Ageism and risk of technological Darwinism

Glòria Galvez

Image by Flickr

According to the Spanish National Institute of Statistics (INE), in 2020 about half of the people over 75 years of age-connected to the internet daily. The pandemic and the need to feel integrated into society have forced them to enter the digital world, although their opinions, aptitudes or preferences have not been taken into account in the design of the tools used.

Shadowing for understanding the patient experience

Glòria Galvez

Reference: SoyArte

Who has not seen and cared for a patient who seems lost in the corridors of the hospital and asks for information from every person in a white coat that he comes across? It is likely that if a few days later you asked how it went, they would state that they are generally satisfied with the care, focusing their narrative on the most clinical part, or perhaps they could omit information of interest, giving the answers that he thought we expected to hear.

Initiatives to define a patient-centred research agenda

Glòria Galvez
 

By Society of Hospital Medicine

Despite the strong impact that the results of clinical research have on the health and quality of life of patients, the contributions they make remain anecdotal and do not go beyond participating as passive subjects in clinical trials. This, together with the practice of opportunistic strategies such as calling patients at the last moment to give their impressions of their participation, makes it necessary to move towards a new model of biomedical research in which, in addition to carrying out pharmacological studies, it seeks to respond to unresolved questions that would undoubtedly improve the patient experience.

Remote visits, are they always the best option?

Glòria Galvez

By Healthwatch Dorset 

The coronavirus pandemic has had an explosive and profound impact on health care systems, especially concerning traditional care. Presently, in addition to caring for patients affected by a coronavirus, it’s necessary to continue caring for the "invisible patient", who is still there, affected by other pathologies evolving at their usual pace, some of them potentially severe. Remote visits, which in a short time has gone from being a rare modality to being the usual form of interaction with the patient, are presented as the best option to carry out their follow-up, thus avoiding crowded waiting rooms and the risk of infection.

Arrogance, condescension and indifference in communication with patients

Glòria Galvez

In traditional society, men have had an authority role and women a secondary and subordinate role. As a result of this form of behaviour comes the term mansplaining, a combination of the words man and explaining. The term appears for the first time in a text by Rebecca Solnit “Men explain things to me” to define the habit of some men to express their opinion with authority, condescension and a paternalistic tone on all kinds of subjects, even if their experience is little or non existent.

John Launer, in the article published in the Postgraduate Medical Journal, talks about medical condescension or "docsplaining" that, like mansplaining, has to do with paternalistic and condescending behaviour. In this case, it’s the professionals –men and women– who, to maintain control of the conversation with patients, address them with a certain arrogance exercised from parental ambiguity.

“Always Events” for patient-centred care

Glòria Galvez

What would we like to happen if we, our families or our friends had to be treated in a health centre? The details are important and, although some may seem minor, they will make the difference between having a good or a bad experience. The NHS England, in collaboration with the Picker Institute, the Institute for Healthcare Improvement (IHI) and the NHS Improvement, developed in 2015 a program to identify and ensure the achievement of these details that will be the ones that add value to the patient's experience. The program called Always Events,® as opposed to "never events", aims to translate the principles of attention centred on the person and family into concrete actions.

How to build an agile experience for the patient?

Glòria Galvez

Our environment is subject to constant changes that organizations try to adapt to by becoming agile institutions, capable of developing projects quickly and flexibly. According to the report by the McKinsey consultancy, agile organizations are recognized by five key elements:

1. They are committed to open innovation, co-creating with different actors, from their professionals to the clients of the organisation.
2. Foster networks of autonomous people, free to devise disruptive proposals; a model of red arch versus one of hierarchy. 
3. They prefer to be quick and take risks than fall into excessive planning. 
4. The style of leadership gives prominence to people and encourages development talent. 
5. Integrate technology as a resource that provides agility to formulate new proposals. 

Some organizations undertake small transformations related to innovation or patient experience, but few dare to make a global transformation adopting an agile methodology. 

A new clinical visit format: shared medical appointments (SMA)

Glòria Galvez

The model of patient-centred care suggests the need to redefine some models of care and look for others that respond at the same time to the needs of patients and professionals. An example of innovative care is that which affects the traditional medical consultation, which is insufficient to address certain diseases with a prominent psychosocial component.

Value-based healthcare: the patient's perspective

Glòria Galvez

More and more organizations are adopting the new model of value-based healthcare (VBHC) where, according to the formula developed by Michael Porter:

                                                         Results that matter to the patient

                                        Value = ______________________________

                                                                           Costs

In order for the results to be measured correctly and standardized, the International Consortium for Health Outcomes Measurement (ICHOM) -a non-profit organization recently joined by Vall d'Hebron Hospital- is defining sets of indicators standardized by clinical conditions. In this line, the Vall d'Hebron Hospital, which is implementing this new model of care, has set up working groups to define the indicators that they provide value to patients for the clinical conditions of stroke and localized prostate cancer.

The Lean methodology to improve the patient's experience

Glòria Galvez

There are management methods that having proved useful in the industrial sector have now ended up being incorporated into the health sector. For them to be successful, in addition to the methodology used, it’s essential to give the appropriate approach. This is the case of the Lean methodology that tries to eliminate or minimize everything that doesn’t contribute value in the processes. It was initially applied in the automotive sector; hence it is the reason why it was received with some scepticism in the sanitary sector with the argument that "People are not cars". However there are numerous examples in the USA, Canada or Spain of their positive impact on hospitals; such as the case of the Consorci Sanitari del Garraf, which has recently been awarded at the World Hospital Congress 2017 for implementing the Lean Healthcare methodology in its health centres.

Effective communication for planning living will

Glòria Galvez

Planning living will is a key element for the care and attention of people with advanced chronic diseases and their families. In recent years, models and proposals have been developed throughout the Spanish territory, such as in Andalusia or Catalonia, based on respect for the person and framed in quality care, taking into account their wishes, expectations and preferences.

