Health care indicators and quality improvement in Saudi Arabia

Patient Safety

The goal of any health care provider, no matter where he or she is in the world, is to provide quality care to his or her patients -- consistently, efficiently, and effectively. One way to ensure that quality care is achievable is to take note of the leading quality health care indicators that are recognized globally by health care professionals. Similar to leading health indicators (LHI), which measure the health of the patient/population and include everything from the prevalence and mortality of chronic disease to the proportion of the population experiencing positive mental health (IOM, 2011, p. 3), quality health care indicators measure the provider side of health care delivery. If LHI help health care professionals to know what to look for and how to prepare to address issues that arise from examination, quality health care indicators help providers to assess themselves and ensure that they are putting in place the mechanisms needed for quality care to be achievable.

Indeed, in the U.S., the Department of Health and Human Services has "issued a national agenda aimed at improving the health of all Americans" by focusing on LHI and the concomitant health care objectives for its Healthy People 2020 campaign (IOM, 2013). What can be seen from this American initiative is how being mindful of health indicators links with a strategy of providing quality care, which links with the strategy of using indicators of quality health care in a continuous feedback loop that promotes improvement in all areas. By being aware of the measures of health and health care, providers can be better situated to treat patients with a range of ailments. As health care indicators have also been identified by the Institute of Medicine (IOM) that, like LHI, also serve as measurements, providers can use these indicators of quality care to assess themselves. These indicators should be especially important to care providers in the Kingdom of Saudi Arabia. As Almutairi and Moussa (2014) point out, the IOM indicators of quality health care "(safe, effective, patient-centered, timely, efficient, and equitable) are used to determine the current quality of healthcare in KSA" (p. 802). Additionally, these same indicators can be used by health care providers to assess their quality of care anywhere in the world.

In Saudi Arabia as well as the rest of the world, a similar strategy to that which the U.S. Department of Health and Human Services has developed with Healthy People 2020 may be implemented to help both health care providers and patients achieve the goals they set out for themselves in terms of providing and receiving quality care respectively. As this chapter will show, such a strategy is needed now more than ever as new problems, such as the emerging prevalence of obesity, become concerning issues (Al Othaimeen, Al Nozha, Osman, 2007). Deficiencies in care associated with a failure to identify LHI lead to numerous health problems for all populaces, just as deficiencies in quality of health care lead health care providers to ineffectively treat patients and provide the type of preventive care that persons need. In Saudi Arabia particularly, there is much room for growth with respect to addressing health indicators and promoting health among the population -- and there is much room for growth with respect to the indicators of quality health care, as Almutairi and Moussa (2014) have shown.

This chapter will examine the relationship between measuring both health and health care and providing quality care; it will also show what can be done both globally and locally in Saudi Arabia to better address quality of care issues currently impacting the health care world and its patients.

The Quality Health Care Indicators

As the Institute of Medicine (2011) has stated, an indicator is nothing more than a measurement. Therefore, the quality health care indicators are the measurements of health care that can be used to gauge the extent to which providers are fulfilling their potential. According to the Institute of Medicine (IOM), the quality of health care indicators include safety, cost effectiveness, patient satisfaction, efficiency, and timeliness. Safety, first and foremost, is one of most important indicators of quality care because, as Goldhill (2009) has shown in his own analysis of American health care, most of the illnesses and deaths that occur in hospitals are the result of errors that could have been prevented with a little concern for safety. Preventive care is a much-needed and highly-valuable practice that providers should take note to exercise in all their interactions with patients (Harris, Aalsma, Weitzman et al., 2017). Patients themselves would much prefer to have potential threats to their health prevented via preventive care than to have the threats become realities that then require more treatment. A provider's level of safety in terms of delivering health care is, therefore, a major indicator of the extent to which quality care is being achieved. In the U.S., part of the reason that preventive care, and by extension quality care, is missing in many health care facilities (such as hospitals) is that the health care industry is subsidized by the government -- i.e., providers are incentivized to treat patients rather than to give preventive care (Goldhill, 2009). Because of this type of situation, safety concerns can be looked down upon as unnecessary -- after all, if the patient gets sick because of carelessness or errors in the ER, he or she can be treated later -- especially since the government is paying for it.

In the KSA, such a mindset will not do. It should not exist anywhere in the world, but in countries where there is substantial collusion among the various health industries (pharmaceutical, practice, insurance, etc.), there is bound to be corruption (Goldhill, 2009). Health care providers in the Kingdom are fortunate enough to be free of this type of collusion for the time being and so can focus on doing that which is expected of them -- meeting the needs of patients and providing the quality care they themselves have been trained to provide.

The quality of health care has improved in Saudi Arabia in recent years, as Almutairi and Moussa (2014) show in their study. However, there is substantial room for improvement still. This room for improvement is situated within the context of two factors -- patient factors, "such as health literacy, access to care, and culture," and providers' factors, "including medical care, workload, culture, and job satisfaction" (Amutairi, Moussa, 2014, p. 802). In other words, the variables that impact the extent to which quality care is achieved in Saudi Arabia go beyond issues related to safety, effectiveness, timeliness and so on. They are impacted by issues on a more basic and practical level -- such as whether or not the health care provider is being overworked, whether or not the patient has a high or low health literacy or whether he or she has access to literature on preventive care; whether the culture of the patient or the provider is supportive of the aims of quality care, etc. The variables are numerous and should be understood in detail, because the result of a failure to do so is that patients experience suffering, while "institutional waste, and misuse of community resources" also occur (Amutairi, Moussa, 2014, p. 802). Managing not only time but also workers effectively and making best use out of materials that can be put into the hands of patients to help educate them on preventive care is all part of pursuing quality care.

