Introduction to Kuwait’s Healthcare System
Kuwait is one of the developing countries located in the Eastern Mediterranean region. Kuwait’s healthcare system denotes the entire healthcare facilities located in the country including its hospitals, clinics and other healthcare institutions.
As a developing country, Kuwait’s healthcare system fairs well in terms of the quality of healthcare services provided to its people. This is partly due to the large proportion of expatriate healthcare professionals that are operating within the country and partly due to the use of advanced technology in the system. The expatriate healthcare professionals mainly come from the United States, the United Kingdom, and Egypt. Although the country enjoys better healthcare services than most of its neighbouring countries, a lot still needs to be done to improve the safety of patients and the quality of care provided to the people (Casey 2007). The drivers and barriers of the safety of patients and quality of healthcare in Kuwait will be the focus of this paper.
Historical Development of Quality and Safety in Kuwait’s Healthcare System
The focus on the quality of care and patient safety has traditionally been a major concern in Kuwait’s healthcare system. Efforts to improve patient safety and the quality of healthcare in the country were initially made through standards of care. However, the written documents were insufficient to achieve the objectives of quality and safety. This is mainly because the country, being a developing country, faced a multitude of challenges in its healthcare system including staff shortages, budgetary shortages, lack of adequate medical training, and lack of efficient and advanced technologies. In addition, the provision of high-quality and safe care was mainly seen as an individual responsibility.
Despite these obstacles, Kuwait made efforts to improve the quality of care and safety of its patients. These efforts were cemented by the 2004 Declaration on Patient Safety made by Kuwait and its neighbouring countries. The declaration has helped the country to improve the quality of care and safety of patients through the adoption of advanced technologies, employment of highly-skilled healthcare practitioners, and the encouragement of a nationwide organizational culture of quality and patient safety. Today, Kuwait has one of the best healthcare systems in the Eastern Mediterranean region.
Drivers of Quality of Care in Kuwait’s Healthcare System
Quality is a multi-dimensional element of healthcare systems that depends on the interactions between healthcare practitioners and patients. This section will discuss factors that influence and those that hinder the quality of healthcare in Kuwait.
High-quality care of patients depends on the quality of training of the healthcare professionals. A healthcare system that emphasizes the quality of training of its practitioners is likely to report the high quality of care of its patients. In Kuwait, the healthcare system has practitioners who are well trained. The majority of the healthcare practitioners are trained in developed countries such as the US and UK which have advanced medical training institutions.
In addition, the country’s healthcare system has a substantial number of expatriate healthcare practitioners from developed nations. The expatriates bring with their advanced knowledge and skills that help to improve the quality of care provided to the people of Kuwait. The effect of quality of professional training on quality of care has been addressed by Mechanic (2002) who argues that “quality of care depends not only on what clinicians do but the extent to which the sub-systems in which they work enable them to carry out their functions,” (p. 36). The author asserts that practitioners who have undergone high-quality training programs can successfully undertake simple and complex tasks such as scheduling medical appointments, administering medications, and performing complex laboratory procedures.
Healthcare data management systems
In the past, healthcare managers have depended upon error-based approaches for the evaluation and measurement of information accuracy in their organizations. This trend has however changed with the development of evidence-based, data-driven medical practice which has resulted in the representation of the patient and subsequently the organization’s quality of care by data (Lorence & Jameson 2002). In recognition of the importance of efficient data management systems, Kuwait’s healthcare system uses systems-based quality evaluation tools which require the incorporation of assessment of aggregate data (Karapetrovic & Willborn 2000).
One of these tools includes outcomes databases which are “objective measures of post-treatment health, based on defined criteria,” (Lorence & Jameson 2002, p.739). Generally, large outcomes databases of related processes are retained and analyzed statistically to give patients unbiased predictions of the success or failure of their treatment. Outcomes databases have become more available to service organizations and can be used as reference points or standards for measuring the quality of data used in the organizations (Gvozdanovic, Koncar, Tesla, Kojundzic & Jezidzic 2007).
Monetary incentives provided to physicians is one of the greatest divers of quality of care provided to patients in any healthcare system. In the recent past, there have been a lot of heated debates about the effect of physicians’ pay-for-performance (P4P) programs on the quality of care. The logic behind the P4P programs is that physicians would be motivated to work better if they are paid according to the quality of the work they produce (McMahon, Hofer & Hayward 2007). Kuwait’s healthcare system utilizes pay-for-performance programs as a means of providing physicians with incentives to provide high-quality care to patients.
To some extent, the P4P programs are beneficial in that they motivate physicians to offer the best possible care to the patients. This is because monetary incentives are one of the greatest motivational tools that any organization can provide to its employees. One of the disadvantages of the P4P programs is that this market-based approach fails to take into consideration the high costs and patient burden that often prohibit the achievement of high-quality care. Another disadvantage is that healthcare organizations may measure physicians’ performance using their patient’s severity of illness rather than the quality of care provided by the physicians (Epstein 2006). This is unjust because a patient suffering a severe illness may receive a higher quality of care than a patient suffering from a mild illness.
