Challenges in Designing Excellence-Oriented Hospital Systems - Part 1

Last month we have outlined the characteristics of an ideal hospital. The discerning reader might quickly gather that achieving this ideal or even something that resembles it comes with many challenges.

Because the world is experiencing a recession whose end is unclear at the tails of a deadly pandemic, it is more important than ever to develop a systematic approach to optimizing health care systems that is holistic, realistic and has in-built mechanisms for improvement. The first step is to flesh out these challenges in a systematic manner in an effort to connect the traditional silos of decision making.

This multi-part series will be an attempt at generating this comprehensive list of challenges that can inform quality improvement efforts at a hospital level or even at a national or regional level.

Managing patient expectations is challenging in the era of social media and mixed messaging

Patients who are bombarded with information and medical advertising become increasingly frustrated as expectations fail to match reality ₁. Lack of trust in medical messaging leads to poor population outcomes which in turn drives up the cost of healthcare. Collaboration between private and public partners to harmonize messaging can go a long way towards establishing trust with the healthcare system and in turn saves lives. Hundreds of thousands of lives were lost in the fog of vaccine misinformation and conspiracy theories about Covid-19. One can argue that a healthcare system that fails to establish trust with its target audience is failing its primary mandate.

Collaboration between private and public partners to harmonize messaging can go a long way towards establishing trust with the healthcare system and in turn saves lives.

The elephant in the room is that even medical professionals contribute to incoherent messaging. Unfortunately, companies can capitalize on many professionals' failure to understand the principles of evidence-based medicine which makes them easy prey for marketing initiatives especially in the wellness industry which is largely unregulated. A physician or other medical professional who uses their credentials to sell unproven remedies discredits the entire profession. This global issue is yet to be addressed sufficiently and a broader conversation about licensing is required.

A physician or other medical professional who uses their credentials to sell unproven remedies discredits the entire profession.

Major culprits are supplements companies, those selling detailed personalized testing such as hormonal or genetic tests and those selling plant-based remedies that have not been subjected to clinical trials. Medical professionals who endorse products based on anecdotal evidence or an inaccurate understanding of the evidence should have public assessments of their statements by regulatory bodies who are tasked with protecting patients from such manipulation.

Hospitals are diverse in terms of capacity and resource availability.

Hospital systems must be designed according to available resources in terms of staffing, admission capacity as well as clinical skills and equipment. The demographics of the target patient population are also a key factor to consider when designing a hospital system. Reconciling the tension between needing to keep the cost of health care to a minimum while delivering care that is “good enough” is a global challenge ₂.

Hospital systems must be designed according to available resources in terms of staffing, admission capacity as well as clinical skills and equipment.

The specialties available within a hospital and the need to outsource certain patient populations is a common consideration for all but the biggest university hospitals. Workflows that need to accommodate transitions of care into and out of a healthcare system thus have an added layer of complexity. Decision makers that design policies impacting these workflows can be divorced from the stakeholders who are also the subject matter experts contributing to the well-known frustrations and dangers associated with transitions of care ₃.

Building in redundancies for patient safety and minimizing medical error would look entirely different in a 200-bed hospital compared to a 1000-bed hospital.

Designing workflows that are efficient while simultaneously addressing the needs of both the providers and the patients impacted by these workflows becomes a unique exercise each hospital undergoes depending on the particular niche it aims to fill. Building in redundancies for patient safety and minimizing medical error would look entirely different in a 200-bed hospital compared to a 1000-bed hospital.

Lack of a global medical standard remains a major challenge for hospitals.

