Chapter 13 Approaches to difficult problems

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Unit 28: Advocacy


When you have completed this unit you should be able to:

28-1 What is advocacy?

Advocacy is the process of acting on behalf of others to influence organisations and people with the aim of changing attitudes, values, policies or laws. For healthcare workers, this includes the process of speaking out on an issue affecting access to healthcare.

Advocacy is the process of acting on behalf of others in order to improve decisions or actions made by other people or organisations.

28-2 Why is advocacy important?

The Constitution says that government has a duty to “take reasonable measures” to “progressively realise” access to healthcare for all. This means that poor service delivery as a result of corruption, wasteful expenditure, poor planning or other forms of mismanagement is unconstitutional. Many who work in the public sector in South Africa witness issues that have an effect on service delivery on a daily basis. Common examples include medical specialists who are rarely seen in their clinical units but who run large private practices and tender processes that are not transparent. However, providers become used to this and feel powerless that nothing can be done about it. Understanding the process of advocacy empowers us to speak out.

28-3 Am I allowed to speak out?

Yes. The World Medical Association says that doctors have not only a right, but an ethical duty and professional responsibility to speak out. The same can be argued for other health professions. The bottom line is that all those involved in the care of patients can and should speak out, but you have to do this responsibly and in a way that protects you.

The public service regulations state that:

Speaking out is sometimes in the best interest of the patient and hence any section in a job contract that says the employee may not speak to external parties about problems at work can be challenged legally if the principles of the Protected Disclosures Act have been followed.

Healthcare providers have a right and a duty to act when corruption or mismanagement affects the public interest.

28-4 What is the Protected Disclosure Act?

The Protected Disclosures Act is an Act of Parliament designed to protect people who wish to report corruption and mismanagement at work. It lays out the procedures for making a complaint. It is sometimes referred to as the “Whistle Blower’s Act”.

Following the procedures in the Protected Disclosures Act means that a person is protected under law.

28-5 What are the channels through which healthcare providers can make a complaint in the public interest?

There are several channels for making a complaint, more than one may be necessary:

These channels are all protected under the Protected Disclosures Act.

28-6 How can I speak out safely?

Public employees have been victimised in the past for speaking out and this keeps a lot of health professionals quiet. However, advocacy can be safe if done properly and carefully, following the guidelines below:

Advocacy is safer and more effective when people organise and work together.

28-7 Where should I start?

You should make your complaint within the health system where you work, starting at your own facility with your manager. It is preferable to work constructively within the organisation where possible.

You can make your complaint to an outside body when:

The Protected Disclosure Act states that you may make a disclosure to outside bodies, including the media, if one of these situations applies and if you make the disclosure in good faith and not for your private advantage.

It is sensible to seek legal advice from your union’s legal advisor at an early stage if you are reporting to an outside body and fear victimisation.

28-8 How do I speak out at my facility?

It is possible to bring up the issue at a clinical or business meeting, or to take up the issue privately with your manager. If the problem you have identified means that your facility is not meeting the National Core Standards, you should say so because it means that managers have a duty to comply as quickly as possible. Also, by using this approach, you depersonalise the issue and shift focus to compliance with health legislation, policies and strategies. Ideally, you should be able to work out a quality improvement process that specifies dates for action and improvement. You can also assist a patient to issue a complaint through the National Complaints Management Protocol (NCMP).

Access the National Core Standards via their website.

28-9 What is the National Complaints Management Protocol?

The National Complaints Management Protocol is a mechanism for patients to make complaints about treatment at their local facility. As a healthcare worker, if you understand the National Complaints Management Protocol you can monitor its use and make sure that it is adequately implemented at your facility. Referring to the protocol means you can “depersonalise” a problem and concentrate on the failure to comply with the health policy and legislation.

28-10 How does the National Complaints Management Protocol work?

The following steps should be taken:

28-11 Whom should I ask if I need outside help?

The process of advocacy can be very time consuming, not to mention worrying, and much of the above is easier said than done. Although you should certainly take things up at facility level where you can, waiting for a response from several different government departments can take a long time and people usually run out of energy before the process is complete. In other instances, the situation needs to be dealt with speedily, for instance, where inaction or delayed action would lead to avoidable and irreparable harm or even death. Fortunately, there are a number of organisations to assist you. You are allowed to contact any of the organisations in the Resources for advice while going through the process at your facility.

