood from the systems perspective or from a non-punitive, just culture lens (Dekker, 2007).

Results from the Management Support for Patient Safety section of the SQHN survey were highly encouraging. This group of mostly healthcare leaders indicated that patient safety is a top priority and is fully supported by management. Most safety culture surveys show that leaders perceive management/leadership commitment to patient safety at levels significantly higher than perceptions of frontline professionals (AHRQ, 2011).

Conclusions and Further Recommendations

In the absence of stakeholder-driven mandates for patient safety and quality improvement in some African countries, grassroots groups such as the SQHN are attempting to define an agenda for improving patient outcomes that are culturally relevant to their unique challenges. Positive safety culture attitudes provide encouragement that patient safety is not only important to a larger, international healthcare community, but particularly important to Nigerian quality leaders. Nigerian leaders are keen to develop the knowledge, skills and evidence-based safe behaviours necessary to create organizational and system-wide changes to accurately measure and assess patient harm, develop and prioritize improvement initiatives, and evaluate whether changes have improved the quality of care. Without a common set of quality measures or clinical guidelines in place against which care is judged, widespread clinical improvements will remain challenging at best. Understanding the current Nigerian culture of safety presents an opportunity to capture attitudes and perceptions related to patient safety across a wider Nigerian audience, especially at the point of care. Resources are needed in Nigeria to enable widespread safety culture surveying that would inform and create potential opportunities to prioritize education, training, and resource allocation for scalable patient safety improvement. ‘First do no harm’ applies in Lagos just as it does in London, Los Angeles, Lyon, Lahore, Lima, Leipzig, or Lisbon.

References
Agency for Healthcare Research and Quality (AHRQ). Surveys on patient safety culture. Available at http://www.ahrq.gov/qual/patientsafety
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Aspden, P., Corrigan, J., Wolcott, J., et al., [Eds.]. (2004). Patient safety: Achieving a new standard for care. Washington, DC: National Academies Press.
Barach, P. & Small, S. D. (March, 2000). Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. British Medical Journal, 320, 759-763.
Carpenter, K. B., Duevel, M. A., Lee, P.W., Wu, A.W., Bates, D.W., Runciman, W. B., Baker, G.R., Larizgoitia I., & Weeks, W. B. (2010). Measures of patient safety in developing and emerging countries: a review of the literature. Quality and Safety in Health Care 19, 48-54.
COHSASA (Council for Health Service Accreditation of Southern Africa). Safe care launched to raise standard of healthcare in Africa. Accessed April 30, 2011 athttp://www.cohsasa.co.za/safecare-launched-to-raise-basic-standard-of-healthcare-in-africa.
Dekker, S. (2007). Just culture: Balancing safety and accountability. Burlington, VT: Ashgate.
Ente, C., Oyewumi, A., & Mpora, O. B. (2010). Healthcare professionals’ understanding and awareness of patient safety and quality of care in Africa: A survey study. International Journal of Risk & Safety in Medicine, 22, 103–110.
Kuhn, A. M. and Youngberg, B. J. (2002). The need for risk management to evolve to assure a culture of safety. Quality and Safety in Healthcare, 11, 158-162.
Storr, J. (2010) Focused problems, broad solutions. In: Shaping the future: Growth, Impact and Innovation UK Health Links Conference 2010. Nottingham. Partnership for Global Health, 12.
World Health Organization (WHO) Patient Safety Campaigns. Accessed March, 6, 2011 athttp://www.who.int/patientsafety/campaigns/en/.

Attendees worked on prioritizing improvement strategies at the 2011 SQHN Workshop on Patient Safety Culture in Nigeria.