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Healthcare organisations must identify the issues at the heart of their problems before designing a solution to fix them – As published in MedicSA
The problems and challenges faced by most healthcare organisations are remarkably similar and are found worldwide, as uncovered in Mark Britnell’s In Search of the Perfect Health System. They stem from an industry undergoing widespread change, enabled by technology, and driven by the individual expectations of patients, staff and doctors. In the short term, we are being forced to cope with the unpredictability of COVID-19. In the medium term we are experiencing chronic budgetary constraints – and seeing a shift from episodic, reactive treatment of disease to large scale, proactive optimisation of health.
This puts the healthcare system under strain. Patients, staff and doctors suffer, as evidenced by the epidemic of burnout and mental health issues across society. As BeyondBlue’s 2018 survey of doctors’ and medical students’ mental health found, clinical personnel have rates of burnout at two to three times those of the general population or other professionals with similar responsibility. Burnout, characterised by a loss of enthusiasm for work and depersonalisation, leads to reduced effort with implications for errors and a loss of productivity.
However, most failure is a result of the system rather than people. My daily experience in the healthcare setting is of healthcare personnel compensating for the system’s shortcomings. Shortcomings include duplication of effort, delays and other forms of what the OECD in its 2017 Tackling Wasteful Spending on Health report estimated as a 20 per cent waste in healthcare spending worldwide. This represents $40 billion a year in Australia! We are usually so busy ‘doing’ that we are unable to devote sufficient time and effort to thinking about ‘how’ we do. Without coordinated improvement measures, both human and financial capital are wasted. If we are to reconfigure health care, what aspects are most important to redesign?
Four categories can be considered:
Operational issues – these tend to dominate people’s daily work, and include:
- ensuring appropriate resourcing for routine and unexpected requirements in the face of increased patient and treatment complexities, including COVID-19
- reducing resource and energy usage
- security of information, people and equipment
- ‘leapfrog’ developments such as moving from paper to computerised systems, or adding a new department
- optimising bilateral executive-employee communication to avoid information loss, whether translating a vision into daily tasks, or feeding back problems from daily tasks.
People issues – these relate to everyone involved, such as support and administration employees, nursing/allied and clinician employees, patients, and visiting clinical staff. Aspects include:
- attracting and retaining top-quality people
- identifying, training and/or removing problematic personnel
- managing ‘presentee-ism’ – pleasant underperformance – to promote engagement and efficiency
- reducing the use of ‘temporary’ staff, which often comes with higher costs and reduced efficiency
- collaboration –ensuring that the healthcare experience meets patient, carer, staff and clinician expectations.
Financial issues – these exert pressure on decision-making, which can lead to decisions that are detrimental to healthcare as a whole. Considerations include:
- payroll costs – a healthcare enterprise’s major outlay
- clinical variances and cost outliers – where treatments and/or clinicians’ costs exceed benchmarks
- a reduction in revenue streams from macro-economic pressures, competition and fewer customers having private health insurance
- pricing/cost transparency, particularly for medications, devices and insurances
- reducing margins.
Strategic issues – these tend to be drowned by day-to-day operations. Healthcare has a culture of ‘putting out fires’. Factors include:
- modernisation – ways to consistently assess the next ‘big thing’, whether it is equipment, medications, operations, technology, or new healthcare delivery models
- competition from similar or alternative healthcare providers
- governance – meeting external compliance requirements alongside continuous regulatory/ legislative change; in particular, security of data
- risk – improving the safety/quality culture to reduce business and clinical errors
- creating value for society, patients, clinical personnel and administrators.
So, where do we start? Unfortunately, there is no one-size-fits-all answer. As Harvard Professor of Medicine Dr Lewis A Lipsitz has pointed out in his paper, Understanding health care as a complex system: the foundation of unintended consequences, different organisations have different priorities within the complex and adaptive system that is healthcare. However, consideration of the prompts above will highlight for any organisation or business/clinical unit at least two or three directly relevant major concerns.
When major issues for both senior management and frontline healthcare workers are interrelated, the likelihood of a successful improvement increases. A major issue for management will be difficult to improve if it does not benefit front-line staff in some way. Similarly, a major issue for healthcare workers will be difficult to improve if management does not see or understand the benefit to the organisation.
Clinicians often sit in both executive seats and on the front-line, and so have an important role in reconciling these apparently competing demands. Issues at first glance often appear unrelated, especially to those focussed exclusively on their roles. Applying a systems approach to desired improvements, as depicted in the figure, helps to uncover associations – and importantly helps to avoid unintended negative consequences of an intervention.
Considering the whole system often leads to a change in priorities for redesign, resulting in an increased likelihood of success. For example, transitions of care between staff or healthcare facilities cause a loss of continuity and impair the healthcare experience for workers and patients. As much as half of the handover information is distorted or missed. Ensuring technological, financial and legislative support for transitions of care is one way of both supporting and improving all facets of a patient’s health and care.
Recognising that the patient and the patient’s data are the only constants within the care continuum helps us design care pathways that work for patients, healthcare workers and administrators. It also helps to reconcile the competing demands of local, state and federal healthcare. Anchoring healthcare to the constant of the patient and their data enables us to design a resilient yet adaptable healthcare system that can tackle the threats that we face.
- BeyondBlue. National Mental Health Survey of Doctors and Medical Students. 2018
- Britnell, M. In Search of the Perfect Health System. 2015: Palgrave Macmillan. Kindle Edition.
- OECD. Tackling Wasteful Spending on Health. 2017