Monday, 24 October 2016

Modern clinical management: the basics

In recent decades, clinical management has had a couple of conceptual disruptions that have generated interest in the welfare act as an object of study. The first was when, in the early 90s a group of epidemiologists moved clinical epidemiology from the academy to the consultation and developed evidence-based medicine; and the second came when governments and health professionals became knowledgeable about the clinical work’s ability to do harm. The "To err is human" from the Institute of Medicine report in late 1999 was the turning point of patient safety programs. Now, in the second decade of the century, starting from those two fundaments (security and evidence), all the interest is in knowing what is the value that clinical practice brings to the health of people.

The conceptual foundations of modern clinical management

The three pillars of Michael Porter. The veteran Harvard professor, an expert in business competitiveness had an experience with the health system and from his own observations wrote a book that went on to say: "I see them obsessed by the effectiveness of their actions and not focused enough on the effectiveness derived from them.”  Synthetically, the Porterian contribution to clinical management is summarized in his three pillars: a) define health goals that are valuable for each patient, b) know how to measure the health value that is provided with every clinical act and c) reorder care services according to the process needs of each illness.

Shannon Brownlee’s fight against clinical waste. From the book "Overtreated", the author joined the Lown Institute where she started the movement Right Care Alliance. In this conceptual panel, Brownlee’s position, a recognized scientific journalist, is to provide reflection on the social impact of a clinical practice that never cease to focus on the health value. Right Care Alliance is the crystallizer movement of professional and social debate on all controversial aspects of current clinical management: overdiagnosis, shared clinical decision, transparency of the investigation, emergence of new diseases under the pressure of consumerism, inappropriate technical development of the end of life process, etc.

The professionals’ impulse of making things better by Donald Berwick. Paediatrician by profession, Berwick has held several public offices in the US and created the Institute for Healthcare Improvement (IHI) from where he launched a simple and useful tool, the Triple Aim, a triangle to measure whether a proposed clinical improvement is balanced, according to a basic test: a) Is it expected that the new project will improve the clinical effectiveness? b) Is it also good for the patient experience? c) Is it efficient? Today there are lots of Triple Aim projects led by clinicians providing high quality for health systems.

The organizational changes proposed by Richard Bohmer. Physician and professor at Harvard, Bohmer is an author who develops criteria to implement modern clinical management, and the question that he answers in his article, "Fixing healthcare on the front lines", is one that troubles many clinical managers minds: "How are we going to do all this?" The Bohmerian recipe is concretized in three points: a) rigorously implement best practices, b) address the complex processes with mechanisms of trial and error, and c) learn from daily activity.

Sometimes, when things cost so much or when we lose heart, it’s healthy to take a stroll through the fundaments in order to take a breath before trying again. This post was just for that.

Jordi Varela

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