Staff, Stuff, Space, and Systems

We often think about healthcare from the patient or demand standpoint: how can we best improve patient care? But, how often do we think about the supply side: what factors are involved in delivering that care and in providing hospitals with the means to be successful vectors of timely, high quality care?

Healthcare management can be largely contextualized in the framework “staff, stuff, space, and systems”; administration of high quality healthcare depends on the presence of all four: staff - individuals involved in healthcare services, stuff - healthcare resources, space - physical rooms where care may be delivered, and systems - processes and organization that enables administration of quality care.

During my time in Uganda, I spent a few days with a US-based physician team which was focused on teaching residents at Kabale Regional Hospital. At the hospital, I assisted with a needs assessment in terms of resource scarcity and staff burden. While working, I was able to draw comparisons between the American and Ugandan healthcare systems; while these two systems are embedded within each nation’s respective cultures, it is interesting to observe the stark differences in patient experience and resource allocation.

In my previous article “Similar Systems Different Results,” I discuss the different levels of health centers in Uganda; Kabale Regional is a Regional Referral Hospital that serves roughly 2 million people in Southwest Uganda. Patients from Level 2, 3, 4, General, and Referral Hospitals may be sent to Kabale Regional. The hospital is also one of the largest teaching hospitals in the nation.

In the US, teaching hospitals are amongst the most funded and scrutinized, in the hopes that new generations of healthcare providers are taught best practices and given ample resources to learn. In Uganda, this principle is still true yet educators must work within the confines of the decentralized national healthcare system and use the scarce resources they have. With minimal administrative oversight, students who are highly motivated must seek out opportunities to learn and become models of success for others. 

STAFF

Uganda has a significant physician shortage with roughly 1 doctor per 25,000 people and a recent report indicates that there are approximately 15 emergency physicians in the nation. (1) Kabale Regional operates semi-autonomously with little administrative oversight. In this system, department leaders and physicians act seemingly independently creating a feeling of inconsistency to patient care. Making the process of education even more complicated is the fact that students, upon joining Kabale Regional, possess different skill levels. During medical school, students are sent to different lower level (community oriented) hospitals where they complete their preliminary education. While many students may train at Kabale Regional, only a few physicians and students may be fully capable of delivering care to an acutely-ill patient.

STUFF

In “Similar Systems Different Results,” I discuss a trickle-down of resources from higher to lower Level Clinics in Uganda. However, the Ugandan healthcare system suffers from a general shortage of medical supplies. In Kabale Regional, a hospital serving roughly 2 million individuals, physicians have access to 1 partially-functional suction tool and no functional cautery equipment (to seal bleeding vessels). 

As a result of limited supplies, equipment must be constantly cleaned (sterilized) and reused. Yet the hospital lacks proper sterilization tools: at the time of my visit, the hospital possessed 2 autoclaves and one broke during the two weeks I was there. As a result, healthcare providers were forced to walk about 5 minutes outside the operating rooms to reach the central autoclave. Autoclaves clean used equipment under high temperature and pressure; the hospital lacked protective equipment to open and remove tools from the autoclave increasing the risk of burns. 

An image of the malfunctioning autoclave near the operating rooms can be seen below:

Healthcare functions similarly to a complex conveyor belt - resources must be provided and delivered at the right time, and the patient experience can be broken up into identifiable segments (hospital entry, pre-operative care, the operation performed, post-operative care, and hospital release). Throughout these processes, communication between providers at different stages and coordination by administrators are vitally important to maintain the quality and speed of care. When this complex system breaks, patients’ experiences and outcomes decline rapidly.

SPACE

Kabale Regional has 3 operating rooms to serve a patient population of approximately 2 million. The extreme resource scarcity makes providing care to 3, and even 2, patients concurrently especially challenging as equipment is frequently in use. 

In terms of pre-operative care, patients travel for hours and sometimes days to reach the hospital and often wait outside until their scheduled time of arrival. If their care is rescheduled, they may even wait days before receiving care. Images of the hospital exterior can be seen below. The first image depicts the training and lecture area and the second depicts the exterior of the operating room where cloth is dried before patients enter.

SYSTEMS

Upon arriving to the clinic, patients generally lie on a bed in the waiting room before the healthcare team is ready to provide care. However, patients are often forced to purchase many of the medications and supplies to receive care. While these supplies are often very expensive, bringing these tools to the hospital requires transportation, which many patients lack.

The “staff, stuff, space, and systems” approach highlights the needs of Kabale Regional Hospital; these needs are of the utmost priority as millions of patients depend on the clinic for acute and chronic medical care. Ultimately, with increased investment in resources and training and improved coordination between administrators, patient care and outcomes may be improved.