Barriers to Quality of Care in Kuwait’s Healthcare System
Cultural incompetence is one of the common factors that negatively impact many healthcare systems. In Kuwait’s healthcare system, cultural diversity is mainly a result of physician expatriates from developed countries such as the U.S., the U.K. and neighbouring countries such as Egypt. Cultural diversity affects the quality of healthcare mainly through language barriers and ethnocentrism. If physicians and the patients fail to understand each other’s language, problems of misdiagnosis and medication errors are highly likely to occur. Ethnocentrism refers to the belief that one’s own culture is superior to another’s culture.
Ethnocentrism often breeds ignorance and lack of compromise. Physicians can only provide quality care if they understand their patient’s cultural values, particularly as they affect their health and general well-being. Napoles-Springer, Santoyo, Houston, Perez-Stable and Stewart (2004) conducted a study to examine cultural competence in the American healthcare system. The researchers found that various cultural factors play an important role in the quality of care provided to patients. These factors include sensitivity to traditional medicine, spirituality, family support systems, language concerns, social class, and immigration status (Napoles-Springer et al. 2004, pp. 13-14).
The increasing dominance of marketplace models of healthcare (such as systems-based data management approach) has, in turn, attracted much attention to the informational environment of healthcare that enables purchasers to make informed choices that best address their needs and interests. Kuwait’s healthcare system acknowledges the importance of information accessibility on the part of healthcare purchasers and is making efforts to address this issue.
The system’s efforts are indicated in the Kuwait Declaration on Patient Safety which was prepared in November 2004 (World Health Organization Regional Office for the Eastern Mediterranean, 2004). However, the efforts made by the country’s healthcare system are limited to a comparatively small number of process measures which depend to a great extent on voluntary and irregular reporting by the health plans.
The greatest impact of the system’s efforts is not on the actual information, but on creating a model of evaluating the performance of different healthcare organizations and making such information accessible in a systematic manner to the prospective purchasers (Mechanic, 2002). Unfortunately, such information is normally complex and contradictory and hence potential purchasers are unable to make sensible meanings from the data. Krumholz, Rathore, Chen, Wang and Radford (2002) argue that the lack of accessible information limits the ability of the patients and other healthcare purchasers to make informed choices.
The global economic crisis that originated from the United States and spread to other regions resulted in budgetary cuts in all sectors of the economy in most countries including Kuwait. Parallel to the budgetary cuts has been the increasing costs of medications and treatment procedures. As a result, practitioners in Kuwait’s healthcare system are forced to take cost-effective measures in their practice. These measures involve decisions concerning not only the amount of time and attention accorded to patients but also the kinds of treatment procedures the patients will be provided.
Bar-Yam (2006) states that “physicians have to decide whether the amount of time and effort devoted to a particular appointment, individual, diagnostic test or therapy is worth it – that is, not only whether a successful outcome is likely but also whether it is cost-effective,” (p. 462). The cost-effectiveness judgment made by physicians is usually rife with uncertainties and contrary to the physicians’ medical training. In addition, such decisions vary from one health care organization to another and from one physician to another. The result is that the quality of care provided to patients becomes unbalanced and varies according to the organization and individual physician of the patients.
Drivers of Patient Safety in Kuwait’s Healthcare System
Patient safety refers to the freedom from accidental injuries. This may seem like a simple task to be performed by any healthcare organization but it is not so. Ralston and Larson (2005) argue that “in the complex world of healthcare, patient safety is a moving target. It is a continuously emerging property of a complex system involving people, processes, patients, families, and technology that makes up the system,” (p. 61). This section will discuss factors that influence and those that hinder patient safety in Kuwait.
Organizational culture of patient safety
Upholding patient safety requires healthcare organizations to adopt a new paradigm of care that views patient safety as one of the organization’s key values. This cannot be achieved without an organizational culture of patient safety. A culture of patient safety is one of the most difficult yet the most important measures an organization can take. In Kuwait, the culture of patient safety is ingrained in its healthcare system.
This culture is characterized by organizations’ values, beliefs, a blame-free environment and leadership. The values and beliefs of Kuwait’s healthcare systems are centred on promoting attitudes of patient safety among the practitioners as well as measures that address potential and actual risks in different healthcare settings. A blame-free environment recognizes that humans are bound to make mistakes. Such an environment encourages physicians and other healthcare practitioners to report the occurrence of adverse events so that the most effective and immediate remedy can be found (Ralston & Larson 2005).
Leaders of healthcare organizations provide the resources needed to enhance patient safety such as adequate and competent staff as well as technical infrastructure. Leaders also encourage an organizational culture of patient safety by actively engaging in activities that promote patient safety (Larson 2002).