29-12 What are the important points to remember when lodging a complaint?

Important points to remember are:

It can be very effective to work with patient rights advocacy groups, combining the insider and outsider advantages in addressing a problem at your facility. Patients, communities and rights groups can also use their own agency to demand attention to a serious problem affecting patients’ access to healthcare.

Useful organisations which can help with advocacy procedures are listed in the Resources.

Case study 1

In 1998, when South Africa was facing a growing HIV epidemic, a group of activists came together to campaign for access to antiretroviral treatment (ART). This was the start of the Treatment Action Campaign (TAC). The government’s initial argument was that ART was unaffordable. The TAC argued that this was a violation of the constitutional Right to Life and that the government therefore had a duty to find ways of overcoming the cost restrictions. The large pharmaceutical companies were also branded as human rights abusers because of the high costs of the drugs. Working with lawyers, the TAC successfully took the government to the Constitutional Court at least 5 times. In addition, the TAC made sure that people living with HIV were given accurate information about their disease, the possible treatment, and their rights. This successfully built a large grassroots organisation that was very effective at demanding that government meet its responsibilities. As a result of legal action based on constitutional rights and a large group of people asserting their rights, the campaign was a success. The pharmaceutical companies considerably reduced the costs of treatment and government resistance was overcome. Today, South Africa has the biggest ART programme in the world.

They also built up a large group of grassroots activists who asserted their human rights.

Case study 2

Dr Prudence has started work as a community service doctor at a small rural hospital. She is often on call by herself, and has had to make some quite scary decisions for a newly qualified doctor. Three months into the job, she is surprised to find that there is a full-time principal medical officer appointed to the hospital. She has never seen him before, but recognises the name because he has a large general practice in town and frequently sends referral notes requesting X-rays or ultrasound scans for his patients. She has tea with a young man from Human Resources and he says that this doctor has an overtime contract, together with rural and scarce skills allowances and, although he makes out the roster, he is never on call himself. Prudence thinks that it is corrupt to accept so much money and not do the job, so she decides to do something about it.

1. How should she proceed?

There is strength in numbers and she should not proceed alone. The first step is to get some allies. She should speak with all the other doctors and get their support, perhaps together with nursing colleagues. They should document the problem by collecting the on call rosters. As a first step, they should work within their facility and approach the medical superintendent or hospital CEO.

Case study 2 continued

The junior doctors arrange a meeting with the superintendent. She tells them that, although they may not have seen him, the principal medical officer contributed important administrative duties and worked from home. Also, although they may not have realised it, he actually provided senior cover 24/7 while they were on call. Unsatisfied, the junior doctors return to work, but try to call him over the next 2 weeks with difficult problems. On the first 2 occasions, he suggests they speak with the referral hospital, and they then find his phone is switched off after hours. They document this.

1. What should they do next?

At this time, it is quite legitimate for them to go outside their own facility to ask for help. There are a number of options and they may need to use more than one:

Unit 29: Managing adherence


When you have completed this unit you should be able to:

29-1 Is providing access to healthcare enough?

“Access” is defined as the opportunity to use healthcare. Access to healthcare is a human right, and in South Africa the government has a constitutional duty to provide access to the best possible healthcare to all its citizens. However, this is not the whole story. A common source of frustration among healthcare providers is that patients may be given access to care or treatment, but they either choose not to use it, or use it in a way that was not intended. When thinking about solutions to health problems, adherence must also be considered particularly for chronic diseases.

Many people have access to healthcare but choose not use it or use it in an unintended way.

29-2 What is adherence?

The World Health Organisation (WHO) defines adherence as: The extent to which a person’s behaviour – taking a medicine, following a diet and/or executing lifestyle changes – corresponds with the agreed recommendations from a healthcare provider.

The term “agreed” is important. It means that the patient and their healthcare provider have discussed the problem and have agreed on what the patient needs to do. Therefore adherence refers to more than taking a medicine. There has to be an agreement between the health provider and the patient. This is different from the older term “compliance” which refers to whether or not the patient is just following recommendations.

