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How do we define Best Practices in Global Health?

Why this subject for a blog on CHSC web site? Christian Health Service Corps policies and procedures were created to help us become an organization that exemplifies best practices in global health missions. It is important to have discussions about how to improve global health initiatives, but we believe it is even more important to demonstrate what best evidence based practices in global health look like.

Welcome to the Best Practices in Global Health Missions Blog!!!

As I start this blog I thought it would be good to cover some foundational principles that I outlined in When Healthcare Hurts, and even include some excepts in case you are reading this blog unfamiliar with my past writings. If you take anything away from this blog, my articles, or books I hope it would be this: Best practices in global health can largely be stated as practices that support both human dignity and patient safety in healthcare delivery. This is the framework upon which I wrote When Healthcare Hurts: An Evidence Based Guide for Best Practices In Global Health Initiatives. Here is a little more detail on this idea from the introduction of the book (page xxii). Certainly evidence based practice for resource poor environments is also a consideration and will be discussed later but the foundation must be built on these two pillars, human dignity and patient safety.

Best Practice Guidelines

There are four general categories of best practices for global health initiatives; they are as follows.

1. Patient Safety 2. Healthcare System Integration and Collaboration 3. Facilitation of Health Development 4. Community Empowerment

The first three aspects of best practices are very much intertwined and overlap on many levels. They serve and support each other, and it is difficult to discuss one aspect to the exclusion of others. Collaboration with healthcare systems and providers makes patient safety more achievable and can improve healthcare quality on both ends of the collaboration. This, in turn, can facilitate health development by increasing attention to patient safety in medical facilities and programs around the world. This is perhaps a simplified summary, but it may help as the starting point for learning and studying best practices in global health. Community empowerment applies to programs working at the community level. For those who send healthcare professionals to volunteer in developing countries, patient safety is often our biggest challenge. This is especially true when sending groups of volunteers or short-term teams to serve developing communities. In the coming chapters, you will find tools, strategies, vision, and direction for your short-term global health work that will lead to improved patient safety. Achieving systems and structures to ensure patient safety in global health is not without challenges. The ability to create patient-safety strategies is directly proportional to our commitment to quality improvement and creating a patient-safety culture in our programs. There are a number of common practices and commonly held assumptions that represent significant barriers to achieving higher levels of patient safety in short-term global health initiatives. We will outline six general best practice guidelines that address these barriers and actively promote improved patient safety in global health mission programs. All six guidelines included in this book are directed toward creating a culture of continuous quality improvement in global health programs that empower communities. This book holds one underlying assumption, which is that healthcare professionals seek to first do no harm. We do our best to improve patient safety and avoid adverse events related to the care we provide. The Institute of Medicine (IOM) defines patient safety as “the prevention of harm to patients,” and they direct special attention to creating a system of care delivery that “(a) prevents errors; (b) learns from the errors that do occur; and (c) is built on a culture of safety that involves healthcare professionals, organizations, and patients” (Mitchell, 2008).

As healthcare professionals, we agree that there is an ethical and moral responsibility that comes with providing healthcare from which no provider or organization is exempt; this is the responsibility to provide safe care to patients. The World Medical Assembly puts it this way: “Quality assurance should always be a part of healthcare, and physicians in particular, should accept responsibility for being guardians of the quality of medical services” (World Medical Assembly, 1981). The question is, How do we achieve this cross-culturally? Healthcare—wherever it is provided, in North America, in Europe, or in Africa—has the potential to harm the recipients of that care. As healthcare professionals who engage in cross-cultural healthcare activities, we want to accept the responsibility of healthcare delivery to “first do no harm.” However, this is not easily achieved even in fully developed countries. It is estimated that more than 200 Christian healthcare mission teams leave the US alone each month to go somewhere in the developing world (A. Hester, personal communication, September 20, 2011 ; L. Morris, personal communication, September 21, 2011). This does not count strictly humanitarian global health initiatives. In 2010, the two leading suppliers of pharmaceuticals to medical teams, Kingsway Charities and Medical Assistance Programs (MAP) International, sent 3,448 medication shipments, sending a combined total of more than 440 million dollars’ worth in pharmaceuticals (Kingsway Charities, 2010; MAP International, 2010).  The significant volume of such projects combined with the potential for adverse outcomes makes establishing guidelines for patient safety and quality improvement in global health initiatives an operational imperative.

