Hospital standards, doctors’ ethics and profits

Have you often wondered the meaning of posters like ‘we take good care of all our patients’ accompanied with pictures of smiling faces and friendly nurses that are plastered on the walls of some private hospitals?

Is this what people experience when they walk into a hospital, inquire at the counter or ask the nurse on duty as to when a consultant they have channelled will be available? Just like some consultants, they will mumble a reply without looking up, be indifferent or respond “Api danna (we don’t know when the consultant is coming).” One of our readers wittily commented, “They will give you a ‘ GAL’ stare.”

Ever since private channelled practice entered the domain of the local health service some decades back, the service has provided a mix-bag to the public.

While the private hospital sector has grown by leaps and bounds, so has the cost of care, resulting in longer waiting times as doctors in demand resort to hospital-hopping (going from one hospital to another) resulting in patients having to wait for a long time.

In one peculiar case, patients who channeled a doctor and were told to come at a specific time were in for a shock when they arrived in time for their appointment.

The doctor had come and gone as the first few patients didn’t turn up and instead of waiting for the others who were given prescribed times for their appointment, had left. Hospital staff looked on helplessly as patients let off their fury on the hospital. Now if patients can wait for hours for a ‘paid up’ service, why can’t doctors do the same?

The debate of the doctor versus the patient in private channeled practice will go on for years with the patient being at the mercy of the doctor and the hospital, with their ‘ take- it- or- leave- it’ attitude.

A poll by the Business Times with its polls’ partner, Research Consultancy Bureau (RCB) this week on ‘channelled practice’ arising out of an interesting debate on this issue at the Sunday Times Business Club two weeks back, proved beyond doubt that the public is fed up with waiting time for doctors, the limited time and attention given by doctors and the attitude of the hospitals.

Results of the poll conducted by email and through a street survey are reported elsewhere in this newspaper but the message is clear: Channelled private practice has become a necessary evil and patients (big or small, rich or poor) are at mercy of doctors. Ironically patients are now spending almost the same amount of time at a private hospital they would otherwise spend at a government hospital to be examined by a doctor, one of the reasons why private hospitals proliferated. In fact a consultant would spend more time in a government hospital because he or she sees a limited number of patients while less time (at huge cost to patient) is spent with patients outside.here are two comments that were received in this week’s survey:

*Patients should not be taken for granted. Doctors still behave as if society is at their mercy. The waiting time is unbearable for patients who need urgent attention.

* Sometimes consultants don’t even look at the patient and write prescriptions in a jiffy while quickly calling in the next patient. Hospitals should insist that the consultants should spend at least 15 minutes for each patient thereby informing the consultant that he could see a specified number of patients within the time the consultant is in the hospital.

The other side of the coin is that due to the demand to see the best, some doctors are compelled to see as many patients as possible as everyone comes to them because of their skill, expertise and judgement.

Do patients have rights just like in any consumer society? Are patients able to complain to a hospital that they should not be kept waiting? A veteran, now retired, doctor says that one of the problems is that in Sri Lanka there isn’t a culture where patients complain.

Private hospitals like the rest of the private sector get certification from all kinds of international and local bodies (Sri Lanka Standards). Some of them are International Organization for Standardization’s (ISO) 140012004 for environmental management or ISO: 15189 standard for quality and competence in medical laboratories.

Both are important like any other certification. However has any hospital got certified for ‘good and friendly’ service where patients are greeted by friendly staff at the counter, in the corridors and by the nurse who helps the consultant in question? The last-named, often a junior nurse or trainee is often indifferent, flippant, rude or curt while most patients are compelled to be ‘nice to her’. What a state of affairs!

Discussing private practice and the attitude of hospitals to patients is like opening a can of worms – so much to talk about but so little that can be done.