Such pursuit has to be systemic at root. On an individual level, primary care givers can attempt to be the best that they can be in terms of providing quality care, but if they are working in an environment that is disruptive, unstable, and negative, their own ability to provide care will be impacted by their surroundings. That is why it is important to consider the minute details of all health care facilities and how they are structured, arranged, supported and managed. An analysis of the details shows that when nurses and physicians are overworked or have poor job satisfaction, they are less likely to put in the effort needed to ensure quality of care in terms of patient safety, timeliness, efficiency, effectiveness and equitability (Thomas, 2005). When nurses and doctors are rested and participating in a positive workplace culture where job satisfaction is high and a top priority, quality care is more likely to be the outcome -- and to that end, administrative support and training is required, especially in Saudi Arabia (Cowing, Davino-Ramaya, Ramaya, Szmerekovsky, 2009; Al Hosis, Mersal, Keshk, 2013).

Problems with Quality Care in Saudi Arabia

Safety

One of the biggest problems with achieving quality care in Saudi Arabia is safety. In order for providers to be safe, they must be consistent, conscientious, and systematic in their approach to providing care. To support the development of these characteristics, medication committees and safety officers assist in the oversight and regulation of care giving. Yet, in Saudi Arabia, less than a third of all hospitals have a medication committee and less than 10% of hospitals have any kind of medication safety officer on staff (Aljadhey, Alhusan, Alburkian et al., 2013). Nearly all hospitals in the KSA lack a "look-alike, sound-alike" list of pharmaceuticals, which is helpful in preventing the wrong drugs from being administered to patients. Likewise, more than 20% of medical errors committed in KSA hospitals occurred during operations, while more than 18% occurred in the ER. As a result of these deficiencies, medical errors and the ensuing cases of litigation that naturally follow such cases have disrupted the lives of patients and providers, particularly in hospitals operated by the Ministry of Health (Aljarallah, Alrowaiss, 2013).

With respect to the rest of the world, Saudi Arabia's quality of care in terms of safety issues is neither better nor worse. As Aiken, Van den Heede, McKee et al. (2012) show, "the percentage of nurses reporting poor or fair quality of patient care varies substantially by country" and the same goes for nurses who grade their hospitals on safety. Burnout is considered a contributing factor to safety issues and work environments are also considered factors in how well safety precautions are followed and/or implemented throughout Europe as well as the United States (Aiken et al., 2012). What this shows is that "deficits in hospital care quality" are a common feature among all countries of the world (Aiken et al., 2012). Improvements, such as those recommended by the IOM, are needed across the board.

Effectiveness

Patient satisfaction can be used as a gauge of health care providers' effectiveness in providing quality care and patient sentiment is typically obtained during discharge. Of patients assessed in eastern Saudi Arabia, those leaving private hospitals were found to have higher levels of satisfaction than those treated in public hospitals (Mahrous, 2013). However, communication between pharmacists and patients has been shown to be poor, with more than 60% of patients reporting that they failed to understand their pharmacists' instructions and about a quarter of all patients reported receiving no information about their prescriptions whatsoever (Alturki, Khan, 2013).

In Riyadh, patients reported slightly higher satisfaction with pharmacists, stating that doctors not only gave instructions about the prescription drug but also discussed possible side effects (Al-Arifi, 2012). However, still nearly half of all patient respondents in Riyadh failed to express or communicate satisfaction. Still more troubling is the percentage of patients who do not report errors committed by health care professionals as a result of "administrative barriers" -- i.e., poor access to reporting for patients (Almutairi, Moussa, 2014).

Patient-Centeredness

Patient-centered care is often a problem in Saudi Arabia. One of the main aspects of patient-centered care involves informing the patient of his or her rights -- "especially the rights to be kept fully informed of his/her diagnosis and treatment plan" (Almutairi, Moussa, 2014, p. 804). By acknowledging patients' rights, providers show concern and respect for patients. As Al Momani and Al Korashy (2012) show, "failure of nurses and other health care providers to take into account factors observed and reported by patients as important to their nursing care is inconsistent with the notion of patient-centered care and patient empowerment" (p. 42). Treating each patient in the manner that he or she wishes to be treated is what providing quality care is all about. This means that understanding patient needs and interacting with patients in a way that demonstrates respect for the patient's culture, beliefs, and attitudes is a significant part of health care. Administering to symptoms, ailments and illnesses is only one portion of providing care. Because patients are people with feelings, concerns, fears, and questions, they have to be approached with empathy. The study by Alturki and Khan (2013) showed a significant lack of empathy on the part of health care providers towards patients in Saudi Arabia -- and this is a considerable problem that must be addressed.

Providing patient-centered care while recognizing cultural diversity and the patient or designee as a full partner in the decision-making process is a vital standard to primary care nursing, as stated by the National Organization of Nurse Practitioner Faculty (NONPF, 2013): the reason for this is that patient-centered care places the patient and his or her needs at the fore of the care giving process and orients the nurse practitioner to the idea of being fully attendant to the patient's rights, needs, cultural beliefs and desires. By being sensitive to the uniqueness of every patient and respecting every patient accordingly, the nurse practitioner is better able to provide the highest level of quality care possible to the patient.

Timeliness

Timeliness is a problem on both ends of the patient-provider relationship. First, many patients do not seek out medical advice in a timely manner, which results in conditions worsening or in a lack of preventive care being possible to administer. The main cause for this delay in the seeking of care is found in cultural beliefs that are firmly embedded in the Saudi culture. However, the second point to be made is that a third of specialists sampled in a study by Eleishi and Allison (2009) showed a significant failure to refer patients to the respective help they needed, again resulting in an obstacle to preventive and quality care being achieved. Thus, on both ends of the spectrum, timeliness is an issue in Saudi Arabia that both patients and providers must address.

As a study by Mourra, Fish and Pfeffer (2015) shows, timeliness is also an issue that needs to be addressed in European hospitals: "deficits in communication between inpatient and outpatient physicians in the post-hospital discharge period are common and potentially detrimental to person-centered doctor-patient relationships and to patient health." Mourra et al. (2015) suggest that education, better use of communication tools, and a shift to a more person-centered health care approach can help nurses and physicians to overcome obstacles related to timeliness.