Adherence refers to whether a patient, who has agreed to a plan of management, actively plays their part in carrying out the management, such as taking their medicine correctly.

29-3 How big a problem is non-adherence?

Non-adherence is a very big problem and likely to worsen as the burden of chronic diseases grows. Adherence is difficult to measure, but the World Health Organisation estimates that about half of people on long-term treatments in high-income countries are non-adherent, and the problem may be worse in low- and middle-income countries. This may help explain the large number of admissions with uncontrolled chronic disease.

Non-adherence is a very common problem especially in patients with chronic diseases on long term treatment.

29-4 Why might a patient be non-adherent?

There are several reasons why a patient might be non-adherent:

29-5 How does misunderstanding about medications happen?

Somebody might not understand how to take their medication because:

29-6 How do different health beliefs affect adherence?

Health beliefs are crucial. During a consultation, somebody might appear to agree to a lifestyle change or medication out of politeness, but have deep-seated opposite beliefs. For example, exercise to increase physical fitness can be very helpful in chronic lung disease. However, if somebody believes that the tiredness and shortness of breath caused by training is making them worse, they will not exercise.

29-7 Is forgetfulness important?

Yes, forgetting to take medication is particularly important in the elderly.

29-8 Why might somebody think the effort of collecting or taking medicines is not worthwhile?

Common reasons include:

29-9 What about side effects?

People may experience side effects, but they may also be concerned about rumoured side effects. If they are able to read, they may also fear the many possible side effects that are listed in the package insert without understanding that most of these are rare.

29-10 What is the role of access barriers?

Access barriers determine how easy or difficult it is for people to use services, but also refer to the way they are treated when they are there (acceptability). Access barriers can make the effort of collecting medicines seem not worth the effort. Examples of access barriers are long queues, inconvenient times to collect medicines and rude staff.

29-11 How can adherence be improved on an individual level?

Simple ways to improve adherence include:

A pillbox organiser can be very helpful in remembering to take medication regularly.

29-12 How can adherence be improved on a community or population level?

The following have been used to improve adherence:

The responsibility for adherence can be shared between patients, supporters and health services.

Case study 1

Dr Prudence sees Mrs Molefe, who has comes to casualty feeling unwell and dizzy. Mrs Molefe is overweight and has diabetes and high blood pressure. Her blood pressure and glucose are badly out of control and very high. Prudence notices that it is the fourth time Mrs Molefe has been to casualty with severely uncontrolled disease in 6 months. She decides to admit her to sort her out properly. Mrs Molefe’s daughter has brought in a large carrier bag with Mrs Molefe’s home medications. Prudence writes up these medications on the ward prescription chart. Two days later Mrs Molefe is having hypoglycaemic attacks and needing sugar drinks to keep her glucose up.

1. Why is Mrs Molefe’s blood sugar so low in the ward when it was so high at home?

It is likely that she was not taking her medications properly, or not taking them at all, at home. Her blood sugar probably remained high when she attended the outpatient clinic and as a result, she was prescribed ever higher doses and more medications. When she actually took these prescribed medicines in hospital, they were far too much for her. This situation is not uncommon.

2. Dr Prudence realises that there is likely to be an adherence problem at home. What general advice would you give her in starting the conversation with Mrs Molefe?

It is important not to be judgemental. Dr Prudence needs to get Mrs Molefe comfortable talking about her beliefs and understanding of her medication. One good opening statement might be: “Oh, I see your sugar is quite difficult to control. How has it been going with your pills at home?” A bad opening statement might be: “I see you have not been taking your pills correctly. Do you know you are going to kill yourself?”

3. What specific things does Dr Prudence need to explore during the conversation?

She should explore Mrs Molefe’s understanding of diabetes and the treatment she needs. She must ask about actual side effects and fears of possible side effects. She also needs to explore access barriers (although the large bag of medications suggests that Mrs Molefe is able to collect her drugs). Mrs Molefe also needs the opportunity to express herself and to ask questions.

4. Dr Prudence works together with Mrs Molefe to produce a simpler treatment plan with a twice daily dose of a single drug for diabetes and a once daily dose of a hypertension drug. The contents of the large carrier bag are returned to pharmacy. Mrs Molefe is ready for discharge and will see Dr Prudence in 2 weeks for review. Who else might be able to help with management of Mrs Molefe’s diabetes?

