Fieldset
Refugees in Jordan: 'Month End' or 'Some Wicked Problems'

Mike, a family doctor/GP from the UK, currently working for MSF/Doctors Without Borders in Jordan. With his manager away, Mike must take on new responsibilities, including the daunting 'Month End'...

‘Not everything that counts can be counted, and not everything that can be counted counts.’

One of the (many) privileges of a life spent as a doctor is that I have largely been insulated from the normal challenges of writing reports to managers at the end of every month or year.

However, as my medical team leader is on an extended break, there isn’t anybody else to write the important Monthly Medical Report (MMR), and as the last Mental Health Activities Manager (MHAM) left their role on the day that I arrived in Irbid, there is the Mental Health Monthly Report (MHMR) to write as well. (I’ve been assured that there is no link between my arriving and the MHAM leaving!) 

Why these?

I’m aware that having not compiled these reports all my life, I may have a different set of assumptions to those who have done them throughout their careers. It probably took me a bit longer to reflect on the statistics of how many people are seen in the clinics, or have diabetes, than others who are used to this.

I worry that we are contributing to a culture in which we are measured by the things that are easily measured

But my naivete about reports also leaves me wondering why these particular statistics are chosen, and why some are monitored so frequently (though may change very little) when we are not really sure if the changes are meaningful until we review several months’ changes and others (which I know from the project’s annual plan we hope to achieve) are not currently being monitored at all.

I worry that we are contributing to a culture in which we are measured by the things that are easily measured, rather than looking at whether we are delivering quality by occasionally delving more fully into particular areas.

It could appear that I would like to avoid collecting data at all. This would be misleading!

Wicked Problems

I’ve been reflecting a lot on how to generate quality Improvement, as I’ve been lucky enough to be allowed to continue a very small part-time role with the Royal College of General Practitioners (RCGP). (Understandably, MSF does not normally allow those working on foreign missions to do other work, but this was discussed and agreed.) 

So in my spare time this weekend, as Jordan was getting much needed rain and it was wet and cold for our Friday/ Saturday weekend, I was back skyping with a UK-based colleague on national resources and assessments to help trainee GPs demonstrate their learning about Quality Improvement.

The key messages we kept coming up with were that we should measure and analyse using appropriate tools, and then the local team should discuss these results, suggest small changes, and then implement them.

You need to adapt and review rather than looking for a single change that will bring resolution

This cycle keeps repeating: collecting more carefully chosen data, analysing, changing and planning, to try to see whether the changes made have resulted in enough progress. The evidence on changing complex systems or ‘wicked problems’ is that you need to adapt and review rather than looking for a single change that will bring resolution.

These ‘wicked’ problems often entail a mixture of personalities, beliefs about priorities and complex data, so the final best possible answer is not going to be found except through many reviews and data to show what is happening (rather than a hunch that things are improving!). 

So I’m fascinated by the different approaches to data taken within the different systems that I’m part of and how they approach generating change in such different ways. Some are experimenting at shop floor level and reaching answers whilst others are managed by experts at the top of a hierarchy... and may struggle to adapt in the 21st century. 

Then I remember that at the macro level the National Health Service (NHS) in the UK is too full of management, collecting endless data and judging people by this, though the NHS Improvement Project would recommend such a different approach!

Limited resources, limited time...

For any charity, there is a difficult balance to strike. On the one hand, collecting more routine data so that (amongst other things) those who donate have evidence of benefits. On the other hand, allowing the local teams to adapt and improve quality using modern, evidence-based tools. There are only so many resources, only so much time.

One of the big challenges coming out of the Monthly Medical Report in December is the number of patients who we have identified as having suicidal thoughts. This has come to light through starting to use a screening tool when patients are in the clinic for their chronic diseases. The tool is a questionnaire which asks patients about how often they’ve experienced different symptoms of depression over the past two weeks.

One of the big challenges coming out of the Monthly Medical Report in December is the number of patients who we have identified as having suicidal thoughts

Balancing the needs of the 219 patients who have recently identified themselves as thinking about harming themselves more than half the time, with the fact we have only three full-time counsellors and two-and-a-half consultation rooms is not a problem that is easy to solve.