Non-academic institutions often struggle to prioritize time for continuing medical education and expect clinicians to do this on their own time. This can lead to divergent ideas about what clinical standards should be that ultimately directly impact quality of patient care and potentially outcomes. This becomes even more exaggerated where a national standard of care is not well defined. Creating opportunities for clinicians to learn from each other in an environment that not only encourages but demands continuing medical education is important to give clinicians opportunities to agree on clinical pathways that will ultimately lead to more seamless patient care. Failure to do so can lead to delays in patient care and possibly poor patient outcomes due to lack of well-coordinated care. The author goes so far as to state that a hospital that does not have mandated continuing medical education for all levels of staff is failing its patients because of the well-studied phenomenon of attrition of clinical knowledge over time without consistent intervention _4,5,6.

Creating opportunities for clinicians to learn from each other in an environment that not only encourages but demands continuing medical education is important to give clinicians opportunities to agree on clinical pathways that will ultimately lead to more seamless patient care.

Countries that primarily rely on clinicians trained abroad face a unique challenge. Although American, Canadian, European and Australian standards are considered comparable, a unifying global standard is missing. Resource considerations can impact what is considered “good enough” care in many countries and clinicians trained abroad can have ideas that clash with local standards of care. Local patient demographics also affect considerations about prevalence of various conditions and thus can have a direct impact on diagnostic and treatment protocols. Limited resources also create more pressure to create systems that best optimize what is available to maximize benefit to patients.

High-quality of care does not guarantee good patient outcomes.

Even in resource-rich countries where clear standards of care exist, implementing systems that assess quality of care is a challenge when high-quality of care does not guarantee good patient outcomes. Accordingly, quality assessment standards from well-regulated industries have been adapted to evaluate process rather than outcomes with the associated challenge of using secondary or sometimes tertiary measures for what constitutes good quality care. Variables like mortality and morbidity are tracked but need a case-by-case evaluation by a professional committee to determine if appropriate care was provided due to the complex variables affecting patient outcomes. Patient satisfaction scores are used in the USA as an important quality measure ₇, however an important criticism of this is that patient satisfaction is not actually correlated with the quality of medical care received ₈.

Conclusion

The above are just a few of the many challenges facing hospitals that aim for excellence. Mainly, lack of a global clinical standard and diverse ideas about what constitutes appropriate clinical decision making creates a confusing environment for patients and providers alike. Individual hospitals and hospital systems each need to apply effort to establishing an internal standard of care based on resource considerations, medical education systems and local patient demographics. Next month we will go more in depth about challenges in reimbursement models, creating holistic care and care coordination.

References:

1. Lateef F. Patient expectations and the paradigm shift of care in emergency medicine. J Emerg Trauma Shock. 2011;4(2):163-167. doi:10.4103/0974-2700.82199

2. Akinleye DD, McNutt LA, Lazariu V, McLaughlin CC. Correlation between hospital finances and quality and safety of patient care. PLoS ONE. 2019;14(8):e0219124. doi:10.1371/journal.pone.0219124

3. Naylor M, Keating SA. Transitional Care: Moving patients from one care setting to another. Am J Nurs. 2008;108(9 Suppl):58-63. doi:10.1097/01.NAJ.0000336420.34946.3a

4. Elsevier. Medical knowledge doubles every few months; how can clinicians keep up? Elsevier Connect. Accessed February 7, 2022. https://www.elsevier.com/connect/medical-knowledge-doubles-every-few-months-how-can-clinicians-keep-up

5. skills-fade-literature-review-full-report.pdf. Accessed February 7, 2022. https://www.gmc-uk.org/-/media/gmc-site-images/about/skills-fade-literature-review-full-report.pdf?la=en&hash=8E0E20E07337E2344A5467F9B302C2D83CF2EBA5

6. Basow DS. Use of Evidence-based Resources by Clinicians Improves Patient Outcomes. :14.

7. Jackson JL, Kroenke K. Patient Satisfaction and Quality of Care. Mil Med. 1997;162(4):273-277. doi:10.1093/milmed/162.4.273

8. Shirley ED, Sanders JO. Measuring Quality of Care with Patient Satisfaction Scores. JBJS. 2016;98(19):e83. doi:10.2106/JBJS.15.01216