Attaining global best practices was my focus as CMD —Prof Alonge

How will you describe your experience as CMD of UCH and what were your achievements in the eight years you spent in office?

Truth must be told that the concept of a teaching hospital is to offer training for health care, manpower development and engage in research activities, which we often call translational research that we impact on service delivery for patients in the hospital. My mandate as the Chief Medical Director over the past eight years has revolved around those three core tripod setting up the teaching hospital. I will begin from the last one which is clinical service delivery. Service delivery is premised on an understanding of what needs to be done to ensure that we limit the incidents of preventable death because some patients, by the virtue of the disease, irrespective of what you do, may still succumb.

 

Preventing avoidable deaths

The attention, therefore, should be to ensure that those who should not succumb should be given the rightful place to survive and survival is dependent on how quick and appropriate your interventions would be. The area of primary attention, that is the, inlet to the hospital, where people come in, one of them is the emergency department. The attention was more or less tailored to those areas. In the emergency department, we had an unfortunate incident of a fire outbreak, which actually made it possible for this administration to completely overhaul and redesign the department to be in tandem with best global practices.

 

Corridor of life

We were able to create what we call the corridor of life and the emergency corridor parallel to each other. And between these two parallel corridors we have the cubicles. We were able to ensure that the clients in each cubicle have their names on the white board on a daily basis, their clinical condition and the current status of care. You walk into the emergency department, peradventure you don’t know which patient you’re coming to see as a specialist or as a super-specialist, you can walk to the board, read through and pick out the particular patient; though someone will be there to assist you and then, you can attend to their needs. We have also installed oxygen delivery points in each cubicle. So, for patients who need oxygen when they come in, they go into the trolley next to the oxygen gauge and those who do not need it are left on the other side of the cubicle. At a glance, sitting at the nurse’s desk, you can see the patients, their clinical conditions and what they are expected to do prior to admission or discharge and that makes it mandatory for you to do something so you don’t keep them longer and you can intervene as you should.

 

X-ray in emergency

We also brought on board the X-ray images which are from the digital X-ray machine. You don’t have to get the hard films; you can download the pictures right in the emergency department. It changed the complete outlook of the emergency department. We also noticed that we had more deaths in the emergency department at night, from a survey that was carried out by the total quality management department and it was discovered that the number of nurses on night shift as at then (that was three years ago) were smaller compared to the afternoon and morning shifts. We also looked at the experience of those nurses and as soon as we changed the order, we had a mortality that reduced from 30 per cent to about 7.5 per cent. That is what I call preventable deaths and it was because we needed more manpower at night which we now have, we have more experienced nurses at night; the issue of transferring patients that are very ill is now prompt than they used to be.

 

Staggered appointments

On the out-patient clinics, we have expanded the scope of care such that attention has been drawn to what is called the staggered appointment system. It has been functional for the past one year in ophthalmology. We have now moved over to MOP. If you come in the morning and your name has not been slated for that day, it means you were not given an appointment. The staggered appointment has both the electronic information where the patients are notified by SMS, the appointment date and time. So if your appointment is for 2.00 p.m, there is no point in coming at 6.00 a.m. hanging around doing nothing. That is now fully operational in ophthalmology and it will go round the whole clinic. It is courtesy of the tele-medicine department because that job was given to them to handle and they have done a very good job.

 

Multi-care departments

Even MOP has ECG machine in the event that the patient comes in and complains of chest pain. They don’t have to come to the third floor. The ECG is in the medical patients department and they also have it in the paediatric cardiology clinic. The ophthalmology department has the CT scan, which is called the OCT, which allows them to access the patient right in the clinic rather than going up and down for evaluations. That has improved care. For patients who have diabetes, we have noticed that many of them come down with complications of the eye because they have not had any evaluation of their eyes properly, particularly using what is called a fundus camera which we bought  for the ophthalmology department and ensured that the diabetic clinic liaise with them. That has saved a lot of eyes and a lot of vision but then it will give room for a lot of publications so we can tell predisposing factors to blindness or permanent eye damage in patients who have diabetes.

The cost of this test outside is 10,000 but it was reduced to N2,500 by the hospital; the essence is not to make money but provide excellent care but at the same time, have enough resources to maintain the machine over a period of time. For the ENT clinic, many of us did not know that a lot of children are deaf and we can detect deafness from birth. What people do is that they flog their children because they are not doing very well but in fact, it may be that the child is out of hearing. So, we bought a new machine for them that we use to check hearing in new born babies.

