Roger's first post

This sign is near the office where I work on a team that is helping nine Malawian hospitals reduce the number of women who die in pregnancy. It illustrates the universal problem of how technical failures in communication can lead to terrible outcomes (in this case it's just unflattering to the business).

The other consultants on the project are teaching and coaching about how to improve the processes of care; e.g., are the post operative women's vital signs monitored frequently in the first four hours after surgery? They include specialists in obstetrics, neonatology, nurse-midwives, quality improvement experts and a process engineer.

My role is helping the clinicians and the data clerks improve the quality of operational data in the hospitals and measure the processes and outcomes of care. One hospital where we work has improved its scores on post-op monitoring from 22% in June to about 75%. Although it doesn't yet show in their statistics they have anecdotal evidence of preventing at least one death from a complication that otherwise would have slipped by. Another hospital has improved its protocol for managing eclampsia and can already point to several avoided deaths.

The moral of the story is that the small stuff matters