Carlos Hiran Goes de Souza‚MD, Vice President
Carlos Hiran Goes de Souza‚MD Vice President

So many things happening simultaneously. Many losses and, if we consider from the other side, unexpected gains as a natural consequence as well. Changes that inevitably push us to think about the substantial social transformations and paradigms being challenged in a very short time of this unprecedented viral devastation.


But besides the virus, we also have ideas in the air. We should believe.

It is unquestionable the effort and the mobilization of creative minds trying to spread the ideas of solution massively challenging the collective thinking and reflection. We do not lack examples during the confrontation of this pandemic. We are not lacking examples of people or systemic or local models of research, planning, implementation, control and evaluation which are being applied everywhere, empirically and voluntarily, often, but always based on the science and technical guidance. We are talking about ideas that emerged somehow to give consistency to current actions and that will definitely provoke trends in the near future.

Precisely in these last days, professionals interested in the processes of continuous improvement of health care are being challenged to analyze this ultra-fast movement of transformation of assistential models. As a consequence, the analysis of trends in the field of safety of care and in the experience of those who use and those who provide health services becomes inevitable.


In crises, thinking, rethinking and innovating is crucial.


The quality management always encouraged us to think the unthinkable and to consider corrective, preventive and innovative actions, even in those situations that arise from the unforeseen care. Taking into account, evaluating and managing all avoidable risks and being on the alert for the unpredictability of risks means guaranteeing the best responses and the best reaction capacity of the organisation in times of adversity.

Pandemics of influenza have been on the public health agenda for a long time. Still, the overload of service’s demand associated with an outbreak of infectious disease invariably exposes processes that were already failing in the non-outbreak phase. As hospitals in many countries routinely operate close to their maximum capacities, the difficulty in managing the increased flow of patients and the unexpected increase in the demand for inputs, materials and medical equipment needed in these circumstances is enormous. And, indeed, at this point, it is much more significant for those hospitals that have not prepared themselves for such a contingency, those ones that have not designed or envisaged scenarios of this magnitude and have not laid down policies and protocols for the ensuing problems. An emblematic aspect for this moment is the availability of mechanical ventilators which involves a complex determination of the patient’s clinical risks and the likelihood of recovery. A further example of equal importance for the management of clinical risks is the personal protective equipment necessary for professionals in the frontline of hospital care.


Disregarding these predictive issues, COVID-19 raised key and necessary questions as to whether hospitals affected at this time of crisis have any contingency/emergency plans that are recommended as one of the quality and safety standards by any accreditation program, or certification processes around the world. More than that, if they have them and if the plans are updated and tested as expected. This unprecedented sanitary context and the rapid spread of coronavirus require that these plans are consistently carried out, even though they have had to be adjusted and adapted at the last minute to suit the urgent care of the affected population.

At this stage, a sensitive impact on hospital care environments and their internal and external relational environments was to be expected. Likewise, it is not surprising that specific intensive or non-intensive care models have undergone some kind of technical-operational transformation. As a result of changes in the provision of care, the paradigm change in the management of services somehow tends to occur taking these critical issues into account.

This became now a common challenge for all quality professionals, standards developers and accrediting bodies, as a current process of continuous improvement and innovation. A challenge that allows us to recognize and interact with each other towards putting into practice our fundamental principles of learning from each other’s errors or examples of success, mindful of the disruptive processes and the ones that push us for change. Likewise, in general, quality professionals have the same security awareness to manage automatic trends and know how to seize the opportunity that this contemporary history is opening up to a collective grow.

As the Coronavirus has spread around the world, the weaknesses and threats of health systems at international, national, regional, and even individual levels have become more apparent. In general, these critical periods have become, paradoxically, throughout history, appropriate to take a better look at the strengths or the weaknesses of the care given to the communities. In this context, the American physician Joseph Bagley Shumway, Medical Director of United Family Healthcare, one of China’s leading private healthcare systems, recently stated one of the lessons he has learned in the light of the COVID-19 outbreak. He said that “given the new issues that have emerged, we need to approach drug administration differently, and we will certainly need new standards of health care delivery.

Dr Shumway’s considerations, in the midst of the global crisis, indicate us how much visionary leadership needs to be aware of the transformations that are gradually taking place in our current activities and how much we will still need to review and re-evaluate what we have established as good practices in health care. I dare to say that the moment is suitable for everyone to do so, but in particular, I would say that the hospitals’ quality management groups would benefit significantly from this. The point is that Dr Shumway presented several suggestions to contribute to the struggle and control of the epidemic in China but that, in a certain way, has influenced many other global actions. The main lesson we learn from this is that in fighting the virus, he transmitted his ideas thinking outside the box. I mean, one of his interesting proposals, among others, the concept that he called “hospitals or clinics of minimal contact” is a sample of disruption that emerged from the pandemic. Without challenging the health professional/physician-patient relationship or questioning the medical sovereignty, clinical thought or physical examination, this doctor signalled, simply, the tendency to change the concept of people’s waiting for hospitals care. His concern was regarding people waiting in specific rooms, check-in admission and check-out discharge at the reception of these organisations, and even the provision of medication in areas of hospital pharmacies. In his analysis, minimizing and simplifying contact would be a preventative action, among others, to reduce risks for patients, professionals and the general public. Based on the rationale of this example, we should consider that trends can emerge as alternatives to the traditional models of waiting rooms in outpatient services, blood banks, urgencies, laboratories, and even medical offices. This issue would be a topic to be reflected and analysed by all quality professional. A reason for a group discussion. And in this way, it would be worthwhile for the quality and safety management groups to join in virtual debates through the available electronic media to share their hospitals’ experiences during the pandemic. The exchange of information, at that time, is fundamental so that standards of good practice prevail within the plans and actions of the institutions. Risk assessment methodologies should be considered in any situation, whether normal or at the peak of a public calamity.  Also, only data collected, analyzed and discussed can help us rethink the standards we have adopted so far and realised how useful they will still be for us to ensure the safe care forward. However, the point now is not just to uphold or guarantee existing standards of good care in practice. It is also part of our responsibility to rethink these standards and develop new ones, if necessary so that they become acceptable and applicable in such adverse situations and in the operational normality that we hope will return soon.

The challenge is immense for this moment, indeed, but it is also encouraging for the sustainability and credibility of the quality and safety programmes that we so much believe in and defend. Therefore, try to schedule weekly virtual groups meetings, addressing individual reflections and discussing ongoing projects. Try to keep in touch somehow.

For now, keep safe the frontline staff, save lives, stay at home. But don’t forget to put your ideas out there.


Ideally, by thinking “outside the box.”