Ethical leadership in a complex adaptive system (CAS) reducing out-of-pocket healthcare expenses in an emergency department in Nepal.

Purpose: This research used ethical leadership to engage doctors to implement an international National Institute for Clinical Excellence (NICE) guideline (NICE, 2014) in an emergency department (ED) in Nepal. The purpose of this study was to reduce unwarranted clinical variation in decision-making and thereby reduce unnecessary costs for patients by paying for computed tomography (CT) scans after a head injury where they are not clinically indicated. The World Health Organization (WHO) in its 17 Sustainable Development Goals (SDGs) (United Nations, 2017), identified SDG 3.8 as a goal to reduce "out-of-pocket" (OOP) health spending in low medium income countries (LMIC) to reduce poverty.

Design/methodology/approach: A quantitative study was designed, using a multiple-choice questionnaire based on the NICE head injury guideline 2014, with n = 27 doctors at pre- and post-training. Retrospective baseline patient data was collected from 149 patients (n = 149). These data were individually matched with the patient online record system and a detailed history, and the indication of CT head referral was reviewed on the clinical history part of the patient's notes. A teaching session for doctors explained a flowchart for the NICE CT Head Guideline and different figures and case scenarios regarding patients presenting with a head injury were discussed. All data were collected and entered into a Microsoft Excel spreadsheet 2013. An analysis of the data was done by Statistical Package for Social Sciences version 18. A sample of 302 patients (n = 302) were followed up after implementation of the guideline in the department.

Findings: In this study, most common causes of head injury are RTA followed by physical assault and fall injury. There was no statistical difference in the type of injury p < 0.05. X² (2, n = 454) = 2.4467, p = 0.2942, meaning that at both stages of the research the injury pattern was the same. Compliance has not improved statistically, and this may be due to a low power as it is only 44%. However, there is an appreciable improvement of compliance from 46.3% (before) to 56% (after), which is nearly 10% improvement. Translated to CT scans, this can be taken as reducing unnecessary CTs by 10%. Since 302 CTs were performed in the second phase, this study has demonstrated that nearly 30 unnecessary CT scans have been prevented from being carried out. If one CT cost 20 pounds, then the total saving was 600 pounds. If this study was undertaken over one month, then the total saving for a year would be 600 × 12 = 7200 pounds.

Research limitations/implications: This study set out to improve the quality of care provided to patients with a head injury who presented to an ED in Nepal. In Nepal as in other LMIC healthcare delivery is improving but there are still low levels of health insurance resulting in many patients having to pay OOP expenses for healthcare. The drive to undertake this study was influenced by the aim to reduce the amount of OOP expense incurred by patients for unnecessary CT head scans following a head injury. Measuring OOP expenses of a population helps to assess the impact on living standards and the impact of the health care financial system on improving financial protection (Hsu et al., 2018). It is also an important risk factor for death, physical disability and impoverishment (Baggio et al., 2018). In this study OOP expenses were reduced by 10% with the implementation of a clinical protocol. This study has shown a direct correlation between the training of doctors to implement a clinical protocol and the reduction of OOP expenses.

Practical implications: The WHO's SDG 3.2 seeks to reduce "OOP expenses" in relation to healthcare. This study has shown that by implementing an international protocol, standardization in decision-making will be improved resulting in reducing "OOP" expenses in healthcare for patients.

Social implications: In LMIC, there is a need to identify practical and social strategies to prevent patients falling into poverty when accessing healthcare. This research study shows the potential for providing ethical leadership as a framework to support the implementation of a protocol to reduce OOP expenses for patients.

Originality/value: To the best of the authors' knowledge, this is the first time a research study has identified the role of ethical leadership positioned with complex adaptive systems to promote the combined bottom-up and top-down approach of integrating ethical leadership in clinical research design to reduce OOP health expenses for patients in Nepal.