IN pursuing the crucial exercise of successfully planning health care delivery on a national basis, decisions must be made by any progressive society about what constitutes an adequate level of health care for the population.

Additional issues which are to be deliberated upon in the decision-making process are what services should be made available to each citizen and what are the uniformed standards that the society should seek to require from those delivering health care in the public and private sectors.

Specific measures should be geared towards creating a floor or minimum level of healthcare/health-care delivery. As far as possible, these measures should apply to the entire population, without regard to socioeconomic status or whether the individual is receiving care in the public sector or private sector. In addition to creating standards, there are additional issues of monitoring and compliance which are to be resolved towards ensuring that standards of quality service provision are universally and consistently followed. Another important point to consider is what are the pathways towards a society successfully seeking to compel accountability and compliance in all sectors of the health-care ecosystem (public, private, and payers).

The issue of standards for health-care delivery may be thought of at various levels. Each country and region may need to consider its own unique experiences and health-care needs. After careful reflection and consultation with stakeholders, standards may be developed considering current medical knowledge but crucially, those standards should be tailored to ensure adaptability, sustainability, and uniformed application. Some health-care standards have universal application, for instance childhood immunisation which is an area in which Jamaica has done well. There are clear recommendations for a schedule of childhood immunisation, that is, which shots and at what age. Whether seen in the public sector or private sector, a Jamaican child will have an immunisation card that lists the immunisation dates and administration site. When the child reaches the age for enrolment in an educational institution, the immunisation record is reviewed before entering the formal school system, irrespective of socioeconomic background.

We may quickly assess whether standards are maintained at a country level, and perform corrective action based on data. For instance, we may embark upon the process of auditing and improve a government clinic where children are not being immunised as per schedule. Whether in private or public practice, a paediatrician who does not have a consistent record of well-patient visits for an immunisation schedule can be investigated or sanctioned by the medical council if complaints are made. Similar standards can be applied to maternal care. A normal pregnancy has a routine schedule of care. There are specific procedures that should be performed during the initial antenatal visit. The spacing of antenatal visits and the manner of assessing a routine pregnancy are conditions for which standards exist. These standards are expected to be uniformly adhered to, whether in the private or public sector. When a female presents for delivery, the physician then has the opportunity to review the antenatal record and clearly see whether an adequate standard of care has been met.

Why is there a need for the establishment and enforcement of uniformed standards?

In many areas of medicine, experience and scientific investigation have found that doing things in specific, scientifically validated, and proven ways will improve patient outcomes. Routine childhood immunisation has dramatically improved childhood mortality and morbidity. Death from heart attacks is reduced by initiating prompt interventions to open blocked arteries. The time between arriving at a facility with a heart attack and placing a balloon in the artery to open a blocked vessel is a measurable indication of the quality of cardiac care an institution delivers. This concept is called “door-to-balloon time” (D2B). The D2B in heart care is a uniform quality measure applied to all facilities providing heart care in the USA, Canada, and Europe — whether the patient is seen in a private or public facility. Emerging markets are using the same approach to ensure uniform standards are maintained across the entire health-care delivery value chain, without distinction between the location of care. Mistakes in the operating room, including wrong-site surgery, can be minimised by simple measures such as the surgeon marking the correct limb before surgery, with the patient watching, and including the operating room staff in a pre-operative briefing before surgery. By creating and following standards, we improve health-care delivery, patient outcomes and, over time, reduce health-care costs. It is essential to recognise that while many standards exist, many parts of healthcare are not readily amenable to standardisation. At times, patient factors may lead to the need for deviation from otherwise applicable standards. For example, an immunosuppressed child may not be able to take certain routine vaccinations and would require a waiver because of the overriding need to ensure safety.

In rethinking health-care delivery, it’s important that stakeholders ponder upon universal standards of care and ensure that all Jamaican patients benefit from the same quality measures which guarantee that uniform and appropriate standards are promulgated, maintained, and uniformly enforced. The development of standards requires consultation among many different stakeholders. This standardisation must be informed by best practice medical evidence and uniformly applied to various aspects of health-care delivery. Uniform application of standards ensures that health equity is maintained for the population and avoids a dichotomy that enshrines a higher level of care for the wealthy, who routinely seek care in the private sector, as opposed to a lower standard or level of care for the poor and most vulnerable. For instance, we have uniform standards of childhood immunisation and maternal care as described above. We may have standards related to hospital beds per unit population, standards for training requirements of health-care personnel, as well as standards related to hospital or clinic infrastructure. These are standards that have been shown to improve population health but must be uniformly applied in both the public and private health-care space.

Can the fox guard the henhouse?

Having convinced ourselves of the need for uniformed standards in health-care delivery, we must then ask ourselves what the framework for developing and delivering these standards will be. In most health-care delivery systems, oversight falls to an independent statutory entity which usually assesses a facility’s adherence to the mandates of various regulatory authorities or agencies. We may have agencies that have dual remits in that their primary role is health-care delivery, but implied within this is ensuring that health-care delivery is at an acceptable level. Our regional health-care authorities may be thought to function in this way except that, unlike independent entities, they are also involved in the running of public hospitals, which creates a potential conflict in their role as monitors and enforcers of standards in their own facilities. Other agencies, for example the nursing council and medical council, represent more autonomous entities without a direct role in health-care delivery but have a large part of their mandate beign to ensure that nurses and physicians practise at a high level. In a future article we will discuss some of the essential responsibilities of authorities/agencies in standards development and maintenance.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to info@caribbeanheart.com or call 876-906-2107