Monday, 5 October 2015

Factory Hospital vs General Hospital

The report "Future Hospital Commission" (Royal College of Physicians 2013) proposes organizing hospitals into two distinct divisions. According to the described model, patients would enter two alternatives doors that lead to almost opposite paths: a) there would be a specific route for standard processes (lower part of the graph), such as: laparoscopic procedures, hemodynamic, scheduled surgeries, stroke codes, heart attack codes, etc, and b) the other route would be for patients admitted through the emergency room (except the codes) or suffering complexities that require general assistance, with the occasional support of specialists (the trajectory above the graph).

This proposal seems not only timely, but also hospital models nowadays are or should be largely along this line. But the publishing of an article in Health Affairs, signed by a team from the service of Cardiac Surgery at Mayo Clinic, has led me to consider that we should advance more in the methodology inherent to each of the two paths. This referenced work is titled: "From "Solution Shop" Model to "Focused Factory" in hospital surgery. Increasing care value and predictability", or the equivalent of a study of the evolution from store solutions where every client is different and requires a tailored response towards the targeted factory that uses the methodology of an industrial process. And this is where the Mayo Clinic are pushing the  accelerator: if we are able to indicate certain clinical procedures for well-defined types of patients –they say– we ought to know how to prepare to act with criteria of maximum efficiency and effectiveness.

The factory hospital model
(could cover 1/3 of hospital activity)

Here are the industrial characteristics defining the processes that are integrated in this division:
  1. Candidate patients are classified according to risks and complexities in order to choose the suitability of the process that will apply to them.
  2. We need to develop an industrial mapping of selected clinical trials, so that doctors and nurses should be supported by systems analysts, project managers, technologists and economists.
  3. Thanks to the industrial mapping, the functions of doctors and nurses are strictly bounded to those that are suitable. All other professionals (medical or otherwise) are clear about what their responsibilities are at each point in the proceedings.
  4. The patients will be informed of all steps to be followed in the process and will have to be explained what is expected of them at all times. If appropriate, advanced communication techniques will be used to get the patient to get involved.
  5. Modern industrial process instruments should be implemented such as Lean or Six Sigma in order to improve efficiency and methods of process and results quality control ought to be used systematically.
  6. Whenever possible, factory hospital processes will apply in specific hospital facilities or in special facilities reserved at the general hospital such as operating rooms or ICU beds. The important thing is that the staff involved, whenever possible, does not mix general hospital with factory hospital.
The results of application of factory methods published by the Mayo Clinic Heart Surgery Team

The starting point described by the researchers is that of doctors with a high variation in both indication criteria and surgical techniques, with the expectations on the part of patients, somewhat unrealistic, that are giving rise to medical overacting and poorly evaluated results. After applying the methodology of factory hospital in much of casuistry opting for cardiac surgery, the variability of practice, the disparity in the use of hospital resources and also the costs by process have been reduced; in addition to improving some post-surgical complications as septicaemia, pneumonia and kidney failure.

In every hospital there are doctors and nurses more gifted for technique than for general practice. The proposed factory hospital suggests that we ought to draw the best out of these professionals. That is to say that instead of disorient them with features they dislike, we ought to shift their focus on what they know how to do, endow them with quality instruments for industrial process and we demand results.

The post for next Monday will address the other side of the coin of the issue discussed today, "General Hospital vs. Factory Hospital" or how to approach with current criteria, the other 2/3 of the hospital casuistry.

Jordi Varela


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