Medical services, an anachronism

Jordi Varela
Editor

 

@varelalaf

Clayton Christensen says that if you want to be efficient, you have to offer services as close as possible to where the need arises. Michael Porter and Thomas Lee, for their part, defend the creation of Integrated Practice Units (IPU), while those of Corporate Rebels affirm that attractive projects are made because of the commitment of professionals and not because of the hierarchical command structure. This post is contrary to the status quo of hospital organization charts and, for this reason, I have chosen these three references that, from various perspectives, direct us against centralism, corporatism, and the hierarchy that current medical services give off, anchored in a vision more typical of the last century than of the demanding complexity of today's health problems.

Transversal and Collaborative Functional Units (TCFU), a challenge within reach

In a recent post, I explained how Porter and Lee's Integrated Practice Units (IPU) can be adapted to the reality of a National Health System like ours, which has well-established primary care in the territory and, therefore, I have proposed that, for the most frequent clinical processes, Transversal and Collaborative Functional Units (TCFU) be created, in which primary care is the backbone, multidisciplinary teams specialized in each of the processes act as unique hospital references and patients are protagonists, both in clinical decisions and in the improvement of criteria and circuits.

Transversal clinical processes must break organizational charts

In "Integrated Practice Units: A Playbook for Health Care Leaders" (2021), Porter and Lee offer a playbook worth considering. It's a proposal that once adapted to our environment (remember that we have a backbone of primary care and Americans do not), is very useful for rethinking the current model of medical services in hospitals, in the sense of removing power to give it to the multidisciplinary teams responsible for offering integrated and continuous services throughout the cycle of the disease, which should end up becoming references for patients and primary care teams.

Instead of being structured in medical services for each of the recognized specialties (Neurology, Digestive or Oncology, to give three examples), the new organization charts of hospitals must define clinical units that group all the professionals who work together in a single team giving services to patients throughout their disease (multiple sclerosis, inflammatory bowel disease, or liver cancer, also to give three examples). These multidisciplinary teams (TCFU) will be in charge of offering their patients all the required services: diagnostics, hospitalization, day hospital, therapeutic, but above all coordinated with the other care levels: primary care, intermediate services, and social services.

Current medical services, far from becoming TCFU

Current medical services work for patients from the perspective of their specialty and, therefore, have their resources, which encourages fragmentation, especially when they have to care for complex and multi-pathological patients. The majority of medical services, aware of the need for adaptation, have opened specialized units, but always with the logic of the limits of the specialty, such as hemodynamics, stroke, or pain, units that, despite their effectiveness, it should not be confused with the TCFU (or IPU), since they are far from the desired continuity of services.

Differential table between Medical Services and Transversal and Collaborative Functional Units (TCFU)

**PREM: Patient Reported Experience Measure / PROM: Patient Reported Outcome Measure

FAQs of the new organization charts based on TCFU

• Why TCFU and not IPU? The IPUs have North American logic, but in our environment, intermediate services and social services cannot be designed apart from primary care. To this end, maintaining the essence of the Porterian IPUs, I have emphasized the concepts of functionality, transversality, and collaboration.
• Where will hospital professionals be assigned? Each professional must be assigned, full or part-time, to the TCFU that best suits him/her according to his/her skills, assuming that a professional can attend more than one TCFU if this is reasonable.
• Who will take care of non-classifiable patients when they require hospital services? No casuistry should be left out of the new model. Therefore, there should be TCFU for multi-pathological patients, clinically complex patients, frail geriatric patients in acute phases, patients with systemic diseases, with rare diseases, etc.
• What happens to patients who go to the hospital for a scheduled intervention? For them, there must be a "factory" specially designed to achieve the best possible effectiveness.
• What place will diagnostic, therapeutic or rehabilitative services occupy? They will act with "factory" criteria, more or less as they do now, to efficiently solve their specific processes, but they will also have to develop, more than they do now, support strategies for the TCFU, to refine the indications, and give clinical value to their activity.
• What will happen to medical services? Once they have transferred this function to the TCFU, they must cease to be management bodies, to become academic references that must ensure the correct exercise of their specialty at the TCFU, for which the medical services will be responsible for designating which of their specific specialists will be assigned to each TCFU. The medical services will also be in charge of tutoring the MIR program and promoting research projects, many of them, obviously, in collaboration with the corresponding TCFU.
• And the hospital infrastructures? They will have to change drastically because the TCFU will need spaces that respond to the new needs for integrated care in a multidisciplinary work environment and patient involvement. Take as an example what they did at Dell Medical School in Texas where they took advantage of the spaces destined for waiting rooms to make the necessary reforms for the new IPUs.

The time has come to take a step forward in hospital organization charts: clinical units have to take the helm, while medical services must stop being management bodies and become academic benchmarks.