The private hospital industry needs a wake-up call and tougher government regulations to be more patient- centric and caring. Otherwise there would be a time where people revert back to state hospitals if there are more paying wards like the Merchants Ward at the Colombo National Hospital providing a far better and more caring service. What is Ergonomics? To explain this multi-disciplinary science, it is best to cite some simple examples under each discipline. To carry out any type of work by a human being in an optimum, safe, profitable and efficient way there are some obvious needs to be satisfied. For example, the environment, the work tools and the job itself must all fit the characteristics of the worker.

Heat is a form of energy. The main sources of heat are environmental heat and body heat. The major source of environmental heat is solar heat. Heat can cause thermal discomfort or thermal stress. There is a misconception among people that the thermal environment depends only on temperature. The factors such as air humidity, air movement, radiant temperature, type of clothing worn and activity performed can all influence the feeling of thermal environment on man. Examples: In a crowded passenger van with the shutters up during rain the passengers started to sweat and it became quite warm. Why? Not due to high temperature but due to factors such as radiant heat given out by the humans (crowded passengers) and the lack of air movement and ventilation.

When building a large concrete walled rectangular factory it is best to face the short walls to the East and West and the long walls facing the North and South. Why? If the long walls face the East and the West, the radiant heat from the sun is absorbed by the large area of the walls which will adversely affect the indoor climate. The inmates will be affected by the radiant heat. This is a common mistake happening in Sri Lanka because of the ignorance of some architects about building orientation and the thermal climate.i walked into an upcountry star-class hotel and experienced thermal discomfort in the restaurant. The management was clueless why the occupants of the restaurant felt uncomfortable as on one side along the wall there was a row of open large windows. Unfortunately, however, on the opposite wall there was no opening for the air to escape. In other words, there was no cross ventilation. This is another mistake made in many factories, workplaces and houses in Sri Lanka. The lack of adequate cross ventilation which blocks the air coming into the room causes thermal discomfort to inmates. Lighting Light is a form of energy. The two common sources of lighting are natural lighting from the sun and artificial lighting from electrical energy. Lighting is not only illumination (light falling onto a surface). Factors such as luminance (amount of light reflected or emitted from a surface), reflectances (rate of luminance and illuminance at a surface based on material characteristics), glare (imbalance of surface luminances and categorized as disability glare, discomfort glare and reflected glare), contrast (based on luminances of two surfaces, bright and dark colours) and flicker (malfunction of lamps which can cause visual fatigue), are other characteristics of lighting. The above factors influence the vision and lighting in a workplace. Examples: A night driver facing the head- Noise Noise can be described as unpleasant sound. Sound has a pitch or frequency and loudness or amplitude. Loudness or sound pressure level is measured by a db or log scale which means that if two machines of sound pressure level 80 db each are situated close to each other, the total sound pressure level is not 160 db but 86 db. The db linear scale is the actual sound intensity and the DB(A) scale approximates the sensitivity of the human ear. Exposure to noise levels of 85 DB(A) or over for long periods can cause hearing deficiencies. The frequency of the noise expressed in hertz or cycles per second is important to know when measuring deafness in man. The danger of hearing deafness caused by industrial noise is that it is permanent or incurable. Examples: A music teacher who was exposed to high noises of the school band for several years developed signs of deafness at 4 kilohertz. The deafness later spread to other low and high frequencies which made the teacher significantly deaf for life.

In a spinning mill where the noise level was around 90 DB(A) hearing tests were carried out on a routine basis. It was detected that two workers out of the team of 10 workers after an exposure to the noise for 5 years developed deafness to noises of 4 kilohertz frequency. This is the first stage of deafness which can soon spread to other frequencies

