Iraqi effective medical care. The routine hospital care improvement

        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 1,2,3Thamer,
Liu,Ghani    

            
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 modeled first in a
manufacturing to make ongoing improvements more systematic, data – guided and
efficient1,2 .

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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 research3. Putting improvement activities under research
regulations can precipitate substantial delays , costs, and conflicts 4-7. 

          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 date 2016 healthcare facilities, equipment and professionals are in
critical short supply that have led to increased mortality rates in all areas Ghani et al 2016.

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 setting8. 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 functions8. 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 practices9,10.
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 11. 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 units11. 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
requirements12 for the protection of human participants in QI
activities are:

Social or
scientific value.Scientific
validity.Fair
participant selection.Favorable
risk – benefit ratio.Respect
for participants.Informed
consent.Independence  review.The
characteristics that to be used in the construction of guidelines for
categorizing QI activities as overlapping with human subjects research are8:

Testing
of issues that go beyond current knowledge based on science and experience ,
such as new treatments.Random
allocation of patients into different intervention groups to enhance confidence
in differences that might be obscured by nonrandom selection.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.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.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
follow13,14:

Clarify
professional and organizational responsibility for QI. Clarify
patient’s responsibility for QI.Develop
guidance on QI methodology and dissemination of QI results.Develop
new models of internal management and supervision of QI and of QI  – human subjects research overlap projects.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:

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.Control
of the private sector of health care delivery.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. 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, gynecology, pediatrics, 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.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.   Implement
research programme from neutral individuals to evaluate the quality of health
care in each governorate. This is to be the responsibility of the governorate
mayor.Activate
surgical pathology weekly conference.Activate
mortality meeting. Activate death conference for each case
without any exemption.Stick
to medical ethics regulation.Provide
health care according to guidelines.Iraqi
Medical Association must get more and more supervision for medical practice.Development
of specialty and subspecialty societies on national and regional grounds.Iraqi
Medical, Dentist, and pharmacist  Syndicates
should act as professional body and not a political or social organization.