Category: Service

My 9-year-old plays Beethoven.  Most people recognize it.  My brother-in-law, a concert pianist, plays the same notes on the same piano with a different outcome.

Same piano.

Same score.

Different outcome.

Identical structure and process do not produce an identical outcome.  Health care obsesses over structure and process but, for the most part, ignores patient outcomes.

Donabedian first studied health system performance in the mid-20^th century.   He suggested we look at structure, process and outcomes.

Structure

Providers love to talk about structure.

“Just give us more beds/nurses/doctors/operating-room time…”

“We don’t have enough X, Y or Z!”

With Beethoven, you might say performer talent counts as structure, the raw materials.  Fair enough.  Even so, healthcare isn’t sophisticated enough, or brave enough, to differentiate between provider talents.

Process

Regulators love to talk about process.

“Standard of care; best practices; quality based procedures”

Ontario’s Quality Based Procedures focus on process.  Essentially, QBPs define complicated tick-boxing to qualify for funding.  They completely ignore patient experience and do not put patients first, ahead of process or budgets.

Despite medical miracles like heart transplantation, antibiotics and test-tube babies, the greatest leaps of innovation mostly ended in the mid-20^th century. Healthcare distrusts innovation.  No one wants to mess with success.  We’d rather do more of the same or look to experts to tell us how to do it.

Outcomes

Patients care most about outcomes.

Inadequate structure plus innovative process can produce great outcomes.  Dr. Venkataswamy developed an assembly line process to deliver cataract surgery, at a fraction of the cost, for millions of poor people with as good, or better, outcomes in the Aravind eye hospital in Mumbai.   Dr. Venkataswamy could never develop an Avarind in North America.  We obsess over process.  We refuse to change without sufficient structure.

Venkataswamy focused on outcomes, first.  He gave millions of poor people their sight without having money or surgeons to do so.

Patient Outcomes

We should start with the sound of Beethoven, with patient outcomes.

Focusing on structure and process, before outcomes, is backwards.  We need to focus on what we hope to achieve, how we are going to measure success, and then fund structure and build process to deliver it.  Not the other way around.

(photocredit: houstonpianocompany.com)

 

Canadian Medicare still falls behind other universal health systems.  Please view this one page summary:  2014 Report Card.

For all the money you spend – yes, you the taxpayer – we should expect better service for patients.

The Wait Times Alliance does great work highlighting patient service.  Check them out and share widely!

 

Some argue that patient care is all or nothing; that we cannot give part of it and still do a great job.  Unless we do a ‘proper job’ and give idealized patient care, we should not even start.  ‘Proper’ care requires thorough examination, investigation, treatment and discharge excellence.  If it isn’t ‘proper’, then you should not do it.

The same people find time to

• take breaks
• talk about honeymoon plans
• visit with police, fire, or ambulance personnel
• help their colleagues

All this while completing their patient care work.  They find time during the day for things they value by adjusting the time they spend with patients.  Most of the time, this is reasonable.  Each patient requires a different amount of care.

Patient Care: Discrete or Continuous?

Sewing together a skin laceration is a discrete event.  You cannot sew it halfway.  Hanging an IV requires a certain minimum time to complete.  You cannot hang half an IV.  Closing lacerations and hanging IVs are discrete tasks that will always require at concrete minimum of time and effort by even the most efficient provider.

Most patient care depends on providers and patients.  It varies widely.  Some patient histories contain only a few words while others require pages and could go on for days.   Most patient care exists on a continuum from a few seconds, to minutes, to many hours.

Cutting Corners

Patients especially appreciate care when they know we can’t give them the whole deal.  They know and appreciate when corners were cut to provide them some relief, any small help.

Providers, who argue for rigid ratios of nurses or doctors to patients, or ideal numbers of patients seen per hour, think of care as bundles of ideal service.  The same people tend to defend waiting rooms and boarding admitted patients in overcrowded emergency departments.

In a system stretched beyond function, we need to provide some patient care even when we cannot give it all.  We need to do something – anything – for patients suffering and waiting, even if it’s not ideal.  For most patient care, just a few seconds can make a world of difference.

(photocredit: dailymail.co.uk)