Chapter 8. Integrating performance: linking healthcare domains
Marc Berg, Wim Schellekens and Cé Bergen
Introduction
The US Institute of Medicine reports ‘To Err is Human’ and ‘Crossing the Quality Chasm’ have had repercussions throughout Western medicine (Committee on Quality of Healthcare in America, 2000 and Committee on Quality of Healthcare in America, 2001). Given the resources spent and the qualifications of its professionals, the reports argue, there is a chasm between what the overall quality delivered by the system should be and what it actually is. The US healthcare system is fragmented and ‘wasteful’. Any journey through it includes many ‘steps and handoffs that slow down the care process and decrease rather than improve safety’ (Committee on Quality of Healthcare in America 2001:28).
As the earlier chapters in this book also testify, the reports’ insights are applicable to most Western countries, and the demands on the healthcare system in the near future will only increase. The safety, effectiveness, patient centredness and timeliness of care have to be improved, while keeping costs from rising further. How can we align these targets? Small, local improvement initiatives will not do the job. Nor will large, sweeping ‘quality-improvement initiatives’ have a lasting impact if the improvements do not become embedded in a more fundamental redesign of the operations of healthcare work.
In this chapter, we take up this challenge. We do not discuss the (country-specific) payment and regulatory systems that stimulate or obstruct change at the level of the care process. We will, rather, describe a series of less country-specific, interrelated design principles that depict how healthcare delivery could be organised. This vision is futuristic: no healthcare practice has fully achieved it. Yet it is simultaneously realistic, in that it builds upon elements that are broadly accepted and proven – both theoretically and practically.
The design principles pivot around the notion of care programs: work routines based on multidisciplinary protocols that encompass tasks, decision criteria and work procedures for the care professionals involved in the care of a patient category. Such care programs touch upon all levels of the organisation: operational, tactical and strategic. On the operational level, they streamline work processes and, when designed properly, increase efficiency, patient safety, effectiveness and patient centredness simultaneously. Yet these operational characteristics may ultimately not be the most important ones. On the tactical and strategic level, we will argue, care programs will be the organisational building blocks around which the healthcare organisations of the future will be shaped. Care programs will bring together teams of professionals producing optimal quality care for patients with a given condition or problem. In line with current trends in healthcare financing and regulation, the teams running these care programs will become self-steering – responsible for their own clinical and financial results.
Integrating professional and organisational quality
In current healthcare practices, many individuals are working to improve the different dimensions of ‘quality’. Through guidelines and audits, professionals attempt to enhance the evidence-based nature of their work (Grol 2000). Quality managers organise the certification or accreditation of their organisation, information managers develop the information technology infrastructure, and unit managers worry about the optimal planning of scarce resources such as personnel and expensive technologies (Klazinga 2000, Berg 2004). Usually, however, these activities are organisationally separate and the responsible individuals, including professionals, information managers and quality managers, interact more with their peers in other organisations than with each other (Berwick 1998). In addition, they focus on different quality dimensions: professionals mainly focus on effectiveness and safety, line managers on efficiency, and so forth. At heart, the deepest dividing line runs between the professionals ‘owning’ and improving the content of healthcare work and the managers ‘owning’ and improving the organisation of that work.
To overcome the quality chasm, these separate activities have to become integrated. This is partly a matter of organisation: rethinking the composition of a project’s steering group, for example, or organising ‘integrated quality meetings’ at board level (Leape et al 2000, Murray & Berwick 2003). Yet the true integration of these activities requires a conceptual innovation: a vision on how these different activities are part and parcel of the same enterprise. To overcome the quality chasm, to improve the different dimensions of ‘quality’ simultaneously, we need to join state-of-the-art insights from different fields into a single integrated approach. In other words, we need to learn to simultaneously think about content and organisation of healthcare work for radical change to become possible.
Standardisation – creating care programs
The heart of fundamental care delivery innovation lies in the standardisation of care into ‘care programs’ (see Figure 8.1). Currently, the archetypal mode of organising healthcare delivery is the ad hoc step-by-step approach. Since every patient trajectory is unpredictable, the care professional requires the freedom to ‘pick’ what this unique patient requires next from the palette of their professional knowledge base. Every patient follows his own trajectory and in these trajectories each next step is decided upon the step before (de Vries & Hiddema 2001, Strauss et al 1985).
