Quality improvement of health care in Iraq
Abdulghani Alsamarai, MD, MGUM, Ph D. Editor –in – Chief Aalborg Academy Journal of Medical Sciences Chairman of the Scientific Bureau – International Union of Arab Academics. Member of Asian Council for editors. Alaa Bashir, Editorial Director, Aalborg Academy Journal of Medical Sciences.
Journal Title:Aalborg Academy Journal of Medical Sciences
Iraqi health care experts documented that hundreds of patients die each year because of hospitals failures to adhere consistently to standard procedures of safe and effective medical care. The routine hospital care improvement is public health imperative. High quality health care [safe, effective, patient – centered, timely, equitable and efficient] is should be provided for all population. Unfortunately, the growing literature and health care professions documents a serious problem in health care delivery in Iraq, for example: Unnecessary surgery: Such as increased numbers of cesarean section with time; increasing numbers of operation for appendectomy (most of them in is later found to be normal).; High morbidity and mortality following surgery.; Inappropriate use of medications.; Inadequate prevention of diseases.; Avoidable exacerbation of chronic conditions, Malpractice, lack of accreditation and licensing system, malpractice in private pharmacy, drugs irrational use, absence of referral system, short consultation time, no consistent medical record system, no clinical standards in health care providing, fail to maintain sanitation in public health care services, non existence of quality control programs in hospital and health care centers, and non effective diseases prevention and control programs [1-3]. All of the above examples of problems in health care delivery are due to loss of supervision that was previously performed by collaborative activities of Ministry of Health, Ministry of Higher Education, Iraqi Medical Syndicate, Dentist and Pharmacist Syndicates. However, on national ground, some physicians and surgeons are trying their effort to improve the quality of patients care through clinical and managerial changes in the processes of care. Health care practices have always evolved, but mostly in a scattershot way. Globally, in recent years, health care providers have initiated new methods, some of which were modelled first in a manufacturing to make ongoing improvements more systematic, data – guided and efficient [4,5]. Quality improvement [QI] facing problems of ethical issue, because attempts to improve health care may inadvertently cause harm, waste scare resources or affect some patients unfairly. Furthermore, some activities using QI methods have been categorized as research that uses patients as subjects, which brings activities under the ethical and regulatory requirements governing human subject’s research . Putting improvement activities under research regulations can precipitate substantial delays, costs, and conflicts [7-10]. MOH in collaboration with WHO and US Agency for International Development [USAID], proposed a National Healthcare Quality Improvement Program [N-QIP], USAID Primary Health Care Project in Iraq [PHCPI], Training Model Primary Providers [TMPP] led by RTI. Additionally, other programs and practices performed by many Non-governmental Organizations to improve the quality of health care delivery and standards. Collectively, all the MOH, WHO, USAID, NGOs, and private practices and programs not show a quality improvement in health care in Iraq. Up to 2016 healthcare facilities, equipment and professionals are in critical short supply that have led to increased mortality rates in all area . WHY? There is no improvement in the health care quality in Iraq? The health care situation in Iraq deteriorated as a part of national decline in whole services in the country as an outcomes of leadership and financial corruption. The International Union of Arab Academics convened a group of scientists to address the ethical issues associated with QI methods in health care. The committee members are clinician leaders, experienced clinical trials experts, and ethicists. The project committee addressed the following questions: What is the definition of quality improvement? Should all QI activities need ethical approval and informed consent? What ethical requirements should QI activities meet? What arrangement do we need to ensure the ethical conduct of QI? Quality improvement is defined as systematic, data guided activities designed to bring about immediate improvements in health care delivery in particular setting . QI is intrinsic parts of good clinical care, in which data from clinicians own setting guide them in improving their practice. However, QI assumes that the quality and safety are largely characteristics of systems and its methods enable workers to gain insight about their systems relationships and functions . Organizations that accredit the education and certify the competence of health care professionals have come to require practitioners to be competent in improving their own practices [12, 13]. But their practice for improvement must not be away from guidelines for