A Frontline documentary hosted by T. R. Reid in 2008 focused on health care systems around the world. Timeliness was a huge factor in several systems. In the UK, timeliness was not always evident, especially when elective care was the case. Wait times for patients could be considerably long -- many months in fact. In Taiwan, on the other hand, timeliness was very important to the people and the health care system that was devised was based on the idea that for quality care to be obtained, patients should have direct, easy and timely access to providers -- and not have to wait in long lines or put off operations for months on end. The problem that the Taiwanese are running into, however, is that there is simply not enough money to cover this type of care. As a result, the Taiwanese government is borrowing heavily from banks to fund timely care for its citizens. This is not a situation that can be supported in perpetuity. A better solution will need to found.

Efficiency

Efficiency can be measured by evaluating a number of factors in health care -- from the quality of work life for primary care givers to workplace environment, staffing, burnout, professional development opportunities, and so on. One study conducted in the Jazan region of Saudi Arabia showed that the quality of work life for primary care givers in this region is below average and needs to be improved (Almalki, Fitzgerald, Clark, 2012).

Compared to the rest of the world, Saudi Arabia has room to grow, too, in terms of providing quality care by implementing new technology. A study by Chaudhry et al. (2006) notes that "experts consider health information technology key to improving efficiency and quality of health care" (p. 742). This finding is supported by other research in Europe and the US that indicates that the use of new technology and especially eHealth and e-Medicine can be of a great facility in the improvement of efficiency and quality care (Abernathy et al., 2008).

Equitability

Similar to efficiency, equitability can be measured by a number of factors. The study by Al Onaz et al. (2012) examined differences between morning and night shift nurses in Saudi Arabia, focusing in particularly on levels of empathy displayed by nurses on each shift. The findings showed that morning and night shift nurses were perceived by patients to have different levels of empathy.

Equitability is not an issue that is unique to Saudi Arabia. Countries around the world suffer from the same type of unequal application of care to patients, as Ganz, Casillas and Hahn (2008) have shown. The main problem is that every nurse and physician must be aware at an individual level just how he or she is interacting with patients at all moments during the job.

As Reid (2008) shows in his Frontline documentary on health care systems around the world, equitability is a major issue for many countries -- yet not all countries approach it the same way. In countries where socialized medicine is the source of universal coverage, there is competition among providers for government funds. In the UK, this is especially the case as hospitals compete not for profits but for patients. Without patients, the hospitals will not survive and providers will be out of work. It is a system that has benefits and cons just like anywhere else -- and the fact is that there is no one systematic way to ensure equitability. Equitability starts and stops with the individual and must be encouraged and promoted at the individual level. Ways forward with regard to this type of promotion will be discussed in the following chapters.

A Look around the Globe

Around the globe, the number one rated health care system can be found in France, as determined by the World Health Organization (2000), which used the IOM's performance indicators to measure health care systems of states all over the planet. Italy, Spain, Oman, Austria and Japan rounded out the top 5 health systems in the world as ranked by the IOM at the turn of the 21st century. These five systems were shown to be able to keep health care costs down while delivering positive patient outcomes and providing preventive and quality care. Their health systems serve as an opposite example of what is occurring in the U.S., where health care costs are soaring, where nearly 100,000 Americans who are hospitalized every year die as a result of poor quality care (Goldhill, 2009), and where a failure to "translate knowledge into practice and apply new technology safely and appropriately" is a common occurrence (Amutairi, Moussa, 2014, p. 803).

Understanding the health care system in France can help illuminate some of the key issues surrounding the provision of quality care. For instance, in France, the provision of care is viewed as "a national responsibility" -- i.e., everyone is a stakeholder when it comes to quality care, and every citizen bears a responsibility in ensuring that quality care is deliverable (Mossialos, Wenzl, Osborn, Sarnak, 2016). As Mossialos et al. (2016) note, "the French system has evolved from a labor-based Bismarckian system to a mixed public -- private system. Over the past two decades, however, the state has been increasingly involved in controlling health expenditures funded by statutory health insurance" (p. 59). In other words, a national strategy of health care is overseen by the central government, elected by the people, and the members of which place a large emphasis on "prevention and care delivery" -- two terms which are essential in understanding the success of the French health care system (Mossialos et al., 2016, p. 59). When preventive care is made a part of policy -- as opposed to the subsidization of treatment (which only incentivizes care givers to offer more and more treatments and run more and more tests -- most of which are unnecessary, burdensome, costly, and draining) -- the outcomes are more positive across the board.

As the Institute of Medicine (1999) has stated, "it is not acceptable for patients to be harmed by the health care system that is supposed to offer healing and comfort -- a system that promises, "First, do no harm" (p. 2). The Institute of Medicine (1999) to list a number of strategic points that can be implemented to ensure that quality care is being achieved. These strategic points are, moreover, based on the indicators of quality care identified by the IOM and emphasized in the Institute's report on improving quality care around the world. The strategic points for improving care include:

• Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety.

• Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems.

• Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care.

• Implementing safety systems in health care organizations to ensure safe practices at the delivery level (Institute of Medicine, 1999).

In the Kingdom of Saudi Arabia, as elsewhere in the world, following these points can play a pivotal role in helping health care providers to improve quality care for patients in all types of facilities.

Conclusion

The following chapters will examine ways in which quality care improvements can be made in Saudi Arabia. As Hassanain (2017) points out, this is something the Ministry of Health (MOH) has already begun to examine. Its own "patient first" initiative has been tested in order to identify key ways to improve quality care delivery in health care facilities across the Kingdom. As Hassanain (2017) notes:

The MOH initially adopted a wide array of standardized health care performance improvement plans, as developed by the Agency for Healthcare Research and Quality and successfully implemented in the United States, to enhance health care sector competencies and the performance of its facilities in KSA. The goal was to create a culture of quality by emphasizing the "patient first" paradigm. However, a lot of skepticism emerged when this intervention was designed. This was largely because of a lack of motivation systems for workers or administrators due to the 100% public structure of health care at the Saudi MOH wherein all workers are salary based and budgets are based on actual bed numbers and not on performance or volume. Furthermore, there was an absence of quality measures or key performance indicators (KPIs). In response to the overwhelming patient and administrator dissatisfaction regarding the hospitals' performance, the quality and development teams at the MOH decided to develop and implement performance improvement initiatives based on corporate performance improvement methodologies.

