Korea has extensively expanded its healthcare infrastructure over the past several decades, building on a health insurance system that was the envy of a previous American president. There are scores of large hospitals equipped with highly advanced facilities and staff. Developments in diagnostic techniques and treatments have brought the country shoulder to shoulder with other developed nations in terms of cancer survival. The number of cancer survivors surpassed 1.6 million in 2016. Every year, over 300,000 foreign patients visit Korea for its hospitals.
From the outside, Korea looks to be on the verge of becoming a medical powerhouse. Yet despite all the progress, there has been no end to the stream of hospital-acquired infections, incidents affecting patient safety, and assaults on healthcare professionals.
All manner of incidents have occurred in the past few years. To name a few: the 2014 fire at a nursing home in Jangseong, the 2015 MERS outbreak, assaults against medical residents at Pusan National University Hospital and other teaching hospitals, power harassment against nurses, newborn infant deaths at Ewha Womans University Medical Center in Mok-dong, and a fire at Sejong Hospital in Miryang. It is unnerving to think that any accident can occur at any time, anywhere.
In truth, Korea seems a long way from being a medical powerhouse. Despite the expansion and advances in infrastructure and technologies, serious issues remain within the healthcare system. A series of fatal accidents have occurred in hospitals where patients went seeking care. Why is this happening?
It seems inappropriate to shift the blame for this endless stream of errors onto individual hospitals and medical professionals. And while infrastructure expansions may have contributed to the rise in medical accidents, they do not by themselves explain the absurd failings of recent years.
The structural problems in the healthcare system run deep. And among those problems, it is important to focus on the shortage of medical professionals at hospitals and the consequent drop in quality. In many hospitals, one or two people are forced to handle the work of five. Hospitals struggle through by stretching their workers thin and squeezing out of them every last drop of labor.
Every time an accident occurs, understaffing is singled out as the cause. And, like a parrot, the government responds with yet another call for more personnel. Things are not getting better.
Chronic understaffing probably contributed to the deaths in Jangseong and Miryang
A still from YTN’s news coverage of the fire at a nursing home in Jangseong in May 2014 | Rapportian
It was the same when a fire killed 21 patients at a nursing home in Jangseong. The nursing home was run with minimum personnel: on night shifts, one nurse’s aide had to care for thirty to forty patients. As a result, the staff were not able to respond proactively when the flames went up.
The manpower problem goes beyond this specific nursing home. After the fire, the Ministry of Health and Welfare conducted safety inspections and surveys of all nursing homes in Korea, and found that 198 of them were in violation of the Medical Service Act. Violations included not obtaining permission to change the number of licensed medical personnel on staff, and having too few medical personnel on duty. Fully 131 nursing homes had too few medical personnel on duty. In one facility, there was one doctor for every 65.1 patients; in another, one nurse was responsible for 47.1 patients.
In an effort to improve the safety of patients during vulnerable times, such as nights and holidays, the Ministry of Health and Welfare strengthened standards by making it mandatory to hire professional caregivers (three shifts a day) and have a minimum of two doctors per institution. However, the hospital fire in Miryang showed that the new measures were ineffective.
In 2016, Sejong Hospital had an average of 74.5 inpatients and 135.9 outpatients at any given moment.[1] According to the medical personnel standards stipulated in the Medical Service Act, Sejong Hospital was required to have six full-time doctors and 35 nurses. Instead, there were only two doctors, six nurses, and 17 nurse’s aides. If the hospital had the optimal number of personnel, it might have been possible to evacuate more patients to safety at the start of the fire.
The neonatal intensive care ward at Ewha Mok-dong Hospital was understaffed
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The deaths of newborns at Ewha Womans University Medical Center in Mok-dong were for similar reasons. According to the regulations, five doctors were supposed to be on duty in the Neonatal Intensive Care Unit on the night four babies died in succession. Yet there were only two residents on duty at the time.
That day was probably not unusual. If the required number of medical personnel had been on duty at all times, the situation might have turned out differently.
The 2015 MERS outbreak is another case in point
Likewise, during the MERS outbreak, the medical centers treating MERS patients had already been severely short of staff, and the increase in the number of patients requiring quarantine exhausted many medical professionals.
An even more serious problem arose after the outbreak. In order to strengthen infection control and management, the government restructured the entire medical system and related medical costs. Hospitals with infection control rooms are now required to increase the number of beds in such rooms to over 150 by October 2018, and to deploy more staff in those rooms in proportion to the number of beds.
However, even if facilties wish to increase staff numbers in line with the strengthened standards, the number of available doctors and nurses with expertise and experience in infection control is far from sufficient.
According to the Korean Society for Healthcare-associated Infection Control and Prevention, a total of 1,500 new nurses specializing in infection control are needed by the second half of 2018.
Yet considering that there are not enough nurses with expertise in infection control and that many nurses end up quitting due to the difficulty of the work, an increase of this scale is nearly impossible.
Similarly, Korea only produces 20 infectious disease specialists each year, adding to the difficulty of meeting the new standards. The neonatal deaths at Ewha Womans University Medical Center stemmed directly from the infection control issue, which had not improved after the MERS outbreak.
Four academic organizations, including the Korean Society of Infectious Diseases and the Korean Society of Pediatric Infectious Diseases, recently made a joint statement asserting that the “neonatal deaths at Ehwa Womans University Medical Center is a case that shows the vulnerability of Korean medical institutions to hospital-acquired infections, an issue which has not improved since the MERS outbreak.”