management of diseases. Over time, successful QI transforms organizational culture so that everyone has the requisite skills. An effective way to promote QI is to conduct evaluative research on programs designed to implement standard practices for the safety and care of hospitalized patients . Such research, however, poses an apparent ethical conundrum: it is often impossible to obtain informed consent from patients enrolled in QI research programs because interventions must be routinely adopted for entire hospitals or hospital units . Suppose that the research involve patients setting in ICU, emergency unit, or emergency surgical interventions, the patients have no opportunity to decide whether or not to participate or able to decide to give informed consent or not. The question arises here is it ethical to conduct such research without informed consent? Informed consent is meant to protect people from exposure to research risks that they have not agreed to accept, as well as to respect their autonomy. In the above hospital settings none of the QI interventions were experimental and not have increased the risk of hospital acquired infection. In addition, in these hospital units the QI activities could be performed without research, in such case the general consent to treatment by the patients or their families would have covered these interventions. Thus, there are no reasonable or ethical grounds for any patient to object to being included in the study without his or her consent. Ethical requirements  for the protection of human participants in QI activities are:
i. Social or scientific value.
ii. Scientific validity.
iii. Fair participant selection.
iv. Favourable risk – benefit ratio.
v. Respect for participants.
vi. Informed consent.
vii. Independence review.
The characteristics that to be used in the construction of guidelines for categorizing QI activities as overlapping with human subjects research are11:
a. Testing of issues that go beyond current knowledge based on science and experience, such as new treatments.
b. Random allocation of patients into different intervention groups to enhance confidence in differences that might be obscured by non random selection.
c. Deliberately delayed or ineffective feedback of data from monitoring the implementation of changes, especially if this is done to avoid biasing the interpretation of data.
d. Involvement in key project roles of researchers who have no ongoing commitment to improvement of the local care situation, even if others in the team do have professional commitments to it.
e. Funding, sponsorship, or substantial participants by parties outside the clinical setting or organization in which the activity takes place.
The global recommendations for implementing accountability for the ethical conduct of QI are summarized as follow [16, 17]:
A. Clarify professional and organizational responsibility for QI.
B. Clarify patient’s responsibility for QI.
C. Develop guidance on QI methodology and dissemination of QI results.
D. Develop new models of internal management and supervision of QI and of QI - human subjects research overlap projects.
E. Develop and expand external accountability for QI.
The effective approach to overcome the above mentioned national problems and an effective way to promote quality improvement in health care are:
1. Any doctor should provide health care according to his specialty. Not acting by the Computer doctor approach, i.e. WORKING LIKE CARS MECHANIC, which is mean that he knows everything.
2. Control of the private sector of health care delivery.
3. Conduction of evaluative research on programs designed to implement standard practices for safety and care of patients, at least the hospitalized one for the first step.
4. Development of Human Research protection Committee within each governorate. This committee must be headed by an academic specialist, Medical association and society representative, and experts in the disciplines of surgery, medicine, gynaecology, paediatrics, community medicine, clinical pharmacology, dentist, and expert in pharmacy. The responsibility of this committee is to supervise the impact of research on human subjects, in order to achieve protection for the society.
5. Development of Institutional Review Board. This board to establish in each college and reach regional health authority. The member of the board should be specialist in their field and with Ph D or equivalent degree.
6. Implement research program from neutral individuals to evaluate the quality of health care in each governorate. This is to be the responsibility of the governorate mayor.
7. Activate surgical pathology weekly conference.
8. Activate mortality meeting.
9. Activate death conference for each case without any exemption.
10. Stick to medical ethics regulation.
11. Provide health care according to guidelines.
12. Iraqi Medical Association must get more and more supervision for medical practice.
13. Development of specialty and subspecialty societies on national and regional grounds.
14. Iraqi Medical, Dentist, and pharmacist Syndicates should act as professional body and not a political or social organization.