Maria’s story exemplifies some of the major patient safety issues with the way most churches, service learning programs engage in global health work.

Maria’s Story A general medical team was serving a village community in Central America. Maria, a 29-year-old mother of five, arrived at the clinic pharmacy to receive her medication after having her entire family seen by one of the physicians. Maria had three prescriptions for herself, and each child received prescriptions for parasite medications and vitamins. In addition, three of the children were febrile, and two had been diagnosed with otitis media (ear infections) and one with strep pharyngitis (throat infection). Each of them also received prescriptions for antipyretics (Tylenol) and antibiotics. Maria waited patiently with the handful of prescriptions in the pharmacy waiting area. The pharmacy line was long with about 75 people waiting for prescriptions to be filled. There were also people waiting to be seen by the dental, medical, and health education volunteers. Maria finally got to the pharmacy counter, and her prescriptions were filled by a pre-med student under the supervision of a nurse and a paramedic. A paramedic provided instructions for each medication through a translator at the pharmacy counter in front of a crowd of people while Maria was trying to keep her children from getting lost in the crowd. Dosages were explained to Maria, and instructions were written in her own language for the 12-year-old, six-year-old, and six-month-old children. However, Maria could not read. Maria received multiple medications in Ziploc baggies and non-child-resistant containers, and she took them home to her one-room dirt-floor home with no place to store them away from her children. Less than a week after the team left the country, Maria’s six-month-old child was brought to the public hospital in that region with acute liver failure and died. Maria had mixed up the dosages of medication and had been overdosing her six-month-old with Tylenol for the entire week.

Ultimately these kind of volunteer medical / global health volunteer teams make us feel good about serving those in need, but they are often more harmful than helpful, especially in this area of patient safety. Dr. Arnold Gorske in his 2009 paper “Harm From Drugs in Short-term Missions” shares a brief list why patient safety in the is context is such a challenge.

  • Lack of knowledge of the patient (every patient seen is a new patient)
  • Lack of adequate medical record, medication list, allergy record, list of diagnoses, and so on to determine whether a drug may be contraindicated
  • Lack of adequate time for obtaining an accurate and complete history
  • Lack of adequate time/facilities for obtaining an accurate and complete physical examination
  • Lack of availability of reliable laboratory testing
  • Lack of adequate provider training and knowledge of World Health Organization international standards and evidence-based practice guidelines for developing countries
  • Lack of emergency medical systems and intensive care units for timely and appropriate treatment of adverse effects  Confusion due to language and cultural differences
  • Lack of patient familiarity with a medication’s adverse effects
  • Lack of adequate time for counseling by a physician, pharmacist, or nurse
  • Increased risk of drug interactions and drug overdose
  • Disrupted continuity of care for chronic conditions for which the patient is under the care of a local provider
  • Increased risk of accidental ingestion related to lack of knowledge of child-safety requirements, safe storage area in home, or child-safe containers
  • Increased mortality due to lack of poison control centers, emergency medical systems, and intensive care units for timely and appropriate treatment of accidental ingestions or overdoses
  • Lack of availability of follow-up; neither the prescribing provider nor the dispensing pharmacist will be available if there are adverse effects to the treatment
  • Local in-country healthcare providers and pharmacy personnel usually have little knowledge of the medications brought by short-term teams and/ or lack the resources to treat drug-related complications

In the next post we will look at this issue of patient safety with team medical /global health missions in greater detail.



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