So far, my answer to the problem of the patients with suicidal thoughts has been to think about which compromises we might have to make. This could mean longer intervals between appointments; adopting what I’ve heard called a ‘Ryanair approach’ to appointments (I think this refers to booking more people than you have spaces for, and making the appointments shorter too?); using the telephone to consult; prioritising more effectively, etc.

We haven’t yet found a solution - or as I suspect, a package of many different changes that we will need to continuously tweak, (and measure) to get closer to where we’d like to be. (But then of course the NHS has not yet found a solution to the urgent care demands that it has identified, possibly because the solutions are too often not left to local managers but politically driven.)

Teabags and tablets

The Month End for my boss (and me) is not just a matter of doing some reports, important and time consuming though these might be. There are more minor irritations like sorting out the stationery order lists for the several different teams that we manage between us. At the moment I’m just hoping that we have the right amount of toilet rolls, tea, coffee as well as marker pens and information leaflets. Yes, all these are on what is locally called the stationery list!

Time will tell if there are enough tea bags, but I’m aware that some of these are the things that really matter to ensure that a team works well.

More challenging for me as a clinician, but not a pharmacist, was trying to manage the prescribing and medical supplies meetings. I’ve never been a fan of Excel spreadsheets, and for this process we have to be aware of the data from the consumption tools in the pharmacies we run, the Total Stock Report (TSR), the SAS (which I think is derived from the TSR and must mean something but I’m confused what!).

Time will tell if there are enough tea bags, but I’m aware that some of these are the things that really matter to ensure that a team works well.

They say that when you learn Biology in school, you learn a bigger vocabulary that most people do when they do GCSE French. I feel that managing a Month End has been a similar transformation in my acronym knowledge.

I think managing medicines is complex for any project, but the Irbid project is different in so many ways from others, and our pharmacy process definitely is.

Normally, MSF buys its drugs where its big bases are (for our project, this is Amsterdam) but the Jordanian Government requires us to purchase locally. There are usually one of two approaches to how warehouse and pharmacies relate to each other, but the Irbid project has a complex hybrid. This means the normal division of responsibilities between logistic managers and medics gets murky.

MSF doesn’t often work in non-communicable disease, which requires a different range of drugs and sufficient supplies to ensure long-term, continuous treatment, so our challenges here in Irbid are very different from those in most MSF projects.

Predicting the future

MSF, like any organisation, needs to have policies and systems to manage processes for things like ordering stock. These are designed for, and probably work excellently in, ‘normal’ projects, but they have had to be adapted very extensively for Irbid. I’m not used to using them, and Nico our logistics lead, isn’t either.

There are so many variables that we were aware of when it comes to predicting how much we’ll need of our various supplies. There are things like planning for the increased demands that will happen in the run up to Ramadan, or the increased demands relating to the current winter coughs in our smoking population.

How many of our patients will decide to return to Syria over the next six months is hard to assess in advance...

If predicting coughs in winter seems to be relatively medical and possibly clear, how many of our patients will decide to return to Syria over the next six months is much harder to assess in advance.

There are also many different levels to medical supplies ordering to keep in mind. Whilst you never want to have an overstock of out-of-date medication, how important this really is may depend on how much it costs per packet. I am aware of tensions between my financial and medical thoughts, when there is a discussion over whether we should use up an antibiotic with a broader spectrum of cover, instead of a simpler one because that fits the stock we have (whilst this is possibly not what good antibiotic stewardship suggests we should do).

A further level that I later discover is that the Forecast Monthly Consumption is not totally what we expect to consume.. It must be altered for stock ordering and financial reasons so it is something of a compromise between plan, hope, reality and cost.

I’ve finished writing my blog sharing with you the confusion I have over pharmacy supplies which is definitely a wicked problem, in which there are logical elements as well as personalities, history and competing needs. I’ll be doing my best in whatever roles I have with stock management over the next months to make this process as safe and easy as possible and hoping to collaborate, and measure our progress as we try to achieve this!