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.

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

Safety daily huddle meetings

I had the opportunity to visit the Scottish NHS hospital group Ayrshire & Arran in the context of a professional event. The meeting, as expected, was very helpful, and one of the things that I took home was a working tool that for me, was as novel as it was simple: "Hospital Daily Safety Huddle," which roughly means the daily meeting of "circle time" for the patient’s safety. The management of the Crosshouse Hospital, the largest in the group, satisfied with the functioning of the experience, invited us to attend their huddle, that since June 30, 2014, they hold every day at 8:15.

What is a huddle?

According to Wikipedia, the huddle concept comes from the world of team sport. It’s joining in a circle, in the same area, standing, concentrated and often intertwined with the aim of remembering together the strategy and tactics that they have learned but also with the purpose of becoming more motivated for the game. Therefore, you see that "circle time" meeting is an approach of the concept of huddle.

Hospitals: 10 necessary structurals reforms

Hospitals are structures with a powerful influence on the overall health system. Its effectiveness in solving certain acute health problems, especially in the surgical area, gives them a major social prestige. However this fact should not undermine two structural problems that are weighing their image down:

a) The first problem is internal. The own bureaucracies are showing signs of fatigue and this affects the service quality, especially when it comes to the safety of admitted patients.

b) The second problem is relational. The hierarchical superiority of hospitals has placed them apart from the communitarian reality and the primary care, and causes now a serious difficulty in dealing, in an integrated manner, with the complex chronic disease care and with the geriatric frailty.