The following chapters will look more closely at performance improvement initiatives that the KSA might utilize so as to improve quality care delivery. Chapter 2 will examine IOM-recommended collaborative professional practice and interprofessional practice models as a means of achieving high quality care. It will also discuss achieving quality care using evidence-based practice. Chapter 3 will focus on using simulation as a means of improving nursing skills both in universities and in hospitals in the Kingdom -- the goal being to enable nurses to more competently achiever quality care delivery through addressing the key indicators of effectiveness, efficiency, patient satisfaction, patient-centeredness, timeliness, and equitability. It will also examine the role of cultural competency as a means of achieving high quality care in a diverse community such as is found in Saudi Arabia.

References

Abernathy, A., et al. (2008). Improving health care efficiency and quality using tablet

personal computers to collect research-quality, patient-reported data. Health Services Research, 43(6): 1975-1991.

Aiken, L.,Van den Heede, K., McKee, M. et al. (2012). Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ, 344: e1717.

Al-Arifi, M. (2012). Patients' perception, views and satisfaction with pharmacists' role

as health care provider in community pharmacy setting at Riyadh, Saudi Arabia. Saudi Pharm J, 20: 323-330.

Al Hosis, K., Mersal, F., Keshk, L. (2013). Effects of job stress on health of Saudi

nurses working in Ministry of Health hospitals in Qassim region in KSA. Life Science Journal, 10(1): 1036-1044.

Aljadhey, H., Alhusan, A., Alburikan, K., Adam, M., Murray, M. D., Bates, D. W.

(2013). Medication safety practices in hospitals: A national survey in Saudi Arabia. Saudi Pharm Journal, 21: 159-164.

Aljarallah, J. S., Alrowaiss, N. (2013). The pattern of medical errors and litigation

against doctors in Saudi Arabia. J Family Community Med, 20: 98-105.

Almalki, M. J., Fitzgerald, G., Clark, M. (2012). Quality of work life among primary

health care nurses in the Jazan region, Saudi Arabia: a cross-sectional study. Hum Resour Health, 10: 30.

Al Momani, M., Al Korashy, H. (2012). Patient experience of nursing quality in a teaching hospital in Saudi Arabia. Iran J. Public Health, 41(8): 42-49.

Almutairi, K., Moussa, M. (2014). Systematic review of quality of care in Saudi Arabia.

Saudi Medical Journal, 35(8): 802-809.

Al Onazi, M., Al Jondeby, M., Azeem, M., Al Sayyari, A. (2012). Factors affecting

Saudi hemodialysis patients' perception of healthcare providers' empathy. Arab J. Nephrol Transplant, 4: 71-76.

Al Othaimeen, A., Al Nozha, M., Osman, A. (2007). Obesity: An emerging problem in Saudi Arabia: Analysis of data from the National Nutrition Survey. World Health Organization. Retrieved from http://apps.who.int/iris/handle/10665/117265

Alturki, M., Khan, T. M. (2013). A study investigating the level of satisfaction with the health services provided by the Pharmacist at ENT hospital, Eastern Region Alahsah, Kingdom of Saudi Arabia. Saudi Pharm J, 21: 255-260.

Chaudhry, B. et al. (2006). Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med, 144(10): 742-752.

Cowing, M., Davino-Ramaya, C., Ramaya, K., Szmerekovsky, J. (2009). Health care

delivery performance: Service, outcomes, and resource stewardship. The Permanente Journal, 13(4): 72-78.

Eleishi, H. H., Allison, B. D. (2009). Rheumatological medicine literacy among Middle

Eastern populations. Int J. Rheum Dis, 12: 336-342.

Ganz, P., Casillas, J., Hahn, E. (2008). Ensuring quality care for cancer survivors:

Implementing the survivorship care plan. Seminars in Oncology Nursing, 24(3): 208-217.

Goldhill, D. (2009). How American health care killed my father. The Atlantic.

Retrieved from https://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/

Harris, S., Aalsma, M., Weitzman, E. (2017). Research on clinical preventive services

for adolescents and young adults: Where are we and where do we need to go? Journal of Adolescent Health, 60(3): 249-260.

Hassanain, M. (2017). An overview of the performance improvement initiatives by the Ministry of Health in the Kingdomm of Saudi Arabia. INQURIY: The Journal of Health Care Organization, Provision, and Financing, 54: 1-6.

Institute of Medicine. (1999). To err is human: Building a safer health system. IOM.

Retrieved from https://goo.gl/7cXctp

Institute of Medicine. (2011). Leading health indicators for Healthy People 2020:

Report brief. Retrieved from https://goo.gl/SPpp7W

Institute of Medicine. (2013). Toward Quality Measures for Population Health and the Leading Health Indicators. Washington, DC: The National Academies Press. doi:https://doi.org/10.17226/18339.

Mahrous, M. S. (2013). Patient perceptions regarding information given on hospital

discharge in Almadinah Almunawwarah, Kingdom of Saudi Arabia. Journal of Taibah University Medical Sciences, 8: 105-111.

Mossialos, E., Wenzl, M., Osborn, R., Sarnak, D. (2016). 2015 International profiles of health care systems. Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf

Mourra, N., Fish, J., Pfeffer, M. (2015). Analysis of an intervention on discharge summary quality and timeliness. European Journal for Person Centered Healthcare, 3(3).

NONPF. (2013). National Organization of Nurse Practitioner Faculties. Retrieved from http://www.nonpf.org/

Reid, T. R. (2008). Frontline: Sick around the world. PBS. Retrieved from http://www.pbs.org/video/1050712790/

Thomas, M. (2005). Study examines working hours and feelings of fatigue by reported nurses. Texas Board of Nursing Bulletin, 36(4): 2-3.