The communication within planning living will has been shown to have important benefits when a terminal process of the patient is expected, since a shared decision-making process is established in a trusting environment, at the same time as it’s incorporated in to the family and relatives care planning. Addressing these issues effectively involves doing so at the moment when the patient still retains his decision-making capacity, that is, at the earliest time of his hospitalization. Doing it later may pose a greater risk of aggressive and unnecessary treatments.

Despite their high therapeutic value, professionals report great difficulties in maintaining a fluid communication with a terminally ill patient. In a recent Canadian study published in the journal JAMA some of the reasons for this difficulty are described as: uncertainty of the prognosis, fear of causing distress or perception of patients being unprepared to talk about it.

The Catalan Institute of Oncology (ICO), a world reference centre in the design and evaluation of public palliative care programs for the WHO, with Dr. Gómez Batiste at the helm, has designed a new model of palliative care at the Institute in which it is proposed that communication with the patient follow a strategy based upon open questions, considered key to detecting their basic needs: How do you feel? How do you perceive your current state of health? What are you worried about? What do you think may happen in the future? What do you think would help you fight this situation? What do you need us to do for you?

Dr. Gawande, in his book Being Mortal, also proposes some key questions that can help professionals have a quiet conversation about the end of life process. Faced with this open approach, there are those who propose a closed script with previously prepared themes. This can be quite a challenge due to the different barriers that have been expressed by professionals, such as the fear of eliminating all hope that the patient may have regarding his illness.

Both strategies have advantages and disadvantages: the open format allows the patient to express fears or questions that the professionals had not foreseen, and the closed format could facilitate professionals in asking potentially difficult questions. To illustrate the post, I leave the video in which Dr. Meier, a doctor at Mount Sinai Hospital and director of the Centre for the development of palliative care (CAPD) in the USA explains the 10 essential steps in communicating with patients and family members receiving palliative care:

1. Review the patient's clinical situation.
2. Prepare a decent, comfortable space with privacy and confidentiality.
3. Present the attendees and comment with simplicity on the objectives of the meeting.
4. Find out what the patient knows about his illness.
5. Explore what the patient wants to know: ask/explain/ask. Ask about the required information.
6. Explain the thorniest details required by the patient.
7. Ask if they have understood the terms used and encourage them to repeat them in their own words.
8. When faced with difficult questions such as: Am I going to die? Simple and clear answers: Yes, you will die and we will be permanently by your side, watching over your welfare to the maximum.
9. Analyze the therapeutic options, without deceiving but without denying reasonable hopes.
10. Organize and plan the next visit.

Communicating is also being able to know how to listen; it’s a key aspect in knowing what the patient's situation is at each given moment. For active listening to work, it’s better to move away from paternalism and facilitate the patient's participation in the decisions that best preserve their dignity and freedom.

Dying in the hospital: some considerations

Glòria Galvez

Health inequalities are related to individual and social factors. The way people live, work and grow old as well as the political, social or economic factors that accompany them, vary greatly according to the place where they live. Death, which could be "the great equalizer", doesn’t appear to be equal at all, as Dr. Puri states in his article "Unequal Lives, Unequal Deaths," in which she argues that social and health differences during life, are also present at the time of death. As a group of Danish authors suggest in BMJ Supportive & Palliative Care: "Socioeconomic position and place of death of cancer patients” for people with fewer resources it’s more difficult to benefit from a worthy death in their own home.

When a patient chooses to die in a health institution he does it for different reasons. Higginson et al., In "Dying at home - is it better: A narrative appraisal of the state of the science" identified, besides the socioeconomic level, other determinant elements as the preferences of the patients, the access to the home attendance or the support of the family. Let's look at each one separately.

Claims for adverse events: a predictive algorithm

Glòria Galvez

Strategies focused on encouraging patients' participation in the health system, and more specifically those related to quality and safety, have seen some a great deal of progress in recent years. A person-centred health system should promote active patient participation and use the complaints handled by patient care services as a specific instrument of participation. When the patient expresses the disagreement with the attention received, he or she is providing us with valuable information that is very useful in the continuous monitoring and improvement of quality. It doesn’t seem that there are many health institutions that use complaints and claims as a learning tool, but they rather use it as a mere descriptive statistic in the annual report of the organization, thus losing the opportunity for improvement that their analysis and monitoring would provide.

Dr. Gallagher, who, as someone with extensive experience in issues related to patient safety and disclosure of medical errors, has published an article in BMJ Quality & Safety: “Taking complaints seriously: using the patient safety lens” in which he proposes analysing complaints from a point of view of patient safety and treating them as if they were adverse events, in the same way as with the more traditional ones, such as those related to safe surgery or the appropriate use of medications. This is an innovative approach that will provide relevant information when proposing proactive interventions.

Virtual Units: a model to prevent hospital readmissions?

Glòria Galvez

Hospital readmissions are one of the expressions of the complex relationship between the different levels of care, as well as an important indicator of quality. Many of these readmissions are unavoidable and justified, but many of them are inadequate and could be prevented by changes in the care protocol of the registered patient. Even so, an intervention to reduce readmissions has not been found yet.

In an issue of JAMA magazine, Dr. Dhalla, an internist at St. Michael Hospital and professor at the University of Toronto, evaluates and compares the results of a virtual unit with those obtained by providing routine care to reduce readmissions and deaths after hospital discharge. The virtual units were created in 2004 in the United Kingdom for their alleged potential to reduce hospital readmissions, but had not yet been rigorously evaluated. The basic idea is simple: it’s about using already proven care systems from the hospital setting (equipment, coverage, access, etc.) and applying them to complex and high-risk patients in their own homes.