Many of these services were not available before and they had to go outside to get it done. Some would have to travel as far as Lagos to get all these things done. Again, apart from preventing death, we are also preventing disabilities all of these inlets that are called the point of entrance for the hospital. Having taken care of that, we have moved in inwards to look at those on the in-patient care, which we have changed in terms of structure. We found out that babies that were born out or born in, if you bring them together, there is a lot of transmission of diseases. So, we have created new wards for babies born outside.

If they have a problem, we have separated the emergency department from the South East ground where other babies are looked after if they are born out.

 

Separating born in and born out babies

We have now created another infectious disease holding ward for the paediatric age group because it is very difficult to manage them in the main ward when there is an outbreak of viral haemorrhagic fevers. To complement the efforts of the paediatric surgeons, we created a new ward for them so that they can operate on many more children because, before now, they had borrowed beds in the different wards in the hospital and sometimes, cases were cancelled because there were no bed spaces for children to have their surgeries; but that story again has changed because now we have a dedicated paediatric surgical ward that is exclusively for them. And that does not mean that if they have babies or children to be accessed in other wards, they can’t, they still do.

In terms of sanitation, we managed a lot of the toilet system, not completely, because it will require a lot of money to redo a lot of those metal pipes and change them to plastic in some of the wards. But in some wards we have managed to contain a lot of leakages on the wall, which have come out because of the wear and tear due to age. To reduce the infection further we provided on every floor, in each wing, two types of water; 0.5 per cent chlorinated water to wipe the floor and mop the toilet and 0.05 per cent of chlorinated water primarily to wash hands. This is to avoid using ordinary water to wash your hands; when the taps are not working we have buckets on stand that have this 0.05 percent of chlorinated water for washing hands. This is to make sure that we protect both the staff and the patients. We are still trying to find out the outcome of that in terms of the infection rate on the wards and that will be published very soon.

 

Emergency cupboards

The labour ward has a completely new outlook and that for us means that women who are pregnant can have safer deliveries and they will be happy for it. The effect on other wards are also quite glaring, every ward now has an emergency cupboard where emergency drugs are kept for immediate resuscitation. Patients are not asked to pay before treatment, they pay after and if they can’t pay, that becomes our corporate social responsibility. In the operating theatres, things have changed because before now, consumable items that were not readily available led to cancellation of cases. But now, they are in stock for three to six months, even if the supplier does not show up because  instead of using one supplier, we now have between five and six suppliers who bring all the consumables that are required for the patients. To complement the services in the operating theatres, each theatre suite has a solar-powered fridge where they stuck all their drugs so there is no need for people running around looking for the anaesthetic drugs, though the suites have not put them into maximum use, we have made provisions for the past two years for solar-powered fridges in each theatre suite for the storage of anaesthetic drugs.

And then there is what is called the mini blood bank in three levels; one in the labour ward, one in the theatre and one in the emergency department. Those are the core areas we need blood. So if you need emergency supply of blood, those blood banks are put on inverter at a temperature between three and four degrees so as to make sure that the blood is not denatured. All these are geared towards reducing preventable deaths, ensuring we can offer patients quick clinical services and at the same time have good outcome measures. But again, having done all of these, sometimes there are mishaps and when they do happen, you have to prepare for them. So, the first half of the intensive care unit was completely overhauled and we procured six brand new monitors and six ventilators. Unfortunately, I think two of the ventilators have been damaged by staff inadvertently and are still being serviced. But the essence is to make sure that we have all these in the event that the patient needs to have intensive care services. The first half has been completely overhauled. The second has been renovated to an extent that the 12-bed ICU works.

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In general, the attention of this administration has been focused on reducing preventable deaths, adding life to years rather than people just getting old, and that, for me, has been a rewarding exercise. That is not to say that there are no challenges along the way but I believe very strongly that the incoming chief executive, who has worked with me at a point in time, is also very conversant with some of these challenges that we both approached together and is equally as competent, if not better, than I am in terms of getting things done and I believe that he will build very strongly on what we have at the moment.

 

Cancer care

One other way by which the management has extended the service delivery system is cancer care, it has become a big issue and this didn’t just come because it was thought about; it was based on our statistics. The University College Hospital has the first total quality management department established in 2013 and it has 27 statisticians, the data generated have gone through 105 processes in the hospital because a hospital that does not have a process of things being done is likely to fail when the initiator is no longer on the scene.

 

You build people first

So my principle of administration is built on three Bs; you build people’s capacity in the sub specialities, send them on courses and training and when they are very good, they will put down a structure of management in their speciality and that is what I call SOP standard operating procedures. And when they put it in place it becomes an operational guideline. That is what builds an institution. You build the people first. The people you build will build the processes and at the end of the day you build an institution so publications become a lot easier and having UCH back on the map of the world is a lot easier but it must begin with building the people. It is a big task to build people because many people are so recalcitrant and not easily malleable in terms of picking up new training but we pray that the younger ones and the new administration will be able to identify those who are trainable and those who are prepared to give you what it takes to measure up to their colleagues in other parts of the world.

