In 2007 I arrived in Beijing at the start of a philanthropic exercise, and as I was driven into the city and stared at the modern buildings I thought: “Why are we funding something here? This could be Minneapolis.” Later I learnt that there are at least three Chinas: western China, which is as undeveloped as Africa; an Eastern seaboard that is developed; and a large centre that is like a middle income country. And although China showed its modern capabilities in the Olympic buildings and plans to put a man on the moon, it lacks some things that developed countries have—and one of these is highest quality children’s heart surgery.
West China Hospital in Chengdu has 4300 beds, making it one of the world’s largest hospitals, and serves the 80 million people of Sichuan Province as well as other populations in western China. The hospital has a department that offers heart surgery to children, and in 2010 it looked after 742 children, a 36% increase in volume over 2006. In 2008, the mortality for complicated procedures was 22%, but this had fallen to 8.5% by 2009.
In 2006, the department was partnered with the Department of Cardiovascular Surgery at the Hospital for Sick Children in Toronto by a charity called Children’s HeartLink. I’m a member of the International Advisory Board of the charity and heard Glen Van Arsdell, head of the Toronto department, describe the experiences of him, his team and the charity in trying to help the team in the West China Hospital achieve the highest standards of children’s heart surgery.
I suppose I should have known this, but I was fascinated to hear Van Arsdell explain how in many ways the technical operating skills are “the easy bit.” To reach the highest standards you need not only the knowledge and skills but also behaviour to match organisational investment and design, and to develop a “learning team” that thinks critically and is highly responsible. And to get the best results for children with complex congenital heart disease you need not only a first class surgical team but also paediatric cardiology, anaesthetic, and critical care teams—and they must work well together. (As I listened to this I inevitably thought of the disaster of children’s heart surgery in Bristol and thought that probably not all citizens of developed countries do have access to the very best care.)
The main aim of the Children’s HeartLink programmes is to build centres that will offer high quality care and be self-sustaining. The way that the partnership works is that Children’s HeartLink meets with West China Hospital each year to devise a development plan with specific objectives. The full Toronto cardiac team usually visits for a week a year, and other small teams may also visit to focus on particular areas. Medical staff from West China Hospital have also travelled to Toronto to observe and train at the hospital. The main achievements of the initial 2006 visit were to build the Toronto team’s understanding of how the Chinese programme worked and to build credibility with the Chinese team and leadership. The technical skills of the surgeons were good, but there was neither adequate organisational design nor the learning team that is needed for the highest quality of care. Intensive care was weak, and the hospital still does not have any paediatric cardiologists.
The 2007 visit led to further improvements in knowledge and skills but little impact on the other components of good care. It was followed in 2008 by five key members of the Chinese team spending a month in Toronto—and seeing for themselves the importance of teamwork and a fully integrated system. When the Chinese went home they managed to achieve dedicated space for paediatric cardiac intensive care.
A crucial component of the Toronto team’s 2009 visit was a retreat, the sort of meeting that doctors often hate. Helped by the Toronto team, the Chinese team conducted a detailed assessment of what they needed to move to the highest level, developed a vision of what they wanted to achieve, and set priorities for moving towards their vision. There were many priorities, but they included improving the unit’s ability to intubate babies and to use echocardiography in the intensive care unit. In 2010, three people from China visited Toronto, and in 2011 a large team from Toronto went to China and spent two weeks in order to increase the impact.
The department at West China is still some distance from becoming a centre of excellence, but there has been considerable improvement between 2006 and 2011. Intensive care and ward care are where the biggest improvements are needed now.
The ultimate aim of Children’s HeartLink is to help centres in low and middle income countries reach “regional centre of excellence” standards and be able to train and educate others in the region. Amrita Institute of Medical Sciences in Kochi, India, is the first of Children’s HeartLink’s partners to reach this pinnacle. I was left impressed by realising how hard it is to reach the highest standards and how very much more is needed than skilled surgeons and good equipment. Indeed, the organisational and behavioural parts may be the hardest to achieve.
Competing interest: RS is an unpaid member of the International Advisory Board of Children’s HeartLink. He is expecting to have his expenses paid for the next face to face meeting in Washington DC, but he is long past the stage when an economy return to Washington is any kind of a gift.
RS was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.