World Health Organization. (2000). World Health Organization Assesses the World's

Health Systems. Retrieved from http://www.who.int/whr/2000/media_centre/press_release/en/

Chapter 2

Introduction

In Saudi Arabia, solutions to the problems of low quality care need to be developed and implemented. To this end, the Institute of Medicine's (IOM) recommended collaborative professional practice/Interprofessional practice model as a means of achieving high quality care is the first step in a positive direction for health care providers. A second solution that will be examined in this chapter is the achievement of quality care through the use of evidence-based practice.

As was shown in the previous chapter, quality care is what patients seek to receive and what providers hope to deliver. However, certain obstacles get in the way of delivery -- obstacles such as poor working environment, which negatively impacts providers' ability to give efficient, effective and timely care; burnout which causes providers to fail to deliver safe care or to follow safety guidelines; and a lack of equitability among staff, which causes care to be uneven from one provider to the next. All of this can be addressed through careful analysis of the IOM's quality health care indicators and implementation of the same institute's recommended practices and models for quality care delivery.

The IOM's Collaborative Professional Practice/Interprofessional Practice Model

Skochelak et al. (2016) state that interprofessional practice is another way of identifying what is known as collaborative teamwork in healthcare. This concept is defined as "multiple health workers from different professional backgrounds work together with patients, families, caregivers, and communities to deliver the highest quality of care" (Skochelak et al., 2016, p. 82). The main points of collaborative professional practice that should be implemented by care givers are the following (National Academies of Sciences, Engineering & Medicine, 2010):

• Nurses should practice to the full extent of their education and training.

• Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

• Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

• Effective workforce planning and policy making require better data collection and information infrastructure.

In essence, this type of collaboration is being pursued around the world and especially in health care markets where discord is problematic. For this reason, the IOM and other health care organizations and professional consulting services have put out "a call for a transformed healthcare system in which 'interprofessional collaboration and coordination are the norm'" (O'Brien, 2013).

As the Institute for Research, Education & Training in Addictions (2017) has shown, there is a strong link between education and collaborative practice -- i.e., without the former, the latter is unlikely to be achievable. Just as health literacy is needed to support preventive care, education is needed to support collaborative practice. Indeed, the future of nursing, according to the IOM model depends upon all stakeholders in the health care industry working together -- from educators to practitioners. The graph below helps to illustrate this macro perspective:

Source: http://ireta.org/2015/01/06/together-health-professional-associations-determine-core-competencies-in-collaboration/

The goals of collaborative care are myriad -- but some of the main ones include: improving quality of care for patients, bettering the status of communities in terms of health, and lowering health care costs (Stiefel, Nolan, 2012). In Saudi Arabia, these goals can be used to help guide care providers in working together with other health care professionals to ensure that the aims of the IOM-recommended model for interprofessional collaboration are achieved. Indeed, the study by Mason and Suresh (2017) showed that an "interprofessional team facilitated improved coordination of efforts, situational leadership, communication and feedback" in reducing infections in the hospital (p. 563). This kind of interproffesional team approach to safety can revolutionize the way that medicine is practiced in the Kingdom and drastically alter the health care landscape for the better. Likewise, the study by Molaeb (2017) showed how interprofessional team work in Saudi hospitals can help lead to more effective safety precautions being taken and overall safety culture being promoted. Through leadership commitment, accountability, education and feedback, professionals are able to come together and unite under a collaborative practice model that orients them all towards benefitting the patient to the fullest.

The following graph illustrates the concept of interprofessional collaboration and coordination as a series of inputs that lead to the implementation of processes and ultimately to substantial and desired outputs.

Source: Skochelak, S. et al. (2016). Health systems science. Philadelphia, PA: Elsevier, p. 82.

In Saudi Arabia, these inputs should come at the educational level, through the several higher learning institutions available to students of nursing and health care. These institutions, moreover, should be united in their overall program (from designing curriculum to measuring student development) with health care professionals as they plan for the future of health care in the Kingdom. Additionally, professionals should be including patients in these processes because patients are stakeholders in health care as well and -- after all -- it is their health that is at stake. Patients are the ones whom health care providers aim to satisfy. The more satisfaction that can be delivered to patients, the better health care providers will feel about their jobs. This means that patient needs should be thoroughly understood by professionals, and professional providers should be working with educators to help form students into nurses and doctors who are ready to engage in collaborative practice and evidence-based practice.

The inputs at the educational level lead to processes being developed and implemented at the professional level. Better planning among care givers, increased coordination and monitoring -- all of it results in greater levels of equitability, timeliness, safety. In other words, quality care indicators across the board rise. These are evident in the outputs: better overall performance from providers, greater team member satisfaction and improved team viability. The problem of burnout and overwork is addressed as a result and the working environment itself becomes infused with a culture that is positive and supportive because the team members within that culture are all aware of working on the same team, being on the same page, and striving towards the same goal -- quality care for patients through interprofessional practice.

Collaborative Care and EBP

As Newhouse and Spring (2010) note, "Despite the assumption that health care providers work synergistically in practice, professions have tended to be more exclusive than inclusive when it comes to educating students in a collaborative approach to interdisciplinary evidence-based practice" (p. 309). Moreover, the Committee on the Health Professions Education Summit (2003) showed that current health care systems along with a variety of complex patient needs have thwarted health care providers from producing high quality care for patients. In fact, the situation is made worse by the "exponentially expanding evidence base" which is not being utilized or properly to help achieve quality care (Newhouse, Spring, 2010).

To help address this issue, the IOM has issued recommendations that can be used to promote evidence-based practice (EBP) with a view towards better collaborative care. IOM has emphasized that practice should be guided by systematic reviews, and that skills learned in school should include the knowledge and ability to turn evidence into practice. Likewise, education should adopt an interdisciplinary approach so that the different sectors and departments of health care are not so isolated from one another -- after all, health care is ultimately a holistic practice and for holistic practice to be achieved, it should have a total or holistic basis or source -- and that means collaboration among professionals (Committee on Reviewing Evidence to Identify Highly Effective Clinical Services, Board on Health Care Services, 2008).

