In the previous post of today’s previous hospital blog, which suffers the[i]long-standing ills and what the desired futures, the problems were exposed, therefore, now I want to continue discussing this tell something issue, and discuss with health politicians, as we could change the logic. Moving to a professional bureaucracy, from the closed organization, without management, will not be easy, and therefore you would have to select a set of measures to change the culture, the efforts in the experience have been several, varied, endless, unfinished, and successful. They are in which the Know how was incorporated into people and was constituted as the paradigms of complexity prevailing. It is not easy, because it requires political will, professional management, leadership, agents of change, efforts and acceptance of trade unions, which in general their objectives go through politicians and supporters, for benefits, remuneration, more distantly improvements in care.
Some aspects have been selected.
Changing the healthcare model.
Transformation of Lean management processes.
Integration of the hospital with its environment and chronic disease segmentation programs.
Motivate people to work fully.
Post-stay programs and services.
Change payment and billing methods.
Person-centered attention is not just humanistic, but personalized, inclusive, communicative, empathetic, trust-generating, «therapeutic», trusted giver, facilitator of the journeys of patients within the hospital, with someone who takes the patient through the best care matrix, and place him in front of a professional agent, covering the asymmetry of information, but always and fundamentally enabling him in his biopatography, with his social determinants, his fears, his decisions, will end up being shared with their therapeutic team.
The patient attends the health services to receive information, these as knowledge companies and through an agency relationship, incentives through, receives the same, expressed as diagnostic and treatment services. This is done in a model of care that is fatally fragmented and that requires co-production of the user in formalities and bureaucracies, which do not add value, in the «Porterian» sense of the term. The amounts of benefits are linked to income, through contributions, contributions or costs of private health plans. A health system closely linked to social security. What crystallizes in the current framework benefits inequalities and inequity
[i] Díaz CA. 2020. Los hospitales de hoy, los males de siempre, el futuro deseado. Saludbygestión.blog
Hospital Care Model:
The model of hospital care are the actions by which the patient is oriented to the best possible agency relationship and is assigned diagnostic and treatment resources, in an interface that is the model of care, focused on his person, from the consideration of an effective and efficient process, as well as the personalized model of care, based on their needs, on their requirements, on the evolution of the disease.
The actual model is episodic, fragmented, which treats the acute complications of patients, without having designed transitions, nor actions to ensure the reference of patients to other sectors of the system, having to go according to what the patient assumes to the specialist, who will not understand why the patient is consulted. There is a chasm between the health and the social.
The hospital care system continues to focus all its efforts on an acute-focused care model but does not adequately care for chronic patients with care needs other than acute pathologies.
There is a strong fragmentation between levels of care and between watertight structures and compartments (hospitals, primary care, social services). This fragmentation undermines quality, prevents offering continuity of care and efficiency of the services provided (in many cases it is not possible to stabilize patients, which subsequently results in a high volume of re-income and emergencies).
Patients with chronic pathologies are treated episodically, often being «off the radar» of the health system, so that once they leave the consultation or are discharged, they receive no proactive or preventive care, nor is there any kind of remote monitoring or support for the management of their disease.
The model of care should cease to be an unforeseen model, of attention of acute complications, fully segmented and fragmented, which prevents longitudinal and continuous care, to orient themselves, by segmenting the risk to patient care chronically improving self-care, or entering the natural history of their disease and preventing natural evolution, postponing complications, and deteriorating health status.
Then there are the most complex patients, who have more than one pathology and multimorbidity, who become complicated patients, who have clinical, functional, cognitive, mental and social deficits, who demand a more extensive vision than that the specialist, and is integrated by a case manager, then the organization of hospital services with internists or generalists, essentially multidisciplinary teams that can select an individualized treatment scheme and customized of the patient, then and finally, a process care system, Factory type for processes with less variability and quasi-industrialized. Varela J 2019[i].
[i] Varela J. 2019. 5 intensidades de provisión para 1 sanidad más valiosa.
In January 2013, Krumholz publishes a paper called «Post-Hospital Syndrome an acquired transient condition of generalized risk»in which it states that patients who are discharged from the hospital are not only recovering from their acute disease, but also experiencing a period of risk of adverse health events. This period of acquired and transient vulnerability defined it as «post-hospitalization syndrome».[i] [ii] For lack of well-designed continuous care devices. [iii] For example, in patients admitted for the treatment of heart failure, pneumonia or chronic obstructive pulmonary disease (COPD), the cause of readmission is the same as the admission rate in only 37%, 29% and 36% of cases, respectively. Causes of readmission, regardless of initial diagnosis, commonly include heart failure, pneumonia, COPD, infection, gastrointestinal conditions, mental illness, metabolic alterations and trauma.
More and more people are living longer, the population pyramids are acquiring other morphologies, where the inhabitants over 65 years old exceed 18%. The epidemiological pattern is modified by a predominance of chronic noncommunicable diseases, which cause different phenotypic expressions. Diseases with quantitative predominance are described, such as high blood pressure, hypercholesterolemia. People’s lives are medicalized through risk factors. Combined with Metabolic Diseases. Increased body weight. Sedentary. Diabetes. And economic inequality. That kills too. Resource scarcity for financing inflation in health care. Poor distribution of these. That adds an important component of attention linked to income, to coverage. That it is incentivized by elements of comfort, accessibility or social demagoguery that generate aspirational expectations in citizens, by the improvement that this implies in their social status. To have a contract with a prepaid medicine company is to have health care. This being an opinioned and questionable issue. Not just from the ideological sense. But because prepaid medical companies don’t offer health plans, they offer coverage plans. Determined in relation to the payment they receive. Selecting providers for the quote of their beds and their rights. They, in turn incentivize with the visible luxuries in their rooms, comfort issues, rather than better health care.