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| Figure 8.1 |
One-hundred years ago, before the times of medical specialisation, physicians could handle most of what any patient could bring to their attention, and few diagnostic and therapeutic options were available (Howell 1989). At that time, the step-by-step mode of care delivery was both patient centred and efficient. In our times, however, the theory and practice of medicine have become highly complex. Healthcare institutions are populated by many different professions and specialists, handling patients that often require the attention of several of these. Yet most of our care delivery is still organised according to this archetypal form. Every next step (e.g. a surgical operation) is only conceived and planned at the completion of the previous step (e.g. obtaining diagnostic test results), resulting in frequent waits and, more often than not, very ad hoc and variably shaped patient trajectories. The result is a care process that is fragmented (not patient centred), unsafe and inefficient (see Claridge & Cook, Chapter 4).
Yet is patient care not in principle organised this way because individual patients have individual histories and needs (Strauss et al 1985, Timmermans & Berg 2003)? The individual trajectory of a patient suffering from heart failure, for example, is indeed unpredictable. A patient’s personal and medical history will shape his and his physician’s preferences in unique ways, and symptoms and reactions to therapeutic interventions never quite behave according to textbook definitions. Yet at an aggregated level, much of this individual variation disappears. For the category of heart failure patients, the steps that are mostly taken, or that should be taken, can be predicted.
For the major categories of patients that an organisation deals with care programs can be developed. As stated, care programs are work routines based upon multidisciplinary protocols that encompass tasks, decision criteria and work procedures for the care professionals involved in the care of such a patient category (see Box 8.1). Care programs can be limited to a hospital or a department, but they should ideally include all providers having a role in the care of a category of patients. The different professionals jointly develop these protocols, drawing upon evidence-based guidelines wherever possible.
Box 8.1
The term ‘care program’ is used to emphasise the patient-centred organisationof care around the major patient categories the organisation(s) involved deals with. We do not use the term ‘critical pathway’, or ‘carepath’ because these terms usually refer to a detailed protocol, sometimes used in the form of a time-oriented recording sheet. Usually, ‘critical carepaths’ are predominantly about increased effectiveness, although sometimes an increase in efficiency (such as through reducing length of stay) is included. Also, the ‘critical pathway’ literature is largely nursing oriented, while we emphasise the multidisciplinary nature of the care program.
A care program is typified by the integration of activities between disciplines, professions, departments and, in the case of a multi-organisational care path, organisations. Also, care programs are about tackling professional and organisational quality simultaneously: optimising effectiveness, efficiency, patient centredness and safety through integrating (not running side by side) professional and organisational ‘best practices’. Finally, with the notion of ‘care program’ we explicitly refer to both the operational and the tactical/strategic impact of redesigning care processes in such a way.
At the same time, a terminological battle is meaningless: much current ‘carepath’ work comes close to what we address in this paper.
Most of the benefits of care programs are well known: care delivery becomes more evidence based, and colleagues, patients and payers know what care to expect. Time after time, it has been shown that following smart guidelines meticulously yet non-dogmatically saves lives (Berenholtz et al 2004, Luthi et al 2003, Schiele et al 2005). Also, care programs afford safer care. Every safety expert knows that there is nothing more lethal than unwarranted variation in critical processes. Uncontrolled variation obstructs flow, unnecessarily burdens the cognitive processes of those involved in the process check and prohibits learning (because the process outcomes cannot be compared to each other) (Carroll & Rudolph 2006, McManus et al 2003, Rozich et al 2004).
Care programs also afford a reduction of coordination work. Working step-by-step requires each next step to be organised and planned anew, including all the ad hoc phone calls and form filling that comes with that. In organisations that work under pressures of time and resources (and most healthcare organisations do), this implies stress and loss of professionals’ and patients’ time. With care programs, the sequence of activities to pursue and professionals to see is already established. Rather than establishing this anew every time a patient comes in with ‘heart failure’, this care program is made beforehand by the professionals involved. Since everyone knows what to expect in the next, and previous, steps, coordination work is reduced (Mintzberg 1979, Timmermans & Berg 2003).
Finally, well-designed care programs are patient friendly. Those who mistake this call for standardisation for a call to quench the ‘art’ of medicine cannot be more mistaken. There is nothing ‘patient friendly’ in unnecessary waiting times and unnecessary safety risks. There is, on the other hand, nothing more patient friendly than a well-organised, smooth trajectory, in which everyone involved knows what is expected of them, is optimally informed, and can give their full attention to the patient (Millenson 1997).
For this to work, it is crucial that care programs are not just written guidelines. They should be concretely ‘anchored’ in the organisation through working arrangements between professionals and departments, special outpatient and inpatient facilities, the information technologies and forms used, material affordances and constraints, and so forth. For example, charts may be prestructured to indicate the steps to take next, or an outpatient clinic designed for optimal breast cancer care may be put in place. Likewise, the sterilised instrument baskets used in operating rooms can be standardised to ensure that the right tools for the job will be at hand, and checklists can be put in place that must be followed before a high-risk procedure is started (Committee on Quality of Healthcare in America 2000, Norman 1988, Parker 1997). (See Box 8.3 for the importance of ‘flexible standardisation’ in making care programs work.)