Integrated nursing and care
Image of a hospital room that provides integrated nursing and care. This photograph is not directly related to the content of this article. | Rapportian
What of the government’s expansion of the Integrated Nursing and Care Service? This decision was reached in the aftermath of the MERS outbreak, which revealed open hospital rooms (in which guardians and professional caregivers stay with patients) to be particularly strong infection risks. Patients under the integrated service are instead cared for by dedicated nursing personnel.
The successful expansion of integrated nursing and care needs to be premised on an overall increase in nursing personnel. However, other than a few big hospitals in the Seoul area, many public hospitals and small- and medium-sized private hospitals have been unable to secure nurses and therefore have difficulty operating integrated nursing and care wards.
The shortage of nursing personnel in hospitals outside of Seoul has worsened since big hospitals in Seoul started hiring more nurses to provide integrated nursing and care. With experienced nurses from hospitals outside the Seoul area leaving for jobs in the capital, the quality of medical services in those hospitals have deteriorated, and concerns about accidents affecting patient safety have grown.
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Assaults and power harassment
The chronic problem of medical personnel shortages also underlies the assaults on residents and power harassment against nurses. Since there is always a lack of medical personnel, senior doctors and professors do not hesitate to verbally and physically abuse medical residents in order to squeeze out labor.
“The medical resident system in Korea is possible because it basically forces residents into “low-wage, highly efficient, and highly intensive labor”, in line with the government’s three lows: low medical fees, low wages, low burdens. The government irresponsibly sets medical fees at far less than 80 percent of the actual cost and tells the hospitals to take care of the rest themselves. In this system, hospitals need low-wage workers, like residents, and cannot but force profit-oriented business logic on residents.”
— from Time for an Improved Medical Resident System, in the January 2018 newsletter of the Korean Academy of Medical Sciences. Written by Jeong Ji-tae, the academy’s vice president.
Nurses are not in a better position. The chronic shortage of nursing personnel has routinized extremely intensive nursing work, and also created the ‘taeum’ culture, literally meaning ‘burning’, in which senior nurses physically and verbally abuse their juniors to the point of ‘burning them to ashes’. On top of this, hospitals have made unreasonable demands of nurses, infringed on their personal rights, and exploited them by refusing to pay them for overtime work.
‘The series of serious medical errors is a warning sign about Korea’s failing healthcare system’
It is difficult to expect safety for patients under such circumstances. And many have long pointed out the dangers of the chronic shortage of doctors and experienced nurses. Some see the series of medical errors as a warning about Korea’s failing healthcare system.
In a working paper titled “Increase in Hospital Personnel: The First Priority for Improving Patient Safety”, Lee Sang-yun, a senior researcher at the Center for Health and Social Change, wrote: “Qualitative development of healthcare and hospitals is slow compared to quantitative expansion. While hospitals are getting bigger, growing in number, and improving their facilities, medical accidents occur frequently and the underlying issues have not been resolved… these medical accidents and scandals that occur every time we are about to forget the previous one are warning signs about Korea’s failing healthcare system.”
Medical accidents have stirred up drama and controversy across the whole of society, but Korea has so far lacked the resolve to delve into and address the structural problems of its healthcare system.
Patient safety laws and medical institution certifications are of no use when there is a shortage of medical personnel.
When chronic personnel shortages lead to staff exhaustion, it can become difficult for medical personnel to even follow procedure manuals, and serious errors such as accidental administration of vincristine become possible. In certain cases, medical personnel have been unable to perform even basic tasks like confirming the identity of patients, whether or not patients have received blood transfusion, or checking surgical sites. This has resulted in blood transfusions of the wrong type and other very preventable errors.
Lee argued, “The government needs to legalize a minimum level of nursing personnel in hospitals and establish strong monitoring and penalties for hospitals that violate the law. Related laws must be improved to provide hospitals with the drive to enhance the level of nursing personnel voluntarily. In addition, it is important to establish regulations on nurses’ working and rest hours as well as the various labor, safety, and healthcare regulations, which vary with the type of the hospital.”
Above all, more and more people are asserting that the government should take direct responsibility for increasing personnel numbers, a task currently left up to individual hospitals.
To this end, we must establish plans for the development of health and medical services at the national level in line with the provision stipulated in the Framework Act on Health and Medical Services. The plans should set development goals and directions, appropriate allocation and supply of medical resources, and measures to make the system for using healthcare more efficient at the national level. The various healthcare policies should also be promoted accordingly.
The Framework Act specifies that the national plans need to include: 1) basic objectives in the development of health and medical services and the direction for promoting such development; 2) measures to secure and manage resources for health and medical services; 3) policies for managing the total number of sickbeds of each region; and 4) policies for boosting the efficiency of service provision and usage. However, since the Act was enacted and implemented in 2000, the Ministry of Health and Welfare has yet to establish functional development plans.
Instead of deciding on a direction for the healthcare system at the national level and promoting specific strategies, the government is currently promoting whatever policies seem suitable. There is no plan. Whenever a medical accident occurs, the government pours out short-term measures to improve the system, which only distorts the medical treatment system even more.
On January 30, 2018, the Korean Health and Medical Workers’ Union made a statement, asserting the need for “a fundamental change in government policy and hospital business strategies that [currently] focus on investing in facilities and equipment, rather than personnel, in order to maximize profits.” The union also demanded that “the government come up with policy measures to provide a stable supply and balanced deployment of healthcare professionals.”
We should no longer continue promoting “comprehensive measures for X” or “the improvement of the system for Y”. There are too many warning signs across Korea’s healthcare system. From the MERS outbreak to the incident at Ewha Womans University Medical Center and the Sejong Hospital fire in Miryang, these accidents once again remind us that it is now time to set basic goals for the development of Korea’s healthcare system, the direction for promoting such development, and specific strategies to realize those goals.
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