The dietician should also see her before she goes home as she may not be adherent to her diabetic diet. Adherence support may come from Mrs Molefe’s daughter and also from the community care worker. Dr Prudence would also like to put her on an exercise programme with the physiotherapist, but decides to do one thing at a time.

Unit 30: Major incident planning


When you have completed this unit you should be able to:

30-1 What is a “major incident”?

Communities face a broad range of risks from natural events like earthquakes and flooding, to man-made events like shack fires and major motor vehicle crashes, to infectious disease epidemics. These events are different from just a busy day, because:

If the event is manageable but uncomfortable (and sometimes chaotic) it is referred to as a “major incident”.

A major incident is a manageable situation where extra resources need to be called in and decisions made about who is most likely to benefit from treatment.

30-2 What is a “disaster”?

The term “disaster” is used when the influx of patients overwhelms the facility’s ability to deal with them. A bus crash with 30 victims might be a “major incident” for a well-staffed regional hospital, but it would probably be a “disaster” if the nearest hospital was a small district hospital with a single doctor on duty. The “big news” disasters like aeroplane crashes are fortunately few and far between, but South African hospitals regularly face smaller scale crises and major incidents and must be prepared for them. Disasters are uncommon, but major incidents are frequent in South Africa.

In a disaster the facility is no longer able to cope with the demands.

30-3 What is the disaster or major incident life cycle?

Good major incident planning involves several stages that go beyond just a response plan. This is often called the “disaster life cycle”. It is a very useful way of handling both disasters and major incidents. With good planning it may be possible to convert a potential disaster into a major incident, which is manageable. Both may also be avoided by risk identification and reduction (see Figure 30-1).

Figure 30-1: The Disaster Life Cycle.

Figure 30-1: The Disaster Life Cycle.

30-4 Who is responsible for risk identification and reduction?

Risk identification and reduction is a municipal responsibility. Examples of disaster risk reduction at municipal level include the following:

Risk identification is also important for facilities so that they can prepare for them. In South Africa, it is most often major road accidents that will overwhelm local capacity. However, managers should be aware of locally important risks and changing or new threats, for example leaks or accidents from local industries and infectious disease epidemics, and have specific measures in place for them beforehand.

Risk identification and reduction by municipalities can prevent major incidents and disasters.

30-5 How should a facility prepare for major incidents?

There are 2 important goals for major incident planning in a facility:

30-6 What is meant by the “all hazards approach”?

Sometimes a risk is also called a hazard. The “all hazards approach” is the most common approach to writing a major incident plan. “All hazards” does not mean that a hospital should be prepared for every single possible major incident. Rather it identifies the core needs for the response to a wide variety of hazards, such as the use of space and the call out of staff.

If a risk assessment has identified particular measures that need to be taken for individual hazards, such as a chemical spill from local industry, these can be added as an appendix to the major incident plan.

An “all hazards approach” is the best way of writing a major incident plan to prepare hospitals for most major incidents.

30-7 What should a major incident plan contain?

The plan must include:

All hospitals should have a carefully agreed upon major incident plan.

30-8 Who needs to be familiar with the major incident plan?

Everybody who will have a role in the management of major incidents, from security to transport to clinical staff, needs to know what their role is in the event of a major incident. These roles need to be communicated regularly and practiced where possible. A good way of practicing without disrupting normal hospital services is to have a “table top” exercise. In this, the various providers get together and are given a scenario. They then describe what they would do and how they communicate with each other. A written copy of the plan should be easily accessible for reference.

30-9 What is triage?

Triage means sorting patients according to the urgency of their needs and the likelihood that they will benefit from the use of resources. It means trying to do the most for the most. Many South African emergency centres use the South African Triage Score (SATS) on a daily basis to make sure that the sickest patients are seen first. Triage in major incidents is different.

Triage is sorting patients so that those most likely to benefit from early care are seen first.

30-10 How is triage in a major incident different?

Triage in a major incident is different from daily emergency centre triage because:

A triage in a major incident may be harsher (more strict) than that used in the South African Triage Score.

30-11 How do “sieve” and “sort” compare?

