We may not enjoy the best physical ambience, latest health information systems and adequate parking space, but we probably have the best doctors in the country.
Best not only in their varied and par excellence clinical expertise, but also in their contributions to humanitarian needs nationally and internationally. The top three charitable organisations in the country are headed by our clinicians, debunking the notion that private medical practitioners are only obsessed with the bottom line.
Most importantly, we are a group of doctors who pride ourselves in a work culture that is professional, patient friendly, compassionate and caring, what is often described in corporate circles as a just culture.
However, we are greatly concerned to hear about the rise of a toxic work environment that is increasingly pervasive in the Ministry of Health (MOH), described as a culture of fear and intimidation.
Our earlier article “Healing the healing profession” had addressed the bullying work culture that is chronic and perennial in the MOH:
More recently, we had condemned the culture of “pilih kasih” (favouritism), which is prevalent in MOH and everywhere else in the civil and political service, calling upon MOH’s leaders to stop all forms of discrimination from the minister and director-general (DG) right down to the HODs:
The underlying issue boils down to one (and the same) thing – the organisational culture of MOH.
While MOH’s vision and mission statement look impressive displayed on the walls of their Putrajaya office, are they being translated into the work culture of all MOH personnel across the board?
Unless all MOH leaders (from the senior directors and directors in Putrajaya, states, hospitals and health centres) open their eyes and hearts to recognise and acknowledge that critical action is needed pronto, no health care transformation plan will work.
This includes the Minister of Health’s noble and strategic plans for Electronic Medical Records (EMR), Health Financing and Sihat Bersama 2030. One is reminded of the alleged Peter Drucker quote, “Culture eats strategy for breakfast”.
Health care reforms can only be possible if all MOH leaders and personnel adopt a supportive and forward-looking approach in tackling the current mess, and work together as one to create a health care system that is values-based, patient-centric, technology-driven, supported within a health empowering ecosystem.
Culture Change Starts at the Top
The political and clinical governance in MOH has been appalling in the past few years, with everything coming to light during the Covid-19 pandemic.
Health care providers themselves recounted the horrors as such:
“June and July 2021 were horrible, and patients were dying like flies. It was the worst time of my life. Even palliative care was not allowed for the terminal Covid-19 patient.”
This is clear testament that the country cannot afford health care leaders who don’t have a heart to care, let alone cure. We need leaders who are receptive to other opinions, and allow other voices around the table to be heard.
MOH leaders must practise and inculcate a culture of transparency, accountability and honesty to encourage an inclusive and comprehensive exchange of ideas. Affective and effective leadership is key to building great organisational cultures.
Culture Change Starts With Behaviour Change
Change, by itself, is prone to resistance. What more when trying to change the culture of an entire organisation i.e. MOH.
Ultimately, culture change is a long-term initiative, and it must be a whole-of-Ministry effort. This arduous task, best described as an overhaul of the system, involve shifting of mindsets, starting from the top.
To begin with, MOH truly needs leadership that is committed to change – setting the tone, establishing expectations, and leading by example. Strong leadership will help direct health care providers towards the much-coveted reforms within the system.
This is where clinical governance is paramount and must be uppermost in the priorities of the Minister and his top clinical leaders.
Reinforcing Clinical Governance
Clinical governance is the framework that holds health care organisations accountable for continuous improvement in the safety and quality of their services.
Clinical governance typically covers seven key pillars: Patient-Centred Care, Clinical Effectiveness, Patient Safety, Governance and Leadership, Information Management, Training/ Education and Performance Monitoring.
Strong clinical governance framework within MOH will protect the delivery of safe and quality patient care that adheres to ethical and legal principles. It also supports clinical leaders to become affective and effective in implementing and sustaining safe and quality patient care.
Here are some recommendations for MOH’s serious consideration:
The Health Minister, Director General and Secretary General must deep dive with the National Head of Services to drive this message about clinical governance without sugarcoating.