Information and communication technologies
The idea of an integrated healthcare information system has attracted significant interest because of advances in digital communication and hospital information technologies. Patients are also demanding high-quality healthcare services that do not compromise on their time and geographical location (Shi & Singh 2008). These demands can be met through the utilization of advanced technologies such as electronic medical records (EMR) and diagnostic imaging systems in healthcare organizations. The role of advanced information and communication technologies in ensuring patient safety has been appreciated by Kuwait’s healthcare system.
The country uses these advanced technologies in its healthcare system not only to ensure patient safety but also to improve the quality of care provided to the patients. EMR systems provide numerous benefits to patients including reducing the possibilities of medical errors by healthcare providers. EMRs facilitate the electronic documentation of patients’ information and the sharing of such information by the multitude of specialists that are involved in the care of patients (Follen et al. 2007).
On the other hand, diagnostic imaging systems enable healthcare providers to accurately diagnose patients’ illnesses. This is important given the increase in the number of people suffering from chronic illnesses. Although the implementation and utilization of advanced technological systems in healthcare are highly beneficial, such an undertaking is very costly to any healthcare organization.
Shift away from inpatient care to home-based care
In the recent past, there has been a decline in the number of patients admitted to inpatient care units. This trend has been parallel to the increase in Hospital-at-Home programs. This trend has been witnessed not only in developed countries but also in developing countries such as Kuwait. Leff et al. (2006) state, “Hospital-at-Home is a care model designed to deliver acute medical care in the home as a substitute for an acute inpatient hospital admission,” (p. 1355).
The justification for this trend lies in the fact that critical patients in Hospital-at-Home programs are more likely to experience high-quality care that has fewer complications, more satisfaction for both patients and families, and less cost than patients admitted in inpatient acute care settings. The research carried out by Leff et al. (2006) showed that patients move away from inpatient acute care units to hospital-at-home care because the latter provides patients with greater advantages than the former. Relationship between the healthcare providers and the patients, the issue of safe care, comfort and convenience are just some of the major factors that influence patients’ use of the Hospital-at-Home programs vis-à-vis the inpatient acute care facilities.
Barriers to Patient Safety in Kuwait’s Healthcare System
The nursing shortage is one of the many challenges affecting healthcare systems in most countries. Like in other countries, the problem of nursing shortage in Kuwait is most severe in speciality care settings that require the expertise and skills of highly trained nurses such as intensive care units, operating rooms and emergency departments. Nurse shortages have been linked to poor patient outcomes in critical care units and especially to the grave patients’ harm and injuries that result from the use of physical restraints. The small ratio of nurses to patients in critical care units increases the understanding of the use of physical restraints and the development of complications from the use of such restraints.
A study conducted by Demir (2007) indicates that many intensive care units are understaffed. This limits the ability of the nurses to pay close attention to the patients or to reassess the restraints. This occurs especially if the nurse in charge of a restrained patient has to leave the patient to attend to other patients (Robinson, Jagin & Ray 2004). The absence of the nurse in the restrained patient’s room provides the patient with the opportunity to harm himself as he tries to free himself from the restraints.
Other human resources challenges
Human resources issues play an important role in healthcare organizations. They not only influence the safety and quality of healthcare provided to patients but also the profitability and cost-effectiveness of the organizations. Many human resource challenges affect Kuwait’s healthcare system. These include employee turnover, lack of teamwork, employee incompetence, and utilization of temporary personnel. Employee retention is a major concern to the healthcare system.
When organizations can retain their employees, they not only benefit from the lack of the need to continuously train new employees but the employees can establish healthy relationships with the organizations’ clients thereby enhancing patients’ safety. A high turnover rate is also closely linked to a lack of teamwork in the healthcare organization. The establishment of teamwork is a long process that requires heavy investments of time and effort from the parties concerned. The use of temporary personnel is also a common human resource challenge in many healthcare organizations.
This results when there is a consistent and high employee turnover rate (Aiken, Clarke, Sloane, Sochalski & Silber 2002). In such situations, the organization is forced to bring in some inexperienced personnel such as interns or medical students to hold the vacant positions temporarily until experienced employees are hired.
Kuwait has one of the best healthcare systems in the Eastern Mediterranean region. The system is dedicated to the provision of high-quality and safe healthcare to its people. To achieve these objectives, the system employs expatriate healthcare practitioners from advanced countries such as the United States and the United Kingdom. In addition, the country’s healthcare system uses advanced information and communication technologies such as electronic medical records and diagnostic imaging systems. In addition, the country’s healthcare system is characterized by the organizational culture of patient safety and quality care.
Despite these strengths, Kuwait’s healthcare system is rife with weaknesses that negatively affect patient safety and quality of care. These weaknesses include cultural incompetence, inaccessibility of crucial information, cost-effectiveness restraints, and human resources challenges such as nursing shortages and high staff turnover rates. The strength of Kuwait’s healthcare system can further be enhanced through the implementation of measures that address the above-mentioned weaknesses. Only then will the system be able to provide the desired quality and safe care to its people.
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