Pause for reflection
The call for more ‘standardisation’ in healthcare practice is not new. In what forms has this call been heard in earlier years? Why has it been mostly ignored, until recently? What are the factors that might make it heard this time around.
Restructuring and delegating tasks
When developing care programs, the individual tasks, decision moments and work procedures should be critically reconsidered as to their organisational safety, patient centredness and efficiency. Can blood tests not be performed on the same day as the next visit? Can the variety in surgical techniques used by different surgeons be limited (Bell et al 2006, Committee on Quality of Healthcare in America 2000, Dy et al 2003)? This redesign starts by considering the four different components that constitute every care program: triage, intake, the core activities of the care program, and follow-up. Not all care programs will require these steps to be separated, but any care program requires:
▪ the decision whether the patient belongs here (triage)
▪ the selection of the optimal care program (including (further) diagnostic workup) (intake)
▪ a limited set of core diagnostic and/or therapeutic activities (core)
▪ follow-up activities (follow-up).
Triage and intake are often necessarily entwined. In emergency situations the intake and the core activities are often inseparable. In chronic care the ‘core’ of the care program can extend for years. In acute care situations it may last only briefly. In general, however, disentangling these components helps in designing subtasks that can be delegated, or executed in a more effective, patient-friendly and efficient way. In current practices, every individual patient encounter seems unique because every patient comes to that encounter through a different route, with different diagnostic and therapeutic activities being done. In current healthcare practices, every single patient encounter is unique partially because there is no conscious attempt to streamline these encounters. By separating ‘triage’ and ‘intake’, and by organising the care delivery process accordingly, patient flows become more predictable. Patients remain unique, but not in the sense of varyingly incomplete diagnostic histories, or large differences in therapeutic steps already taken.
Often, (specialised) nurses can do (part of the) intake, so that the physician is freed from tasks that do not require their expertise. Ensuring a complete work-up before the consultation with a medical specialist, for example, can save many unnecessary outpatient visits. Given shortages in qualified personnel, such a redistribution of tasks is essential to managing the increasing demand for care. Retinopathy screening for diabetes patients, medication optimisation in heart failure patients (see Box 8.2) and glaucoma treatment are some of the examples where a redistribution of tasks between doctors, nurses and/or paramedics can provide optimal care for more patients (Johnson et al 2003).
Box 8.2
In the Martini Hospital in Groningen, the Netherlands, patients suffering from heart failure used to occupy some 40% of the hospital’s cardiology beds. Most of these patients had been admitted because their conditions had slowly deteriorated to the point that admission was necessary. They had usually been under ‘standard’ care: regular consultations with the cardiologist or visits to the general practitioner had not prevented their hearts from decompensating. A combination of factors appeared to be at work: primarily suboptimal medication (Bouvy et al 2003), but also poor lifestyle education and poor compliance of patients with the medication and lifestyle rules. Working under time pressure, and having many other patients with acutely pressing problems, cardiologists and practitioners often spent too little time on medication finetuning and lifestyle education.
Nowadays, patients with heart failure visit a special outpatient clinic, run by cardiologists and nurse practitioners. After an initial joint consultation with a cardiologist and nurse, the nurse, supported by a computerised decision-support tool, monitors the patient’s blood pressure, weight, renal function and so forth, and finetunes the medication prescribed by the cardiologist over some five to six sessions. Based upon evidence-based guidelines, the computer similarly helps the nurse to counsel the patient on required lifestyle changes. The cardiologist only comes into play during the first session (unless unexpected reactions to treatment, for example, lead the nurse to consult the cardiologist on an ad hoc basis) (de Vries et al 2002).
In this way, the outpatient cardiology clinic has liberated 6–8% of overall capacity, because patients are now handled by the nurse practitioner, and because patients suffer less from unnecessary deterioration of their condition. Overall, 80% of heart failure patients now receive optimal medication treatment, the average patient’s ejection fraction (a core effectiveness indicator) has improved by 60%, and heart failure readmissions have reduced by 30%. The software application is now in use in over 40 Dutch hospitals (de Vries et al 2002).
Care programs and restructuring and delegating tasks are mutually dependent (see the arrows in Figure 8.1). On the one hand, restructuring and delegating tasks makes standardisation feasible: without this, one could not achieve as much quality gain with care programs. Again, multiple dimensions can now be optimised simultaneously: efficiency (optimal use of expensive capacity), timeliness (reduced throughput times), effectiveness (appropriate combinations of expertise at the right time and place) and patient centredness (a care program organises the care delivery resources around the patient rather than vice versa).
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