MOH must be led by strong leadership that is fair, inclusive, and receptive to ideas and positive change. As such, all the highest posts must be interviewed and elected rather than appointed.
Leadership means the ability to bring out the best in others and mobilising their talents towards the MOH’s goals, values or outcomes. State health directors, hospital directors and clinical HODs must all lead by example by displaying unequivocal commitment towards quality patient care, ongoing improvement, and outcomes.
The term of office for HODs is two years. To ensure performance is maintained, his/her re-appointment must be based on an objective assessment that includes 360-degree feedback.
Zero tolerance for unethical and illegal practises of HODs and clinicians who abuse their positions to benefit personal interests eg. doing ward rounds or surgeries in private facilities instead of teaching rounds with their staff, abusing MOH facilities to benefit their private patients etc.
MOH clinical governance must take stern disciplinary action against hospital and state directors who are aware, yet condone such moonlighting practises.
Service memory must be included for specialists who have served in different places but are not promoted because they are unknown to the latest supervisor. There are many senior clinicians on UD56 since 2017, whose seniority and contribution deserve due recognition and promotion to Special Grade C.
These senior doctors, who are bastions of MOH and have served faithfully for many years, are not holding JUSA posts. They are most likely to resign unless they are promoted and remunerated accordingly. The Minister and his promotion board must give UD56 senior clinicians special consideration at the next meeting with the JPA and Finance Minister, or risk losing a large pool of expertise and experience from MOH.
Subspecialists, especially in non-surgical based subspecialties (except for neurology, oncology, respiratory, nephrology, intensive care, and cardiology, who have enough workload) must continue doing general clinical work. There has been a worrying trend in recent years for subspecialists in some disciplines to refuse general clinical work.
Nowadays, almost all hospitals have at least six to eight specialists in each department. However, many specialists are not doing active stay-in on call duties, resulting in patients not getting appropriate specialist care after office hours.
MOH must make it compulsory for specialists in major disciplines e.g Medicine, Surgery, Obstetrics, Paediatrics , Orthopaedics, Anaesthesia and Emergency Medicine to do active stay-in calls if there are at least eight clinicians (inclusive of consultants and specialists under gazettement) in the department.
Previously, medical officers from District hospitals and Health Clinics will refer ill patients to medical officers in tertiary hospitals. Now that MOH has more specialists, sick patients should be referred to the specialist on call to relieve the work burden of junior doctors and eliminate the plausible risk of future medico-legal ramifications.
Create a pathway for specialists who have resigned for various reasons to re-enter the service with attractive personal and career development incentives. Remember that health care professionals, like any other professionals, deserve opportunities for advancements to better serve the health care system. They will, in turn, pass the baton down to the next cohort in the future.
Leadership and communication skills are critical in today’s fast-moving globalised world. MOH needs to continuously hold leadership training programmes to inculcate leadership qualities in future clinical heads.
Currently, almost all leaders are appointed based on seniority, not competency. These trainings should start at medical officer (UD48) level, with emphasis on Servant Leadership so that clinical heads and hospital directors are trained to serve and prioritize organisation first before self.
Conclusions
At the heart of clinical governance is culture and leadership. Political and clinical leaders who genuineley embrace the vision of the MOH will inspire the buy in of other health care professional which will create a culture of engagement, which reflects job satisfaction, commitment and enthusiasm of the MOH’s values.
Clinical leaders in Putrajaya, states, hospitals and health centres who exemplify the mission statement of the MOH, in their words and actions will foster an ethical culture.
Competent, accountable and transparent leadership at the top levels of MOH will promote a culture of confidence and trust in the ministry and empower the HCP to take responsibility at the workplace and helps create leadership at all levels of the MOH.
A culture of engagement, ethics, and trust will be the driver for real health care reforms, as inspired by the ideas in Sihat Bersama 2030.
Dr Musa Mohd Nordin and Prof Dr Azizi Haji Omar are paediatricians from KPJ Damansara Specialist Hospital.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
