The ethics review began with one sentence projected on the wall: `Increase appropriate local management rate by reducing avoidable referrals.`
Dr Salim, the committee chair, read it twice. “My question is simple. Can you get the funding you want without making referral look like failure?”
Wekesa sat on one side of the table, Malik on the other. Otieno from finance had the proposal spreadsheet. Farah had the three-month audit summary.
“The county wants measurable efficiency,” Otieno said. “If we remove the local-management percentage, we lose an indicator that shows our capacity.”
“The problem is not measuring local care,” Malik replied. “The problem is using referral count as a proxy for failure without adjusting for severity.”
Wekesa placed the old memo on the table. “I have said repeatedly that there is no referral quota.”
“And the evidence supports that,” Farah said. “But staff interviews show this phrase was interpreted competitively. Some believed a high number of referrals affected how they were evaluated.”
Wekesa said nothing.
“Is there a case where harm has been proven to result from the KPI?” Dr Salim asked.
“No,” Malik said. “We should not claim that. Kevin’s case contains operational gaps and clinical judgment that the review still has to interpret in context. But the metric may amplify hesitation that already existed.”
“Amplify is difficult language for a funding document,” Otieno said.
“Then don’t put the word in the funding document,” Malik replied. “Change what we measure.”
They brought forward three options. The first kept a `local retention rate` but adjusted for case complexity. The second measured the percentage of cases in which the appropriate level of care was completed within a target time, whether that meant local treatment or referral. The third measured documentation of escalation.
Wekesa studied the second option. “This could lower our number because delays at receiving hospitals would enter our metric.”
“We can separate controllable intervals from shared intervals,” Farah said.
“And the county will understand that?”
“We explain it.”
Otieno shook his head. “They like a simple percentage.”
“A simple metric that teaches the wrong behavior is more expensive than a complicated one that measures the right thing,” Malik said.
Dr Salim turned to Wekesa. “What exactly did your staff say?”
Wekesa opened a file. “Two said they felt pressure to ‘manage locally first.’ One said review feedback made them afraid of being labeled an unnecessary referrer.”
“Do you believe that interpretation was intended?”
“No.”
“But was it possible?”
Wekesa sat quietly for several seconds. “Yes.”
It was the first time Malik had heard her say it so plainly.
“Then,” Dr Salim said, “the governance issue is not motive. It is predictable interpretation.”
Otieno pointed to the deadline. “The funding proposal has to go in by five. If we change the KPI now, we need final wording in two hours.”
Farah drafted:
`Measure timely completion of appropriate care pathway, including safe local management, timely escalation, and documented referral when higher capability is indicated.`
“Too long,” Wekesa said.
Malik suggested: `Appropriate care completed at the right level, with timely escalation when needed.`
“How do we score it?” Otieno asked.
Farah listed the components: local care appropriate; escalation criteria met; referral initiated within standard; communication owner documented; receiving scarcity separated.
“This will make our report look less impressive in the first year,” Wekesa said.
“But more honest,” Malik replied.
“Honesty alone will not buy a CT scanner.”
“And a beautiful number that hides risk will not buy safety.”
Dr Salim stopped them before the argument returned to familiar ground. “Your funding case may actually be stronger if you show data about where your capability ends. The county needs to know which investments would change referral demand, not merely that transfer numbers went down.”
Otieno began changing the spreadsheet. Instead of a target for reducing referrals by a fixed percentage, he entered a target to reduce `avoidable referral` according to appropriateness review and to bring `unowned escalation intervals` close to zero.
“Can an unowned interval really be measured?” Malik asked.
“Yes,” Farah said. “The bridge log has an owner field.”
Wekesa smiled slightly. “So your whiteboard has become a KPI.”
Achieng, had she been there, would have called it a better KPI.
They reviewed the wording one last time. Dr Salim asked Malik, “Can you live with the local-management measure that remains?”
“Yes, if appropriate care is the denominator and referral does not automatically receive a negative score.”
Wekesa was asked the same question.
“Yes. But I want the report to say the hospital still has a strategy to build local capacity.”
“Of course,” Malik said. “Knowing where the boundary is does not mean giving up on moving it.”
That sentence stayed in the notes rather than the KPI.
Otieno printed the new page. Wekesa read it line by line, then took a pen and signed. Malik understood the size of the gesture. She had not surrendered. She had changed the metric without abandoning the hospital’s ambition to grow.
Dr Salim stamped the committee approval.
The time was 16:42.
Otieno gathered the papers. “I have eighteen minutes to submit.”
The chair pressed the stamp down once more to make sure the ink had taken, then pushed the page across the table.
“Send this before five.”
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