Al-Ansary and Khoja (2002) have shown that by utilizing evidence-based practice in primary care, the health of communities in Saudi Arabia would improve substantially. The majority of the nearly 700 primary health care physicians practicing at the Ministry of Health Primary Health Care Centres in Riyadh at the start of the 21st century recognized that evidence-based medicine would improve the quality of care of patients (Al-Ansary, Khoja, 2002). Moving away from opinion-based care to evidence-based care is a recommended practice that can greatly impact both patients and practitioners throughout the Kingdom.

The barriers to implementing EBP in Saudi Arabia include "lack of personal time, critical appraisal skills, and resources" (Al-Jazairi, Alharbi, 2017). These barriers, however, can be overcome through collaboration among health care stakeholders as described above. Personal time issues are factors that might seem like considerable obstacles that are different for everyone -- but by setting aside personal time for workers, who might otherwise have no chance to engage with health literature, health facilities can promote EBP in their very own workplace environments. With the advancements of technology in recent decades, electronic journals and databases can be accessed from personal computers -- and having access to these databases at the health care facilities can be part of a plan to promote EBP as well. Work shifts are already segmented for nurses and doctors -- and adding an hour or two during the week in which each provider is obliged to engage with scholarly literature on a particular subject related to health care (whether safety, timeliness, effectiveness, equitability, etc.) would help to remove the barriers cited by Al-Jazairi and Alharbi (2017). Moreover, weekly or monthly meetings could be held in which nurses and care providers discuss their readings for the week so that everyone can be made more aware of the most recent and important research in their fields. Sharing information can help improve everyone's attention to detail -- and in the 21st century's sharing economy there are even tools online that can facilitate this idea -- tools such as social media sites like Twitter and Facebook that can keep everyone informed about what team members are reading and what they are learning. This is a true example of collaboration in health care. EBP does not have to be based on one care giver's engagement with scholarly material in an isolated context: sharing information, stories, experiences and data helps everyone to come together more effectively as a team. It helps everyone to learn together, to act together and to be mindful together; it also helps providers to be aware as one -- to be oriented towards the same goals through a united and concentrated effort to implement EBP throughout the workplace environment. Facilities should certainly recognize the advantages that social media can bring to this type of operation.

Simply registering team members on a social media site like Facebook can have a profound impact on how teams begin to approach their roles as health care providers. Indeed, this simple step would help to substantially reduce at least two of the barriers to implementing EBP -- a lack of personal time and a lack of resources. By sharing on a popular media site that is quick and easy to access, team members can have access to what others have read and shared. This could become a regular part of nursing and practice in facilities, from hospitals to primary care. The use of social media is transforming many sectors throughout the world and should be utilized in health care to promote concepts that are important to the industry. Because it is such a convenient tool it can also used because it is a cost-effective way to distribute information to a wide number of people.

The lack of appraisal skills that serves as another barrier could be overcome through proper training in both universities and at the workplace. Training is received at every workplace primarily because many organizations have their own unique set-up, arrangements, culture, leaders, and so on. Workers are expected to conform to policies that are established at the workplace. By giving workers training in appraisal skills, EBP can be promoted more efficiently. Facilities could even hire full-time staff who are trained in appraising scholarly literature to read the latest evidence-based research, take notes, and share the main bullet points with hospitals, nurses, doctors and primary care givers. This would address the issue of so much evidence being published with so little time to read it. It would also take the stress off care givers who are already pushed to the maximum with regards to making the utmost of their time while on and off the clock. The important concept here is not that each individual be studying the latest in evidence-based research but that a mechanism be put in place that allows nurses and other care givers to share information among one another, stay informed, and have this intellectual basis for implementing EBP on the job. By devoting time, energy and resources to such a policy, health care organizations in Saudi Arabia could greatly enhance the level of quality care they are able to provide patients.

As Ubbinik, Guyatt and Vermeulen (2013) find in their study of evidence-based practice, "policy exerted at microlevel, middlelevel and macrolevel, and supported by professional, educational and managerial role models, may further facilitate EBP." In other words, in order for EBP to be applied, it has to begin at the local level -- the micro-level, with managers developing and implementing policy changes that would promote the use of EBP in their facilities. Using social media to help bring nurses and research together is a great way that health care in the 21st century can use technology that everyone has (smart phones are popular all around the world) along with a sharing platform that is the most popular of its kind (Facebook allows closed groups to form pages so that everyone can share information just to the members of that group).

Knowledge sharing in online environments has been shown to be an effective strategy (Hew, Hara, 2007) and Bahkali, Almaiman, Bahkali et al. (2015) show in their study of the relationship between social media and health in Saudi Arabia that these two elements can go together in a positive way. Indeed, by allowing nurses and primary care givers to share important information about what a select group of researchers is able to share, using outlines, bullets, or even simple but effective tweets, health care facilities in the Kingdom could literally lead the world in revolutionizing the way that EBP is taught, implemented and used to reach the desired end goal of quality care.

Currently EBP in Saudi Arabia is still at too low levels for the type of quality care envisioned by the IOM to be properly effected. Ashri, Al-Amro, Hamadah et al. (2014) report that "more efforts should be put into strengthening the skills and use of EBP among all medical practitioners" (p. 109) -- and the best way to do that is through the implementation of an EBP policy that promotes learning on the job through the sharing of information. This is corroborated by studies in which communication tools have been found to support teamwork and efficiency. With interprofessional practice as the goal, any type of communication tool that can promote EBP and EBP-awareness is bound to have a place in health care. Leonard, Graham and Bonacum (2004) put it this way: "All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk." By removing communication from the situation- or personality-dependent domain and giving all team workers access to it via a social media site like Facebook or Twitter, health care providers can more fully integrate the information all providers need to use EBP on a daily basis.

Management could easily make EBP an effective part of health care strategy in any type of facility. Daily bullets from the latest research, compiled by on-staff researchers whose job it is to stay up-to-date on all available data can make slogging through all published information a thing of the past for providers. Giving quick, easy updates and repetitive reminders using this type of technology is how health care is certain to advance in the coming years. In this way, EBP and collaborative practice will more surely succeed in becoming a part of Saudi Arabian health care culture. It is the right spirit that promotes the right kind of action -- and this type of forward-looking initiative that is grounded in present realities and the popular culture of sharing information is perfect for health care facilities that are looking for answers to the obstacles in the way of effective EBP implementation.