Human Factors (Anatomical and Physiological) Body Sizes The machines, work tools and work stations used by man have to fit the body sizes of the user. Body sizes differ between inter individual (different populations or nations) and intra individual (within the same population or nation). In other words an article or machine made to fit people in one population or nation may not fit another population or nation. There are also differences in body proportions between different populations. Examples: During a routine factory inspection I walked into a factory with about 100 knitting machines handled by female labour. I observed that the girls had to raise their upper limbs to operate the machines. In other words the operating levels were higher than the elbow level (which is the comfortable level) of the workers. Naturally the female workers complained of shoulder and upper limb pain. When questioned from the management I was told that the machines were imported and installed on the factory floor without any changes. On further investigation it came to light that the people in the producing country of the machines were taller than Sri Lankans. If, the management knew that operating levels of machines were taller than the elbow level of the female operators, the machines could have been installed sunk in the floor. Unfortunately the management was not aware about the average elbow level of the Sri Lankan female labour.

In Sri Lanka, domestic pantry cupboards, dinner tables, kitchen counters and in general most tables and chairs in offices, work and public places are taller than the average Sri Lankan body sizes. It is presumed that furniture in Sri Lanka has been designed to fit Europeans as the British ruled this country prior to 1948. The ignorance of the furniture manufacturers to make furniture to fit short people (Sri Lankans) is causing much discomfort among the users of tables and chairs in homes, schools, hospitals, offices, factories and public places.

Inappropriately designed chairs used in Sri Lankan factories, offices, homes and public places is causing considerable discomfort and unproductive to the users. There are many ergonomic design features to be satisfied in chairs. The height of the seat surface should be the inner leg height, the back rest should support the low back (not so much the upper back), the seat surface dimensions should accommodate the buttock width and upper leg length of the user, the seat surface should be slightly inclined inwards so that the sitter will not slip out, the back rest should be slightly inclined out to relax the back, etc.

A marketing executive had many customers visiting him in his office. Some visitors were important while others were unproductive but spent much time talking and wasted the precious time of the executive. He kept two similar looking chairs in front of his table. One chair was correctly designed with the chair surface slightly inclined inwards and back support slightly inclined outwards. The productive and important customers were casually directed to this good chair. The other chair was incorrectly designed with the sitting surface with a slight slope downwards and the back rest slightly inclined inwards which made the sitter very uncomfortable after sitting for a while. The unproductive customers were casually directed to the second chair. The design features of the two chairs were not clearly evident to the visitors. However the marketing executive was successful in retaining the good customers and discouraging the bad customers. Body Mechanics The main aim of body mechanics is to study the way the body produces force and generate movements. The common health problems which must be avoided are muscle strain, joint problems, back problems and fatigue. It is important to avoid body postural stress when there is a mechanical loading. The spine and the pelvic support the weight of the body parts above them. The spine consists of four major regions: viz. Cervical spine (above the neck), Thoracic spine (rib box area), Lumbar spine (between rib box and hip bone) and Sacrum (below hip bone). The spinal column is double S shaped. The cervical and lumbar spines are protruded to the front and known as lordosis. The loss of lordosis in the cervical and lumbar regions can occur when bending forwards the neck and the trunk respectively and while adopting a sitting posture. This causes pressure in the cervical and lumbar spines resulting in temporary pain at the start and later permanent pain long term. Sitting long periods every day and working with the body bent posture when lifting a weight or manual handling or standing long periods can all cause fatigue and back problems. Examples: During the early 1970s wearing miniskirts was popular among teenage girls in London. A survey was carried out on back pain or back problems among the teenage girls. The results indicated that back pain was not a problem among teenage girls. In the late 1970s the fashion changed and the style was to wear slacks among teenage girls. The back pain survey was repeated and it was found that a significant number of girls complained of backaches. When picking something from the floor or lifting a weight the girls adopted the easy bent posture when wearing slacks. But for rea-

In spite of the advances in technology and the automated industry there still remains much physical activity and manual tasks that are performed in workplaces. Physiology is the study of how the body and its parts function. Therefore knowledge of work physiology helps in the optimum design of manual work and to control negative physiological implications experienced at work.