[ii]Krumholz HM 2013. Post-Hospital Syndrome-An acquired, transient condition of generalized risk. N Eng J Med 368.2.100-102
[iii] Jencks SF; Williams MV; Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2011; 364: 1582.
Processes have waste, have no stable quality, have unacceptable variability, become unsafe and can generate adverse events.
We must analyze the processes and see what value generates each of the «transactions» of knowledge, practices or logistics that are carried out, in a certain amount, and time interval, with redundant displacements, excessive co-production of users, this production has to be with quality, presence and ears, to listen to those who execute them.
Generate value, flow orientation, determine executive sequencing, keep stable quality, logistics, pull. Eliminate waste. Operationally control.
Integration of the hospital with its environment and programs
Integration can be achieved through a series of nuclear actions that do patient identification, nominalization, georeferencing and social history. The staging of patients. The overall assessment. Communication and determination of a rational offer of services. Care planning. Organization and linkage with services and their monitoring. Tracking. Referencing. Care transitions. Linkage between care levels. Links and bridges, to reroute patients always. Alarm guidelines and main actions before them. Channels of communication with pre-hospital care. Medication. Medicine cabinet. Periodic points of provision and checks. Reevaluation. Intersection for special benefits required by patients. Individualized provision of tips. Orientation towards assistance and emergency. Establish home care by empowered agents.
Communication and interaction between primary care and diagnostic services, between primary care and specialized services, between primary care and medium-stay care and post-high care. The after-sales services offered by the system, in order to have continuity of care and avoid avoidable re-internations.
Develop precise links of the health system with its patients, the care they need, the support services, the institutions that make up and are expected of the network. An electronic record that is shared. Contracts that prioritize patient time and integrated patient care. Don’t have to make unnecessary visits.
It should be aimed at promoting integration between suppliers through hierarchical and network mechanisms. These must then be assigned to integrated, hierarchical, and networked health organizations. Generating virtual networks of inter- and intra-organizational integration based on agreements, contracts or alliances between suppliers and insurers. The degrees of integration of the property and the management, the most important being organizational integration, by property or virtual.
Motivate people to work fully.
Organizational fullness is defined as the deep part, the vocation of service, collective institutional development, without development of the individual ego, is to be determined, but also intuitive, rational, with good arguments and reliable data, spirituality at work serves, come to work with a very small part of our life to work is not good, we must enter with the best of us, it is that 13%, we do not like who we are and what we do, there is the secret to tell people the importance of what we believe, for that and why we are. That’s where creativity and passion come in. To do this, create new, more practical benefits for the patient. To do this, create a safe workspace. In which they can be fully displayed.
For people to get involved we must incorporate the vital background of all people, their interests, their skills, beyond formal education, behavior in teamwork, with the different social groups of the organization. Work by taking our masks off. All people are important, especially those who perform roles that others don’t want to do. Feel that people can be themselves and not that they are rented a portion of their lives to do something soulless, heartless, show teams fully, focused on the work they have to do in the role they took on and the responsibility that I Freedom confers upon them. It’s inviting our humanity to work.
Each problem will be an invitation to grow and learn. We’ll always be learning. We’ll never be done. «when we know all the answers, the questions changed us.» There is no single way to deal with corporate problems. Separate yourself from the absolute need to be right for the purpose of listening to and respecting the realities of others. Differentiate between what we think we should be and what we do, say, and behave.
Programs and «hospital post-egress services».
Fragmentation means that hospitals do not have scheduled post-care service, favor and collaborate on care transitions, avoid unnecessary re-internations that impair people’s health status, and put patients at risk and affect the efficiency of the health system. Information. Medication. Telephone inquiries. Follow-up calls. Shifts. Linkage with case managers. Home care scheduling. Alarm systems. Decreased barriers to access and facilitation of road attendance sins. Including rehab. The patient must graduate with a product package. Epicriids. Medications. Disposable material and supplies. Phones. Notices. Alarm guidelines. Scheduled shifts. Pending and in-process studies. Tips. Education on the high. Adaptation of the family environment to the new condition of the patient.
Clinical efficiency is about effectiveness, technical efficiency, and economic efficiency, and that is the responsibility of self-formed, circular teams, with values-incentivizing leadership, and knowledge transmission. Through the presence of decision-holders. From activities of mutual medical control and cooperative support of interaction, complementation. Clinical efficiency is the Holy Grail of management today, where costs grow more than funding.
Patient safety will be the support of the processes correctly performed by trained personnel and patient care.
The big change would be in working on the right or that is done well, of what is done without inconvenience, so that as many things as possible go perfectly, and not guarantee that the least possible things go wrong. Obsessing about zero error, will not make things better, this is considered the security 2.0 that will be within organizations capable of having resilience. In practice this translates into the existing difficulties of how to move from the idea, to the must be, to do all things well all the time, and in all circumstances.
Change of payment and billing methods:
The contractual engineering of public hospitals must change, the problem that the income of doctors is always related and conditioned with the rest of the public employees and cannot be made differences, then these can be found or generated by variables that are linked to the institutional goals and that is paid to achieve those objectives set in the medium-term plan of the institution, with the difficulties and risks that this alternative entails, because it is stronger the cessation of activities when you don’t pay the extra, than when you put it on. In general, measures of economic improvement are exhausted that persist are the transcendent motivations that pass from belonging to a socially recognized organization to belong to the hospital, I want to be in that place, because I learn as a person, respect me care, I can develop my personal project, I have the needs well covered.