Conclusion

In conclusion, the IOM's collaborative professional practice model provides guidance for how health care providers should approach quality care:

• Providers should practice to the full extent of their education and training.

• Providers should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

• Providers should be full partners with one another, with physicians and other health care professionals, in redesigning health care in the United States.

• Effective workforce planning and policy making require better data collection and information infrastructure.

Through these guidelines, and with the help of evidence-based practice being implemented to support the achievement of quality care, health care professionals can be better aligned to achieve the recommended objectives of the IOM. The future of nursing and of health care not just in Saudi Arabia but also around the world depends on this type of quality care being achievable.

One way to advance the aims of EBP could be through the use of social media in the workplace as well. Social media is a popular tool that is transforming industries all over the world. It helps people to stay connected, to easily share information, to get up-to-date data on important topics, and to facilitate communication among professionals sharing their own professional social media group. The real estate firm Keller Williams in the U.S. places its Realtors in a social media group of their own on Facebook so that they can share questions, get answers and obtain feedback in real time. Everyone has access to the group and data can be shared instantly because everyone uses smart phones in today's Digital Era.

For nurses in Saudi Arabia, time is important as timeliness is one of the indicators of quality health care. However, nurses may not always have time to peruse the latest in evidence-based care -- which means a lot of important information is not getting passed through to them. In order to overcome this obstacle, having a professional team of readers and researchers on staff at the facility to go over the latest in EBP care and distill these articles down to their important points then uploading those points to a social media platform that all in the group can see and process can be an effective way to ensure that EBP information is getting passed on to the right people. If the information is not getting through, there can be no way for EBP to happen and no way for quality care to be possible. Social media can be an extremely useful and helpful tool in this regard because it ensures that nurses are able to obtain the information and evidence-based practices essential to their job even if they themselves cannot personally devote time to reading all the material on the subject that is published. This is why sharing sites like Facebook and Twitter can help.

The next chapter focuses on using simulation as a means of improving nursing skills, both in universities and in hospitals. Through practice in simulation, nurses can obtain the needed competency levels expected of health care professionals. Simulation exercises can help support positive development in effectiveness, efficiency, patient satisfaction and all the other indicators of quality care. The chapter will also examine the role of cultural competency as a means of achieving high quality care. In a diverse community like Saudi Arabia, culturally-tailored care can be an effective way to ensure patient satisfaction -- especially in the 21st century where more and more people are coming and going all over the world, altering the social and cultural landscapes of nations and communities. Awareness of cultures and of differences attendant to these cultures can make all the difference in how efficiently quality care is delivered.

References

Al-Ansary, L., Khoja, T. (2002). The place of evidence-based medicine among primary

health care physicians in Riyadh region, Saudi Arabia. Family Practice, 19(5): 537-542.

Al-Jazairi, A., Alharbi, R. (2017). Assessment of evidence-based practice among

hospital pharmacists in Saudi Arabia: attitude, awareness, and practice. International Journal of Clinical Pharmacy: 1-10. doi:10.1007/s11096-017-0430-x

Ashri, N., Al-Amro, H., Hamadah, L., Al-Tuwaijri, S., & El Metwally, A. (2014). Dental

and medical practitioners' awareness and attitude toward evidence-based practice in Riyadh, Saudi Arabia. A comparative study. The Saudi Journal for Dental Research, 5(2), 109-116.

Bahkali, S., Almaiman, A., Bahkali, A., Almaiman, S., Househ, M. S., & Alsurimi, K.

(2015). The Role of Social Media in Promoting Women's Health Education in Saudi Arabia. In ICIMTH (pp. 259-262).

Committee on the Health Professions Education Summit. (2003). Health professions

education: A bridge to quality. National Academy of Sciences; Washington, D.C.

Committee on Reviewing Evidence to Identify Highly Effective Clinical Services, Board

on Health Care Services. (2008). Knowing what works in health care: A roadmap for the nation. The National Academies Press; Washington, D.C.

Hew, F., Hara, N. (2007). Knowledge sharing in online environments: A qualitative case study. Journal of Am Soc Inf Sci, 58: 2310-2324.

Institute for Research, Education & Training in Addictions. (2017). Together, health professional associations determine core competencies in collaboration. Retrieved from http://ireta.org/2015/01/06/together-health-professional-associations-determine-core-competencies-in-collaboration/

Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13(suppl 1), i85-i90.

Mason, B., Suresh, S. (2017). Effectiveness of an interprofessional team approach at reducing CLABSI in a community hospital. American Journal of Infection Control, 45(6), S100.

Molaeb, B. (2017). Electronic Monitoring System Effect on Hand Hygiene Compliance

and Hospital Acquired Infection Rate at a Tertiary-Care Hospital in Saudi Arabia. American Journal of Infection Control, 45(6), S100.

National Academies of Sciences, Engineering & Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health. Retrieved from http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

Newhouse, R., Spring, B. (2010). Interdisciplinary evidence-based practice: Moving from silos to synergy. Nurs Outlook, 58(6): 309-317.

O'Brien, J. (2013). Interprofessional collaboration. AMN Healthcare Education Services.

Retrieved from https://lms.rn.com/getpdf.php/1892.pdf

Skochelak, S. et al. (2016). Health systems science. Philadelphia, PA: Elsevier.

Stiefel, M., Nolan, K. (2012). A guide to measuring the triple aim: Population health, experience of care, and per capita cost. IHI Innovation Series white paper. Cambridge: Institute for Healthcare Improvement.

Ubbink, D. T., Guyatt, G. H., & Vermeulen, H. (2013). Framework of policy

recommendations for implementation of evidence-based practice: a systematic scoping review. BMJ open, 3(1), e001881.

