Frail, cracked or broken?

Marco Inzitari

The concept of frailty historically has been the object of a lot of debate among those who work in the field of elderly health, with differences between epidemiological and clinical outlook.

Frail

For geriatricians the frail have for a long time been people with multiple health problems and often with an already advanced disability, such as those that can be found in hospitals or nursing homes. Epidemiological Revolution introduced by Linda Fried, a most prominent geriatrician and epidemiologist that I have already quoted in the post "Thinking differently in healthy aging", changed the paradigm in early 2000.

In plain language, she indicated as "frail" something at risk of breaking, not already "broken", as in the case of people with advanced disabilities that we mentioned. So a frail person, in this view, is a person with apparent good health, and even without a disability, which has reduced physiological reserves of different organs and systems that makes them particularly susceptible to descend towards disability in case of injuries of a different nature (clinical, such as illness, or social, as a widow, etc). Detection of frailty in this sense is mainly based on measures of physical or cognitive performance, with a clear objective of prevention, since it is proven that the frailty is reversible and targeted interventions (exercise, nutrition, geriatric assessment) can prevent disability.

Dying in hospital

The neurologist Oliver Sacks published an article in the New York Times "My own life" in which he announced that he has just been diagnosed with a liver metastasis. "I find myself facing death. It’s up to me to choose how I will live the remaining months of my life. I have to live as good, as deeply and as productively as possible." Death is an inscrutable fact that each person has to go through in their own way, so far it’s all normal, and Sacks dealt with it calmly, taking the reins of the time left. But how about the health system? When someone calls the ambulance because they have a sudden chest pain, the entire health organization is tense, protocols are activated and everyone knows what to do. The health system has full control of that process so all that’s left to do for the patient is to remain confident. But on the other hand, when what’s left to be done depends on how the patient sees life and death, as is the case with Sacks, the system no longer feels so confident and can act inappropriately, even disproportionately.

Clinical management as a mechanism of change, according to Richard Bohmer

Richard Bohmer is a doctor, a professor at Harvard Business School and the author of "Designing Care". In his article, Fixing Health Care on the Front Lines, Bohmer defines the three pillars that should underlie modern clinical management, in short, these are: a) thoroughly implement the best practices, b) address the complex processes with mechanisms of trial and error, and c) learn from daily activity. "Almost none of the health organization is prepared to excel in these three pillars nowadays, says the author. In fact, most clinical services providers lack the capacity to adapt to the challenges imposed by science, innovation and social pressure, unlike what happens in other industries, constantly reengineering their models to suit the changing needs of their business core".

Rigorously implementing the best practices

The clinical practice guidelines (CPG) and the recommendations supported by strong evidence should translate in care routes (see Care Delivery Value Chain). Modern organizations know that the GPC are not only a matter regarding the medical profession, so they invest a lot of effort in the development of plans to make them feasible. Anyone even slightly concerned must be involved. Transforming a GPC into an operating process is equivalent with improving clinical effectiveness. Some examples: a) applying industrial methods to standard cardiac surgery processes at the Mayo Clinic, b) the myocardial codes and stroke codes that, in many regions, have been deployed with excellent results and c) development of organizational models that aim to reduce resistance to antibiotics (PROA) or to avoid unnecessary blood transfusions (PBM).

Addressing the complex processes with mechanisms of trial and error

A significant number of patients are suffering with pathologies that are not well known or show complexities resulting from a combination of clinical or even social circumstances that are difficult to manage. For these cases, the organizational response is teamwork which aims to find specific solutions while the actions will have to be adjusted by trial and error methods. Some examples: a) advancing the introduction of palliative care in cancer patients who are still following therapeutic healing guidelines, b) reconciling patient medication when transferring between hospital and primary care, and c) developing individualized therapeutic plans for complex chronic patients.

Learning from daily activity

The other day, in a class, I came across a few permanent and non-permanent markers and, as it happens, without realizing it, I ended up ruining the whiteboard. At the end of the class, I sincerely apologised to the head of the classroom and suggested that it would be a good idea, for the sake of their class boards, to withdraw the permanent markers, but the response I’ve got was one of those type "here we, always have done things this way". I assumed that they must go through a change of budgets in order to make changes in the classroom stationery. However to improve every day, is above all, a question of attitude. Some examples: a) in an office, faced with the fact that 20% of scheduled patients do not keep their appointment, a working group was created in order to analyse the causes and find solutions, b) in a hospital, ward nurses make proposals to be able to shift from intravenous to oral medications as soon as possible, regardless of the oversights of medical orders, and c) in an emergency department, they organize daily huddles to ensure that all the professionals can share their opinion on what happened that day and advance proposals to avoid the same problems reoccurring.

When we talk about structural reforms, I suspect that not everybody says the same thing. Many think of labour rights, or in financing or investment. These and other aspects are important, which is why the health care system has a recognized complexity. But make no mistake, only from the clinical management can the effectiveness and resource optimization can be improved. As Bohmer advocates, organizations, with doctors and nurses included, should apply best practices rigorously, should learn to make decisions as a team when the issues are peculiar and ought to have the appropriate attitude in order to change everyday things.

Jordi Varela

Editor

How about the Patient Experience?

David Font

In my previous post, I talked about the formula E = mc2, that is, to achieve excellence (E) we need the commitment of workers (c), trust in the institutional project of the governing bodies and health officials (c from confide) and the appropriate methodological development (m). I would like to delve into the methodology and in particular on the importance of the patient experience when deploying improvement projects and consider it as a priority in the strategic development of our institutions.

The public health system methodically evaluates patient satisfaction which allows us to obtain global information regarding users’ perception. However, we abuse studies that are too general and in which the evaluation differs excessively when it comes to the time dedicated to healthcare. These and other methodological limitations make it difficult to draw conclusions and the possibility of using the information related to the patient's experience as a source of identifying opportunities for improvement is also an element that limited by cultural aspects. To expand on these aspects, it’s interesting to read the articles "The Patient Experience and Health Outcomes" Matthew P et al [1] and "Collecting data on patient experience is not enough: they must be used to Improve care" A Coulter et al [2].