Chronic Complex Patients and the Blue Ocean Strategy

The book "Blue Ocean Strategy" by W. Chan Kim and Renée Mauborgne has been celebrating 10 years, having sold more than three and a half million copies, and now, to celebrate, a revised edition has just been published. The central thesis of the book is that today's markets are characterized by oversupply and therefore, companies must compete fiercely between them and the oceans (It’s a metaphor) are stained red with the blood of the fight. For this reason, the authors propose to companies to go on the search for blue oceans, like Cirque du Soleil or Ikea, where their products or services will be incontestable because people will see them as novel and useful. The strategy of these companies is clear: their contribution must be perceived as a value innovation, and as a consequence would able to open new unexplored markets like oceans that will not go red.

Leaving aside the commercial aspects of the theory, the book left me with the (attractive) vision of a blue ocean that, inevitably, I have contrasted with the difficulties that all health systems have when it comes to implementing convincing programs of patients’ care and I thought that perhaps at this point a blue ocean strategy would be beneficial when aiming to implement new projects that would arise from overcoming current difficulties. I have to admit that applying Chan and Mauborgne's theories to complex chronic patients is a bit far fetched, but I am convinced that there are some strategic methodology proposals that could be of some use.

Hospitals: 10 necessary structural reforms

Hospitals are structures that generate a powerful influence on the overall health system. Their effectiveness in the resolution of certain acute diseases, especially surgical, gives them a great social prestige. This fact should not, however, hide two structural problems that are burdening their perspective:

a) The first problem is internal. Bureaucracies themselves are showing signs of fatigue and this affects the quality of services, especially in the safety of admitted patients.

Patient-Centered Coordination (PCC): case report

In a hospital a fragile geriatric patient dies with multiple cronic diseases

Antonio dies at the age of 88 during one of his many hospital admissions and the primary care team closes the case with the following diagnosis: a) Parkinson 7 years of evolution, b) Heart failure due to valvular dilated cardiomyopathy, c) high blood pressure, d) cardiac arterial arrhythmia by fibrillation that required pacesetter e) depressive-anxious syndrome, f) frequent urinary tract infections, and e) progressive protein-calorie malnutrition leading to death.

The daughter needed her father’s small amount of  money therefore she didn’t want to send him to a residence for the elderly.

In the two years preceding the death, Antonio showed an absolute dependence in activities of daily life with a Barthel zero. He lived with a divorced daughter who had no income, and with his two grandchildren, her children. The dependency aid (destined for the caregiver not for the professional) and Antonio’s small pension were the biggest family’s sources of income so this was always an impediment on the proposed admission to a nursing home; although it was clear that the daughter, even with little support from the municipal home help, could not meet the needs for long term attention in the period towards of Antonio’s end of life.

In the last 3 years of life, this patient had consumed more than 100,000 Euros in services, with an impressive degree of incoordination.

In  Antonio’s case history for the three years prior to the hospital admission when he died, the primary care team counted 24 attendances to the emergency room of the hospital, for very different reasons, many of them linked to heart disease, but also due to falls, fever, depression, pain in the penis, etc. Of these visits, 15 did not result in hospitalization, but, instead, almost all required attention in the short stay unit or follow-up day hospital or an outpatient clinic. Nine hospitalizations (three per year) were made in Cardiology, Internal Medicine and Geriatrics, with a total of 77 stays. Nine interventions of social work at the hospital were also counted. The activity that Antonio has generated in the primary health care and at the municipal social services has not been recorded, but there’s no doubt that it was also plentiful.

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.

"Patient Centred Coordination" a CCM evolution

Edward Wagner, the creator of the Chronic Care Model (CCM), when asked why he promoted a new system, responds. "The initiative came from my own clinical practice. For me, it was frustrating to see how well prepared and well-meaning doctors, were not achieving good results when dealing with the care of chronic patients, while we were starting to see evidence that by doing things differently, patients could better understand what happened to them and clinical outcomes could improve. And for this reason I thought it appropriate to communicate these new findings with the doctors "(The full interview can be found in the post "The chronic model: The Wagnerian Keys").

The current care model for complex chronic patients is usually based on individualized care plans developed for each sector: the primary care teams generally have individualized plans (ICP-PCT in the graphic), the municipal social services also work with customized plans (ICP-MSS) linked to the service portfolio of the dependence law; the long-term centers, meanwhile, develop their specific plans for each admitted patient (ICP-LTC), whereas in nursing homes, healthcare professionals who work there tend to write different plans for each resident (ICP-NH).