Chapter 3: Simulation and Cultural Competency

Introduction

As Zakari, Hamadi and Salem (2014) point out, simulation can be an effective way to apply research-based clinical training. Why is this? Simulation allows students to practice hands-on learning in a controlled environment in which there is no real risk to patients. Students can obtain much needed practice (practice makes perfect) and get a feel for the kinds of obstacles that might come their way in the real world. Just like pilots use flight simulators to train on the ground before learning at the controls of a million-dollar machine in the sky, nurses and nursing students can use simulation to train in a safe environment before entering into the professional realm, where -- if a mistake is made -- it can be costly in more ways than one.

Additionally, providing quality care to patients does not depend solely on one's technical skill but also on one's cultural competence. In a diverse environment like Saudi Arabia's, care is linked to awareness -- awareness of people's differing beliefs, needs, attitudes, desires, and dislikes. Cultural competency allows nurses to know the right ways to approach patients as well as the approaches to avoid. Cultural misunderstanding can result in safety issues just as much as a lack of technical training can result in them. Thus, it is equally important for nurses and all health care providers to be aware of the different cultures in one's community and of the preferences that are typically associated with those cultures.

This chapter will show how both simulation practice and cultural competency can help health care providers give more quality care to patients in Saudi Arabia. At the same time, it is good to remember that the principles and recommendations provided herein may really be applied all over the world for they are based on universal observations that are inherently supportive of good health care practices, no matter what one's region is.

Simulation

Simulation is an excellent method for improving nurses' skills in university-level training as well as in hospital environments. With the overall objective being to focus on the quality health care indicators -- effectiveness, efficiency, timeliness, equitability, etc. -- simulation can serve a tremendous purpose in helping nurses to obtain the skills they need to truly become quality care providers.

How does simulation work? While a great deal of research has been conducted that shows the effectiveness of simulation in developing nursing skills (Lababidi, Munshi, Al-Amar et al., 2015; Ahmed, Al-Mously, Al-Senani et al., 2016), it is worth taking a moment to describe how simulations can be used in advancing the IOM aims of improving quality care. One way that simulation helps nurses to improve their care skills is in the way it can build confidence among them: by practicing that which they know they will be doing in the real world, they can develop good habits under the tutelage and guidance of a teacher or professional who is there to help them every step of the way. A simulation is a controlled or monitored environment where nurses can put into practice the knowledge they have acquired over the course of their education or training. Aside from actual clinical practice, simulation is the most instructive and effective way for nurses to accumulate experience.

Types of simulations that can be effective for learning a new skill in the classroom or in training on the job include:

• Interactive multimedia patient simulation

• Role playing

• Clinical scenarios

• Standardized patient examinations

As Terzioglu, Tuna and Duygulu (203) affirm, "learning from experience is an important part of nursing education" and "using simulation as an innovative teaching strategy in nursing education" is an effective way to reinforce technique, principles, knowledge, skills and practice (p. 34). Indeed, simulation is so effective because it is in line with the "art of empowering others" that Conger (1989, p. 17) identifies as the root of real leadership. Through simulation exercises, nurses can obtain self-confidence and empowerment -- keys to implementing knowledge in practice; skills that can turn them into true leaders.

Since nurses can act as primary care givers, their role in health care both in Saudi Arabia and around the world is to be a true and actual leader. No one can lead without ever having experienced the real thing -- and simulation is a method that eases nurses into the real thing so that they are prepared for the surprises that they will undoubtedly encounter in their field. Like soldiers who prepare for war by playing war games, nurses prepare for patients by practicing nursing in simulated sessions.

These sessions can be effected through role playing -- a type of practice in which one nurse or instructor acts as a patient presenting with a certain issue or issues and in which the nursing student or nurse practitioner must make an examination, perform a diagnosis and provide a treatment. Role playing is a highly instrumental and effective strategy for both measuring student knowledge and skill set and for providing students and professionals with invaluable practice time to allow them to hone their craft and perfect their approach to patients.

Interactive multimedia patient simulation can also be a method to help nursing students and nursing professionals improve their skills and practice their knowledge in action. Students and professionals would use software and computer technology in this type of simulation to obtain practice in treating patients without actually engaging with a real patient. This is different from standardized patient examinations, in which the nurse examines a patient with the assistance of an instructor or team leader. Either is helpful in allowing the nurse to gain experience and since experience is the best teacher, both are suggested practices for nurses in Saudi Arabia.

Simulation can be a highly influential practice that can really make a world of difference in the field of nursing. Fielden (2012) conducted a study of new graduate nurses in Saudi Arabia transitioning into clinical practice and found that simulation was effective in increasing both confidence and competence among the new graduate nurses. Fielden's (2012) recommendation was that a practice development framework in which simulation exercises are pivotal would be a welcome addition to nursing graduate development programs in Saudi universities. The same idea could also be applied to Saudi hospitals where nurses learning a new role can practice that role in simulation exercises before interacting with patients. The important concept to remember here is that simulations offer a safe way for providers to practice their skills and knowledge. Because safety is such a significant part of providing quality care, health care professionals and educators should be very mindful of the power that simulation exercises can have for nursing students and nurse practitioners. Akhu-Zaheya, Gharaibeh and Alostaz (2013) have found the same in their own research: "Nursing students must be educated with the most realistic technologies available to improve patients' safety" (p. e335). Their quasi-experimental research showed that "students trained with high-fidelity simulation achieved higher scores in acquired and retained [basic life support] knowledge and higher self-efficacy perception, indicating the value of simulation in improving knowledge and self-efficacy in nursing students" (p. e335). Thus, the evidence is more than apparent that simulation should be considered an appropriate and effective tool in advancing nurses towards the IOM goal of quality care.

Simulation not only provides nurses with experiential training that can enable them to be safer, timelier, and more effective in providing quality care, it also psychologically prepares them for the job they are about to enter into. This psychological impact has been noted even by researchers outside of the nursing profession. In the business world, for instance, simulation exercises can have a positive psychological impact on students. Wood and Bandura (1987) performed a study of graduate business students using a managerial practice simulation. They found that the underlying beliefs of the students regarding their abilities to perform governed them towards achieving specific goals and guided them in adopting motivational patterns.