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Challenges in Designing Excellence-Oriented Hospital Systems - Part 2

After outlining the characteristics of an ideal hospital, we set out to describe the design challenges facing hospitals committed to excellence. Last month we highlighted three main issues which were: Managing patient expectations, The diversity of the types of hospitals in terms of target population and available resources and finally the lack of a global medical standard of care.

Today we will outline some of the challenges related to the various staffing models and how they impact quality of care.

Continuity of care leads to better patient outcomes but is harder in a shift environment

Tradeoffs between increasing shift work for physicians to minimize burn out and prioritizing continuity of care are often made when making decisions about staffing ratios and schedules.

Continuity of care (or longitudinal care) is a physician/patient relationship over time. Due to the increasing complexity and burden of clinical medicine in hospitals, we can understand why a trend towards increasing shift work led to declines in continuity of care over time ₁. This phenomenon cannot be ignored given the data supporting that patient outcomes, satisfaction and quality of care delivery all improve when the patient is seen by the same physician over time _{2, 3,4}. Tradeoffs between increasing shift work for physicians to minimize burn out and prioritizing continuity of care are often made when making decisions about staffing ratios and schedules. The nature of hospital medicine means that true continuity of care is almost impossible to achieve. However, literature from primary care might come to the rescue which defines three dimensions of continuity of care: informational, inter-personal and longitudinal ₅. Rather than pitting either the patient and the physician’s interests against one another where one of them loses, further efforts to examine this in hospital settings can lead to creative models that are in-line with the needs of both providers and patients.

Improved coordination of care can improve patient experience, clinical outcomes and reduce costs. It can also build robust systems that minimize medical error.

A recent study found that inefficient health care systems in the USA contribute to over 760 billion USD in losses annually ₆.

Six domains were identified as the main culprits in these losses: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity ₇. Another study estimates that reducing silos in health care systems and providing patients with well-coordinated care can save $240 billion USD annually ₈.

Organizational workflow has far reaching impact on both staff and patient satisfaction, yet the evidence on best practices remains fragmented and piecemeal ₉.

Patient safety is often compromised in systems that are not streamlined for efficiency. In inefficient systems providers are often asked to multi-task critical activities or are frequently interrupted. Lack of clear roles or intentional redundancies for safety purposes can diminish the ability of staff to speak up when medical error is suspected. Lack of clear protocols can contribute to delays in potentially critical patient care while providers debate decisions in real-time.

In inefficient systems providers are often asked to multi-task critical activities or are frequently interrupted. Lack of clear roles or intentional redundancies for safety purposes can diminish the ability of staff to speak up when medical error is suspected.

This highlights the importance of a sober, unbiased, clear and customized approach where each healthcare institution critically examines itself for patient safety and patient experience. Examining processes from the perspective of cost saving, value added and staff satisfaction are all important parameters to consider when designing or improving healthcare delivery systems. Bringing all affected stakeholders to the table when designing or implementing changes as early as possible is key to capturing all the critical variables that must be considered.

Every touchpoint of patient care delivery has unique challenges

In an era of value-based compensation for health care, insurance companies will increasingly look for efficient health care systems that reduce the cost of health care. Single-payer systems have a similar remit that extends to maintaining population health. It becomes of paramount importance then to design efficient systems that achieve the required quality of care.

Furthermore, modern medicine has become dramatically more complicated over the past five decades. Common diagnoses now have standards of care that apply to every aspect of health care delivery including triage, diagnostic work-up, acute care and post-acute treatment.

Creating systems that can deal with emergency situations while optimizing day-to-day quality care involves extensive pre-planning, agreement and communication among hospital staff and administration providing the necessary resources.

Triage: This is a critical component of health care delivery. Timely assessment of life-threatening conditions like myocardial infarctions, stroke and sepsis involve completing diagnostic tests and even preliminary treatments within the first hour of a patient arriving at the door. Surgical emergencies like appendicitis, necrotizing fasciitis or mesenteric ischemia require seamless coordination among multiple departments in a timely fashion to get the patient the lifesaving care they need. Creating systems that can deal with emergency situations while optimizing day-to-day quality care involves extensive pre-planning, agreement and communication among hospital staff and administration providing the necessary resources. This ability to deal with emergencies is a separate requirement from the need to keep a high turnover of patients to decrease wait-times for less acute patients in the waiting room. Successful triage is one of the most important determinants of a patient’s experience and safety when presenting to the hospital.

Single payer systems that have not implemented audits or regulatory requirements to ensure appropriate indications are used for diagnostic tests are subject to excessive waste and potentially related poor population outcomes.