Major incident triage should be done either by somebody very junior or somebody very senior. The reason for this is that it is very difficult for clinicians to stop themselves from getting involved in the care of individuals when they see a need. However, if they were to do this, the triage process would stop. The person doing the triage should either not have the skills to get involved in an advanced resuscitation, or should have the confidence to delegate it:

30-12 What is a response framework?

A response framework is an organogram (an organisation chart) that shows who is responsible for what and who reports to whom. If the response framework is standardised across emergency responders working in the same region, each facility or service involved in an emergency response has:

The response framework most widely used in South Africa is the Major Incident Medical Management and Support (MIMMS) framework. The hospital framework is H-MIMMS. This was rolled out in all provinces in South Africa in preparation for the 2010 Football World Cup. It has been variably implemented in different provinces since then.

The Hospital Major Incident Medical Management and Support framework is shown in Figure 30-2, showing who may communicate with whom. The doctor and nurse in charge in the Emergency Centre are called the Emergency Centre Medical Commander and Nursing Commander respectively. The Hospital Operations Centre (HOC) handles all duties other than seeing patients. The Hospital Operations Centre is physically separated from clinical areas and is the only channel for communication with the “outside world”. All information from the clinical area is channelled to the Hospital Operations Centre via the medical commander to prevent duplicated requests.

Figure 30-2: The hospital major incident medical management and support (H-MIMMS) framework.

Figure 30-2: The hospital major incident medical management and support (H-MIMMS) framework.

You can find more about the H-MIMMS response framework and action cards for hospital responders here:

30-13 What needs to be done in the recovery phase after a major incident?

If you are working in a system with well-functioning provincial and municipal emergency structures, you will probably have a lot of support during a major incident, until the last patient has been seen and managed. However, a major incident can have an effect on the function of your facility for some time after because the surge in patients and the use of resources mean there is very little left for your normal caseload. Don’t forget, your surge plan may have involved boarding some of your patients in other facilities but they still remain your responsibility. You will need to be aware of this and:

30-14 Why is debriefing important?

Debriefing is an important part of recovery:

Debriefing is important after a major incident to learn lessons about how you can improve your response.

Case study 1

Dr Retief is a newly appointed senior medical officer at St Jude’s hospital. One Saturday evening, a few weeks after his arrival, 2 taxis have a head on collision 10 km away. Four people die at the scene and 22 patients arrive at the hospital. Three are seriously injured with head and face injuries, five have open fractures and the rest have closed fractures and minor injuries. It is chaos. He is on duty with one professional nurse (sister) and an enrolled nurse (staff nurse). The Emergency Medical Service providers put patients on any available bed and he struggles to keep track of what is wrong with whom. Family members keep appearing at his side to ask why he has not seen their relative yet. There are some children screaming and he decides to see them first.

Sr Dlamini lives close by. Although she is off duty, she hears the uproar and investigates. She sends her husband off in his car to collect other professional nurses who live close by and sends a housekeeper to call in student nurses from the nearby hostel. Between them, Dr Retief, Sr Dlamini and the volunteer staff sort most of the patients out, although 2 of the serious injuries die before they are seen and the third dies during ambulance transfer to a referral hospital.

Dr Retief realises the hospital has no major incident plan and decides to write one. He identifies the important stakeholders in the staff and forms a small team.

1. What should be the team’s first step?

The first step is to assess the local risks and likely causes of major incidents. Motor vehicle crashes are likely to be the most common cause of a major incident, but the team must also identify risks such as spillages from local industry.

2. Dr Retief and his team identify several potential causes of a major incident in the district. He wants to write an “All Hazards” plan. Does this mean a very long document that covers all possible hazards in detail?

No. An all hazards plan contains the core needs that will be required in almost every major incident, such as a call out plan and a security plan.

3. One of the student nurses has not attended for duty for 3 days following the major incident. Her friends say she is in bed. Sr Dlamini goes to investigate. The nurse bursts into tears and says that she was looking after one of the critically ill patients, but they died before Dr Retief could see them and she worries that she should have done more. What important stage of major incident response has been forgotten?

Debriefing and counselling for staff is necessary.

4. The team produces a major incident plan that covers all the components needed. What should they do next?

The next step is to communicate the plan widely, and to test it with a tabletop exercise or a mock major incident.

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