All of these are to make sure that we reduce the number of preventable deaths and add life to people’s years and let them live a very good life. We wanted to know how we were faring and we decided to take statistics of the causes of death in the hospital from 2012. This is to help us know where our intervention procedures will be. It turned out that there were four death-related diseases that were identified; cancer, cardiovascular diseases (predominantly stroke), infections (predominantly HIV/AIDS) and trauma (injuries). In 2015, the commonest was cancer but when we looked back to 2012, 2013, 2014, cancer  was very constant. What we didn’t notice was that other diseases were overwhelming and that was why cardiovascular came first as a killer in 2012 and 2013, infections took over in 2014 but cancer became more prominent and this is because we are addressing the issues that we discovered, that is, we are managing stroke a little bit better than we did before. The awareness of cardiovascular problems was heightened from 2012. Again, maybe people were taking their drugs a lot better than they were and we’re managing the stroke better. So cancer became more apparent and therefore we looked at the three commonest cancers. In men, the commonest is prostate cancer followed by, I think, liver. The commonest in women is breast cancer followed by cervical cancer. We have a Kobox60 machine but that is actually to treat cases that have become established or a little bit advanced whereas the early stages can be treated by brackytherapy machine. So we have bought a 25-channel brackytherapy machine which was delivered today. The Federal Government bought us another brachytherapy machine making two. What this means is that we can treat a lot of prostate cancers now. That is the new addition and it is borne out of the fact that we discovered that cancer took the prominent role as the commonest killer in 2015. The hospital has operated on needs assessment as opposed to just having a brain wave and then deciding to go and do something. Everything has been based on evidence. We have evidence-based procurement processes, evidence-based treatment protocol like SOPs, evidence-based investments and interventions. I believe that the new administration will take a cue from the enormous job that has been done and is being done at the total quality management department of the hospital, a department that was created to police me as the chief executive because primarily they report every month the activities in the hospital including areas where patients complain very badly.

 

What are the other things you expect from the incoming administration?

I expect that the new administration to be headed by Professor J. C Abiodun Otegbayo will lift the hospital even further than where it is. He is a very intellectually minded, very calm, disciplined and focused man. I believe he will build on what we have and do everything to ensure that decisions are made on needs and evidence. Number two, he will definitely promote other research activities. I believe he will entrench the principles of total quality care, meaning that he probably will expand the scope of total quality management beyond clinical care, patients complaint and service delivery. I also believe that he will increase the awareness of various disease patterns that we have mentioned. Over the years, we have been trying to get community liaison department to work on bringing the community much closer to us so that we can reach out to them a lot earlier. I’m sure that he will work very hard to bridge this particular gap. The bridge is halfway done and I’m sure he can bridge it completely and allow a lot of confidence building in the patients because his administration, from his submissions, will be patient centered, dialogue-oriented particularly with the end users as well as the providers of services, that is, the members of staff, increase the welfare packages. If you have very little to struggle over, the chances are that you will be able to have more freedom to improve staff welfare.

We want to establish a degree awarding program for the school of nursing. We have begun the process and I believe that he will conclude it so that we can have the option of a baccalaureate and also the option of a bachelor’s degree in nursing in the University College Hospital. I also believe that he will receive a lot of support from the Ministry of Health in implementing a lot of projects in the hospital. The uplifting of the hospital’s image can only go up and his intention is to get us to a quaternary level. I am very comfortable and confident that God helping him, he will do a very good job.

 

What are your plans as you bow out of office as the Chief Medical Director of this hospital on March 1?

Well, the phones have begun to decline in frequency of ringing now. I expect that by March 1, I am going to have my phone to myself and also have my family and life to myself. I have not made any move except to put myself forward for sabbatical, because I still enjoy research and I may be engaging in research activities outside the shores of this country, maybe within the shores of the country but I think I need a year off for research activities and reorganise myself. But if any opportunity comes up that I believe I can be part of, I will also make myself available. But for now, I think I have an open mind and I’m just looking up to God for what he will want me to do. But I have a lot of interest in carrying out some research work I’ve been working on for almost 18 years. I’m trying to look for a carrier mechanism which is going to be biodegradable and I have already found one material which my older son is working on. So I might be working with him if he allows me into his lab and that would be a lot of fun. Generally, that is what I intend to do.