Klinik Kesihatan Shift System Risks Health Worker Burnout, Human Error: Medical Groups

By Ashswita Ravindran | 08 September 2020

The Malaysian Medical Association and Malaysian Pharmaceutical Society propose that MOH work together with GPs and community pharmacies to reduce the burden at public health clinics.

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KUALA LUMPUR, Sept 8 — Doctors, pharmacists, and dentists warned the government that implementing a shift system at public clinics without boosting manpower may raise worker burnout rates and affect patient safety.

Malaysian Medical Association (MMA) president Dr N. Ganabaskaran said the Ministry of Health (MOH) should increase their staff at government health clinics (Klinik Kesihatan) to ensure adequate workforce for every shift to reduce burnout and fatigue in health care workers.

“Having your senior staff spread over two shifts may lead to lack of oversight for the more junior staff and open the possibility of human errors increasing,” Dr Ganabaskaran told CodeBlue. “We have to ensure that patient safety is not compromised from adequate supervision as well.”

The head of the doctors’ group also highlighted that a motivated, happy employee is more productive and effective than one who is distracted with issues like child care, increased working hours, and reduction in work-life balance that may be seen with the implementation of the shift system.

He also said that the implementation of the shift system requires at least 50 per cent increase in staffing to ensure that workers’ welfare is not sacrificed.

“At the moment, there is a lot of dissatisfaction among the health care workers and there are also reports of very low turnouts for the evening shifts for the clinics. Perhaps the system should be reevaluated sooner,” Dr Ganabaskaran added.

A government health clinic generally operates between 8am to 5pm. A shift system extends the hours to 9.30pm. The two shifts for staff will be from 8am to 5pm and 12.30pm to 9.30pm. CodeBlue understands that several large Klinik Kesihatan in each state are taking part in a pilot project for the shift system.

In a letter written anonymously to CodeBlue by a senior medical officer at a Klinik Kesihatan in Sabah, the writer alleged that a pilot project for the shift system that was previously conducted at Putrajaya Klinik Kesihatan prior to the Covid-19 pandemic “failed miserably within three months of implementation”. The government doctor had cited worker burnout as a major factor in the purported failure.

“Much like studying traffic flow before the implementation of a new traffic system, the patient traffic, as well as their wants and needs, should be assessed before any new implementation of the shift system.”

Dr N. Ganabaskaran, president of the Malaysian Medical Association (MMA)

Dr Ganabaskaran pointed out that the number of patients who are willing to go to government clinics after hours may not be as many in some areas, but favoured in others.

The MMA president suggested that MOH collaborate with the 7,000 private general practitioners (GPs) in Malaysia to offload the burden in the green zone of emergency departments in public hospitals and clinics.

“A patient referral with a subsidised fee to the GPs would be most welcomed and would probably be more effective than the shift system, which was done to reduce congestion in the KKs,” the MMA president said.

Pharmacists With Families Will Struggle With Child Care

Malaysian Pharmaceutical Society president Amrahi Buang speaks at the Health Ministry’s town hall meeting on February 13, 2020, in Putrajaya on the Poisons (Amendment) 2019 Bill. Picture from Facebook @BPFIPKKM.

Malaysian Pharmaceutical Society (MPS) president Amrahi Buang said implementation of the shift system at public clinics with the existing workforce will only create a strain and affect the pharmacists physically, spiritually, and mentally.

“Pharmacists with families will suffer to juggle their children in nurseries, kindergartens, and schools. This will be worse for afternoon and night shifts,” Amrahi told CodeBlue.

“This will certainly create strain and affect productivity and cause mistakes to be done when the pharmacists do not have sufficient rest for a long time,” added the head of the pharmacists’ group.

The Washington Post reported a study that showed almost half of doctors and nurses from the United States experience substantial symptoms of burnout that resulted in an increased risk to patients, malpractice claims, worker absenteeism, and turnover, as well as billions of dollars in losses to the medical industry yearly.

Amrahi also cited the 2018 auditor-general report that showed health care facilities in MOH are understaffed even in providing existing services.

“Has the Ministry worked out the numbers and the ratio to patient’s attendance? Having morning, afternoon, and night shifts requires lots of staff. Is this available in Sabah and Sarawak? The Ministry needs to answer this.”

Amrahi Buang, president of the Malaysian Pharmaceutical Society (MPS)

Members of Parliament from Sabah and Sarawak have highlighted the vast discrepancy in public health care manpower between urban centres in the peninsula and the less developed East Malaysia, besides noting a lack of public transport in Sabah and Sarawak at night.

Amrahi urged MOH to get feedback from health care professionals on the ground before implementing a shift system at Klinik Kesihatan, stating that from his sources, it was not done before.

He cited a survey conducted by MMA that highlighted 92 per cent of 9,320 MOH staff disagreed with the shift system.

“These are voices on the ground and the Ministry should have listened to them. We should stick to normal hours and go for extended hours when needed,” Amrahi said.

The MPS president suggested for MOH to extend their current value-added service of delivery of medicines for patients on long-term medication to community pharmacists.

“The community pharmacists are in a position to provide high-quality services to these patients.”

Dentists Back Shift System To Clear Backlog

Malaysian Dental Association president Dr Leong Kei Joe. Picture from Facebook @mda.org.my.

On the other hand, council members of the Malaysian Dental Association (MDA) supported the idea of the shift system to help to clear a backlog of dental cases that were postponed during the Covid-19 pandemic.

MDA stated that during the peak of the pandemic, only emergency dental care was provided. Hence, many dental appointments were changed or postponed.

“There will be a backlog of cases that are pending treatment and implementation of a shift system could probably be useful in that sense,” MDA said.

They also pointed out that patients who needed elective or non-urgent procedures were given further dates for future appointments to avoid overcrowding at government dental clinics.

However, they also stressed that certain facilities, such as an adequate number of operable dental chairs and staff for each shift, as well as the availability of public transport, have to be fulfilled first before the shift system is implemented.

“Otherwise, having a shift system at government dental clinics could be counter-productive and even be seen as not optimising resources effectively, especially human resources,” said MDA.

“Certain Klinik Pergigian in rural areas just have the bare minimum of staff (both dental practitioners and dental auxiliary staff) and this will pose a challenge and may even cause a burnout among staff.”

Malaysian Dental Association (MDA)

MDA also suggested for MOH to implement the shift system not as a permanent policy, but as a temporary measure to help clear the backlog cases and for normal hours to resume once that has been achieved.

CodeBlue also reached out to Kesatuan Pemandu-Pemandu Kementerian Kesihatan Semenanjung Malaysia (KPPKKSM) general secretary Reostam Dzahar, who said that this matter has already been discussed with MOH previously.

“We will follow what is best for the service of our public. That is our job as civil servants,” Roestam said.

On June 17, MMA, the Congress of Unions of Employees in the Public and Civil Services (Cuepacs), MPS, the Malaysian Nurses Association (MNA), the Malaysian Nurses Union (MNU), and KPPKKSM released a joint statement, urging MOH to conduct a detailed study and stakeholder engagement before implementing the shift system at government health clinics.

Correction note, Sept 10, 2020: CodeBlue erroneously attributed comments by the Malaysian Dental Association (MDA) to the Malaysian Dental Council (MDC). CodeBlue apologises for the error. The errors have been corrected.

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