Diagnosis: Justifying diagnostic tests based on pre-test probability and the test sensitivity/specificity is now a global standard for insurance companies to approve reimbursement. Despite advancements in medical imaging and highly sensitive tests, they have not replaced the importance of sound clinical decision making. Placing clinical experts in key touch points of a patient’s interaction with the system is a complex factor to consider especially in institutions where there are varying levels of physician expertise. External evaluation of clinical decision making is performed by insurance companies and regulatory bodies to make sure that no abuse of resources is taking place. Clinicians are expected to scientifically justify these reasons or can be subject to lack of reimbursement by insurance companies or questioning by regulatory bodies. Single payer systems that have not implemented audits or regulatory requirements to ensure appropriate indications are used for diagnostic tests are subject to excessive waste and potentially related poor population outcomes. Again, clinical decision making has to be balanced with the hospitals resource availability and time of day/day of the week. Considering the processes impacting ease of completing diagnostic tests on patients is a key element to consider that can critically impact patient outcomes.

Situations where input from multi-disciplinary teams is required become even more complex when varying clinician backgrounds lead to lack of consensus on how to best approach a treatment plan. This lack of cohesiveness ultimately hurts the patient the most.

Treatment: choosing the right medicine, at the right dose, to be delivered within a reasonable time limit is of paramount importance. With ever-evolving clinical guidelines and a growing body of literature for clinicians to consider, successful institutions will have to develop effective systems for continuing medical education so that their clinicians can continue to speak a common clinical language that is up-to-date. Clinicians from varied backgrounds will need to agree on the institutional standard of care for common diagnosis and conditions to avoid doing this while a patient’s care is being delayed. Situations where input from multi-disciplinary teams is required become even more complex when varying clinician backgrounds lead to lack of consensus on how to best approach a treatment plan. This lack of cohesiveness ultimately hurts the patient the most. Care to establish institutional standards beyond the individual “judgement call” is an arduous and daunting task. This responsibility is often left to clinicians to deal with after a poor outcome has already occurred and audited by morbidity and mortality committees. Being pulled away from clinical responsibilities to establish cohesive standards without clear parameters and premises of discussion can lead to frustration and ineffective systems being created. Adherence to clinical guidelines is only a single factor in the process of getting the medicines to the patient. Pharmacy considerations, transport staff and nursing availability and skill are all also important factors in getting the patient the correct treatment in a reasonable time. Considering the difficulties in this process alone are very illustrative of how much goes into what looks like a single decision between a clinician and a patient.

Bridging the gap in this transition of care by improving communication with providers receiving the patient after discharge or investing directly in post-acute care programs have demonstrated themselves to be cost-saving over time

Post-acute care: Discharge from a hospital is often a very stressful time for patients. Availability of resources after discharge and trust in the discharge follow up mechanism directly impacts the decision for when to discharge a patient. In the era of nosocomial infections, ageing patients requiring more intensive rehabilitation during convalescence and limited compensation creating pressure to decrease hospital stay: creating robust post-acute care systems can dramatically help hospitals achieve their mandate. Bridging the gap in this transition of care by improving communication with providers receiving the patient after discharge or investing directly in post-acute care programs have demonstrated themselves to be cost-saving over time _10,11.

For each of the above touch points, a large and diverse team needs to cooperate for optimal patient care. Most of the above discussion focused on the challenges of coordinating physicians from various specialties. However, nurses, nurse assistants, technicians, receptionists, transport staff, pharmacists, laboratory technicians, transport teams, janitorial staff and case workers all have integral roles to play to help the patient be in the right place at the right time and receiving the right care. Efficient processes will need investment in training, technology, and stakeholder buy-in to implement changes to workflow that serve the bigger picture. This is why studies conducted on a small scale for one aspect of patient care rarely show wide-spread organizational success in impacting more meta measures like patient safety, patient experience or staff wellbeing. Prioritizing human centric measures while more difficult is essential to affect meaningful system level improvements.

Conclusion

This article highlights the challenges of designing workflows in a clinical setting that optimize patient outcomes as well as sustainable provider environments. Electronic medical records and support of clinical decision making with artificial intelligence have often been cited as solutions to this dilemma. In the absence of honest workflow mapping and identification of bottle necks and insufficient redundancy for critical decision making, these digital solutions will continue to fail to deliver what is hoped. Any hospital would have to honestly assess the workflow of its clinical experts and whether adequate supervision of junior staff is in place. Creating hospital systems that prioritize the provider's needs will ultimately be most successful at creating excellent patient care.

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