6 March 2019

Today we traveled 300 km to ruin someone's day.

During one of my fourth year medical rotations, the nurse practitioner who helped lead the service gave us a very clear explanation of her rules at the beginning of our rotation. One rule involved a calculation of how many flights up versus how many flights down qualified as too many to take the stairs. Another rule was that if a group of people in suits appeared on the hospital floor where we were rounding, we were responsible for pushing her into a patient room, closet, or elevator immediately so that she could escape the suits and their dreaded interrogation. We never had occasion to live up to this directive during my month on this particular specialty service. In residency I did experience Joint Commission visits, but more than the visits themselves, the weeks and weeks of preparation and drilling the hospital went through to make sure everything was up to par before the anticipated hospital accreditation visit.

Today, in a small district hospital in Tchad, we were the suits.

A delegation from our hospital--two nurses, a midwife, an administrator, and one doctor--arrived at the designated hospital after a long trip by Hilux pickup, courtesy of the district, and after a brief wait under the mango trees we were escorted into a room with several rows of benches and a desk at which an administrator sat sweating in his suit jacket. I think he's probably used to the heat and the suit, but this was unintentionally a surprise visit due to some lack of communication between districts, and he was clearly uncomfortable. We sat on wooden benches for several minutes as he and his assistant shifted in their seats, glanced at each other, and complained in various ways that this was a surprise. Eventually they resigned themselves to the fact that we were here and not about to drive 300 km back home without getting this process done. Armed with checklists provided by the World Bank, we split up to the various areas of the hospital in small groups to make sure each department checked all the boxes.

Did the trash cans have plastic linings?

Was there a bedside table next to each patient bed?

Was there a working scale in the delivery room?

Were the charts filled out correctly?

Were there mosquito nets on each bed?

One of the midwives ("sage femme" or literally translated "wise woman") in maternity started to look uncomfortable and defensive with the questioning. Our own sage femme picked up on her discomfort and proceeded to tell her rather aggressively that she should relax. This didn't make her any more comfortable.

After a couple of hours of checking checklists, we all met back with the administrator. All together we did the math and made sure each section of the evaluation had the same totals on all copies of the forms. Apparently we gave them a lower score than another hospital had given them last time, so we sat on the wooden benches again, drank the cold water and cold soda provided, and listened through an awkward wrap-up as the uncomfortable administrator tried to take charge of the situation and sum up our visit findings for us. He told us what he wanted us to write down for strengths and weaknesses of the hospital and what recommendations we should write for what he would change in his hospital.

I would have liked to spend some time asking them other types of questions about how they handle certain challenges of being a hospital in a similar area with a similar patient population and similar resources. But we had already gone well beyond our allotted time on the checklists. I glanced over at one of our nurses. He looked like he was melting, drooping further and further on the bench, as if maybe he hoped that if he actually melted, then he could just flow across the floor and out of the room and not have to sit through this meeting any longer.

Soon we were all back in the Hilux pickup, being jostled against one another as we navigated bumpy dirt roads congested with goats, chickens, and wallowing pigs. Along the way I wondered if there might be a more culturally-adapted way of encouraging quality improvement in these hospitals.

Anyway, our trash cans have plastic liners now, so I guess we learned something important. And we got to be the suits for a day.