Monday, 12 October 2015

Hospital general vs factory hospital

In the post October 5, I explained how, according to the report "Future Hospital Commission" (Royal College of Physicians 2013), it would be ideal that, as soon as possible, the organizational models of the hospitals would be able to evolve in two directions: a) about one third of the health care activities should apply techniques of industrial quality, and b) the other two thirds of patients admitted (complex case-mix) should be treated radically differently from how it is done now, given the shortcomings of the work organization in the hospital wards.

In the current model, each admitted patient has a medical service and a medical specialist assigned. The clinical activity of this medic develops primarily through the clinical course of medical orders (including requests for evidence and pharmaceutical prescriptions) and through interdepartmental advice from colleagues from other specialties. As for the nursing work , there are several intensity models ranging from a major involvement in the clinical process to a trivial change of shifts.

Summary of the limitations of the current model of care for inpatients and the arising risk situations:
  1. The allocation of a medical specialist doesn’t guarantee at all the care continuity because many of these specialists also have their other technical functions, specific to their speciality that are often more attractive that visiting the wards.
  2. The guards’ medical model does not guarantee the maintenance of a homogenous quality of care, nor at night, nor on holidays.
  3. The interdepartmental work, generally means little involvement. Specialists try to fulfil the commitment with an opinion and, rarely, joint clinical work derives from this activity.
  4. In many hospitals, nurses have a working commitment to the continuity of care quality for admitted patients but this is not universal, and great variations between centres are detected.
  5. Inpatients often undergo changes of bed, or even ward changes for reasons of centre’s logistics organization, and this fact is known to subject the patient to avoidable risks.
  6. The quality of transfers of complex patients from the hospital to their homes is not guaranteed in all places and at all times.

The general hospital model
(Could cover 2/3 of hospital activity)

Each patient admitted to the general hospital should have a referent hospitalist and nurse, which are the ones who present the case at the clinical session for the development of a joint  individualized plan (ICP). The meeting would be attended by the necessary specialists and some primary care professionals (physician or nurse, or both) who know that person, and therefore should review the IP-entered with the patient. These primary care professionals are the ones who facilitate the patients’ transfer to their homes.
Key elements for obtaining the desired results in the general hospital:
  1. The clinical sessions to develop the ICP must be fruitful, and therefore we must ensure that the professionals involved in the case attend. All the time spent in these sessions is time gained in efficiency and clinical effectiveness.
  2. The ICP is the instrument of clinical work that marks all the actions of hospitalization.
  3. The referring doctors and nurses must ensure the implementation of ICP while the patient is admitted and should ensure continuity of care during evenings and weekends.
  4. With this general hospital model, hospital beds assigned to the medical specialties, inter- consultations, the guards’ medical model, as understood now, and bed changes caused by logistics, disappear.
What is the new distribution of functions that the general hospital will require?
  1. In the new model, the specialist has two options: a) work in the factory hospital, in highly standardized specialized procedures, and/or b) take the role of a consultant in clinical sessions collaborating in the development of ICP of complex patients.
  2. The hospitalists will be directly responsible for admitted patients as they may be assigned. The internists, geriatricians and other specialists who choose the generalist function will play the role of hospitalist. These specialists, converted to hospitalists, will have a complete dedication to the wards without sharing their time with any other technical function.
The wards are the most expensive health system’s resources. These alone require complex coordination between many different professionals with very different views and objectives. The enhanced role of the hospitalist and corresponding nurse and the joint individualized plan for each patient group should be the catalyst for improving the quality of care to admitted patients.

Remember, if you want the hospitals to be more efficient and more effective, try treating a third of the case-mix with industrial quality criteria (factory hospital), while for the other two thirds (general hospital), nullify fiefdoms, strengthen coordination among specialists through individualized plan sets, and include primary care professionals in clinical decisions for admitted patients. 

Jordi Varela


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