Muscle: Human movement is brought about by the muscular system which is distributed throughout the body. Longer the muscle the more work can it perform. The contractual forces of muscle fibres together give strength to the whole muscle. Muscle strength depends on many factors such as (a) Posture (b) Sex, - at same age female’s muscle strength is lower than male (c) Age - greatest at late 20s and early 30s (d) Body Size - proportional to the transverse sectional area of muscle. Any muscular activity requires energy.

Energy Production: Energy is required for various kinds of biological work. The food taken by man contains energy in the form of chemical energy. The food mixes with oxygen breathed in through the lungs and the chemical energy is converted to work energy, heat and waste products. The above process is known as metabolism. Producing work energy depends on the amount of oxygen uptake and therefore the heart rate is directly proportional to the work energy. Energy consumption is depended on the food as well as oxygen uptake and therefore it has its capacities and limitations. The capacities can be developed through various kinds of physical exercises and to control limitations rest pauses are needed to recover. An individual’s highest capacity to work is his maximum oxygen uptake. Examples: A man was digging the garden and excavating a pit. He was working at a higher capacity almost close to his maximum oxygen uptake. After about 20 minutes he felt extremely tired and exhausted and he rested for nearly half an hour before he could start to work again. Later he did some lighter work e.g. weeding. He could work for nearly one hour without feeling very tired. Again he rested but after just five minutes he recovered sufficiently enough to start work again.

The WORK-REST regime has to be so designed according to the severity of the work and the capacity to do physical work of the individual. Similar physiological principles apply when an individual is engaged in muscular work. Examples: An electrically operated elevator was used to raise and lower goods from the upper floor of the raw material store. The controller of the elevator had three switches one for raising, one for lowering and the other one for stopping the elevator. The three switches were placed horizontally on the control box (showing the up down positions by means of small arrows). Workers sometimes got confused in selecting the correct button. New workers often use the incorrect button.

Solution: The up and down switches were proposed to orient vertically. The result was that the workers easily and naturally selected the correct button. Design Ergonomics Ergonomic considerations are supreme in the design process. To design to fit the user, which is the concept of ergonomics, the design should be user centered. The design has to be based on physical and mental characteristics of the human user, which in other words the final design, and which should have the best possible match with the human use. The ergonomic demands in any design have the following purposes. - Efficient performance of the job - Not suffer work-related injuries - Increase speed of performance - Achieve higher customer satisfaction

All workstations, environments, machines, products, hand tools, furniture, etc used by man have to be ergonomically designed.

Examples: Workstation design Several years ago in the US a passenger plane crashed on a mountain and all passengers died. Subsequent investigation along with the information taken from the black box revealed that the pilot judged that the altitude at which the plane was flying was 10,000 feet whereas the actual altitude was 1000 feet. The altimeter in the cockpit of the plane was installed at the knee level of the pilot. The inappropriate viewing angle and the distance of the altimeter from the pilot’s eye obviously caused the error made in the pilot’s judgement of the altitude.

Note: Important dials such as the altimeter of an aero plane have to be installed at a point which is easy for the pilot to read e.g. at the eye level, and at the shortest clear viewing distance from the eye. After this air accident the design of the cockpit has been changed to avoid such obvious errors in design. cause and effect “after” an accident or a near miss and to train individuals on safety procedures based on “after event” information. In spite of the legal enforcements on prevention of occupational accidents and the methods used in industry based on accident research, there still occur industrial catastrophes where thousands have died in one accident. Therefore an integrated or ergonomic approach has been adopted based on human limitations when designing equipment and procedures with the objective of reducing human error. Many accidents occur due to errors in design or training. Examples: Good housekeeping Blame and punishment have not had a significant effect on reduction of accidents. Good housekeeping which provides a positive feedback is a new strategy to control accidents. Good housekeeping is order and tidiness and a cheap and a sure method to reduce accidents.

A shipyard in Finland once had a long history of industrial accidents. A long term study using the method of good housekeeping reduced accidents by nearly 70%. A very optimistic estimate was 25%.