Creating an “army of first preventers”
While we continue to manage through the COVID-19 pandemic, it is important to reflect on the lessons learned. The response to COVID-19 has shown us that organisations with a commitment to-and competence in- quality, patient safety and accreditation are better prepared to effectively manage a crisis. Published reports from around the globe continue to demonstrate the value of quality, safety and accreditation, providing a framework to guide healthcare facilities as they recover and rebuild. The pandemic is turning out to be a catalyst for innovation, to move into the next generation of quality and safety.
During the height of the pandemic, some of the hospitals in the U.S. were using an incident command structure, which is essentially an emergency structure that has several important themes built into it. This includes a daily or a huddle multiple times a day, where all the leaders get on a call together to talk about how things are going.
“One of the components of the structure is issuing regular guidelines for care, as they are important in day-to-day quality and safety to improve performance. Evaluation, feedback, closure of the feedback loop, all of these things are very relevant to the quality and safety agenda,” said Prof. David Nash, founding dean emeritus of the Jefferson College of Population Health (JCPH) of Thomas Jefferson University and the Dr Raymond C. and Doris N. Grandon Professor of Health Policy, Philadelphia, U.S. Dr Nash has been named as one of the Most Powerful Persons in Modern Healthcare and has also received wide acclaim for his COVID-19 thought leadership.
He highlighted that in the U.S. there has been some evidence of diffusion of an incident command culture, post-COVID-19. This means that things that worked can be carried over in non-emergency situations as well to improve patient outcomes.
Another trend that COVID-19 has brought about is the growth in integrated delivery systems and hospital mergers across the globe. “Many hospitals suffered terrible economic losses and layoffs,” said Dr Nash. “It’s ironic that in the middle of a public health emergency, hospitals were laying off people. As a result of the financial strain, we’re going to see weaker hospitals join larger systems. But this does not guarantee that quality and safety will improve.”
Furthermore, he stressed that there needs to be a recognition of the social determinants of health, factors that have affected society the most in the COVID-19 era and have had a huge impact on health. This is especially true for poor countries that might not have the resources to tackle the pandemic.
“The impact of COVID-19 can’t just be determined by tests and laboratory results. It has to do more with poverty, lack of education, crime, drug abuse, depression, and loneliness, among other factors. Global recognition of the social determinants of health is paramount,” he added.
Dr Nash also touched upon the struggle between public health and the healthcare system: “When public health is working, we don’t pay any attention to it. This refers to access to clean water, the air is clean, people have vaccines for all the previous infectious diseases, so public health operates quietly in the background. But it’s severely underfunded. For example, the national U.S. healthcare spending per person is roughly US$10,000 per person, including children annually, while total public health spending per person in the U.S., in 2019, was US$275.
"That’s why it is no surprise that the public health system got crushed by COVID-19. It failed because it was destined to as it was so severely underfunded and under-appreciated. We are now hoping for a convergence of the public health and healthcare system in the post-COVID world.”
Dr Nash has been an advocate of creating an “army of first preventers”, people who work in the community and are focused on prevention. “It means we should focus on preventing illness rather than always taking care of people after they’re sick. The focus should always be on prevention. So, instead of first responders, we should be speaking to our first preventers,” he explained.
Dr Nash also spoke about contact tracing and how most people hadn’t heard of it until the pandemic.
“Contact tracing is a proven technology and a well-established basic tool for improving public health. Unfortunately, the U.S. was totally unprepared to do contact tracing,” he stressed. “People had not been trained, and most people were scared of it, as it seemed too intrusive.”
He gave the example of China, where one of the reasons for their success was the contact tracing carried out through smartphones. An average Chinese citizen would be tracked and photographed every day, which citizens in the U.S. would never tolerate. “We would view it as a totalitarian state. On the other hand, it’s a very successful tool for isolation and quarantine. Do you want your freedom, or do you want to stop COVID-19? It’s a culture clash."