The future of hospitals depends on systemness

医院的未来取决于系统性

2021-10-14 23:30:11 MedCityNews

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A hospital’s day-to-day operating environment is so dynamic that clinical leaders and frontline staff are forced to make on-the-fly adjustments and reactive decisions because they lack the necessary time and insight to make more intentional, proactive decisions. In this chaotic environment, clinicians can only focus on the patients under their immediate care and make decisions that are optimal for their patients. This localized decision-making becomes problematic because each individual decision has ramifications across the entire system. ‘Systemness’ is the idea that hospitals can broaden clinicians’ awareness to improve decision-making that takes into account the larger hospital ecosystem. Blending Clinical and Systems Thinking Nurses, doctors, and other clinicians are trained to provide the best care possible to the patient in front of them. The natural disposition for most clinicians, therefore, is to be fierce advocates for their patients, which may mean moving a patient to an earlier MRI or demanding a procedure they deem necessary. In general, this inclination is one that aligns with most hospital mission statements of providing excellence in care. It also aligns with the patient desire to feel taken care of and advocated for. However, this well-intentioned behavior is problematic from a system-wide perspective and leads to the opposite of systemness – hoarding. In the clinical realm, hoarding may take the form of putting a hold on an ICU bed for a post-surgical patient whose surgery is still hours away from completion. The instinct to ensure an ICU bed is available is understandable, but if the ICU bed sits empty and can’t be used by another patient with an immediate need, the consequences can be dire. This traditional siloed decision-making is counterproductive and anti-collaborative with clinical peers each pushing to get their patients to the front of the line too. Systems thinkers, on the other hand, tend to look at populations and how various ecosystems interact. They’re concerned about questions such as, ‘How do we optimize resources to best serve our population?’ ‘If I take action in one silo, how will that affect outcomes in another?’ Ultimately, systems thinkers have a heightened awareness that every action has downstream and upstream ripple effects that may or may not be ideal. The traditional clinical mindset is understandable given that clinicians are trained and incentivized to advocate for their patients by any means possible. Furthermore, there’s historically been a lack of tools and best practices to show clinicians how their resource requests affect the larger hospital system and could possibly cause bottlenecks and shortages that reduce overall efficiency of resource utilization. Fortunately, systemness enables clinical thinkers to adopt a system-wide mindset while maintaining the core values inherent to their clinical training. Charting a Path Towards Systemness Systemness occurs when clinicians gain frictionless awareness of the larger ecosystem in which they operate, leading to decisions that are optimal for the entire organization. The path to systemness starts with the ability to quickly visualize any given patient as a node in a larger environment. This enables clinicians to internalize the relationship between their individual clinical orders, and the impact these orders may have on other patients and clinicians. This journey towards systemness is furthered by the ability to simulate the outcome of various resource decisions such as opening surge units, rearranging surgical schedules, or assigning float pool staff to different units. In practice, systemness may enable a clinician to realize that pushing to get a CT scan sooner for a less-urgent case means that a more deserving patient may have to wait longer. Given the right tools, this is straightforward to visualize as well as explain to a patient and family who must wait until the end of the day for a non-urgent test. Another example of systemness in the real world is the growing reluctance to prescribe antibiotics for borderline cases. Most clinicians admit that it’s usually easier to prescribe antibiotics to patients who request them, rather than to explain their illness is more likely viral than bacterial. But the growing awareness of antibiotic resistance makes doctors choose the more difficult path of withholding medication in service of delaying drug resistance. This example shows that clinicians can change their behavior and broaden their awareness with evidence-based tools. Achieving Systemness Requires a Data-Driven Approach The emergence of data-driven tools that combine operational intelligence, digital automation, and people has turned systemness from a theoretical concept into a tangible reality. These tools enable systemness by giving clinicians a global view of the hospital so they can develop situational awareness beyond their immediate patients or teams. In turn, staff recognize the interconnected relationship between their decisions and outcomes at an organizational level, which ultimately leads to more streamlined operations, improved staff satisfaction, and enhanced patient care. A key benefit of using modern data-driven operations software is to nudge clinicians to adopt a degree of systems thinking. This does not mean abandoning the primacy of patient care or compromising the integrity of the patient-provider relationship. Rather, it means that when two choices are clinically equivalent, clinicians choose the one with better operational efficiency. For example, with data-driven insights, clinicians can view real-time demand for ICU beds and have confidence a bed will be available at the time of patient need. If there isn’t a bed available, clinicians can start making alternative plans such as calling in staff to open capacity or arranging for PACU boarding. Instead of bed hoarding which reduces overall bed utilization, data-driven insights enable bed coordination, which means resources are used at peak efficiency. Ultimately, systemness allows hospitals to pivot away from exclusive decision-making and towards cooperative care that benefits both the staff and patient population holistically. With the proper tools and best practices, clinicians can amplify their commitment to excellent patient care by gaining system-wide awareness and making decisions that optimize patient outcomes and operational efficiency. Photo: Feodora Chiosea, Getty Images
医院的日常运作环境是如此动态,以致临床领导者和前线人员被迫作出即时调整和反应性决定,因为他们缺乏必要的时间和洞察力来作出更有意、更积极的决定。在这种混乱的环境中,临床医生只能专注于他们立即护理的病人,并做出对他们的病人最优的决定。这种局部化的决策变得有问题,因为每个单独的决策都会在整个系统中产生影响。“系统性”是指医院可以扩大临床医生的意识,以改善考虑到更大的医院生态系统的决策。 临床思维与系统思维的融合 护士、医生和其他临床医生接受培训,为他们面前的病人提供最好的护理。因此,大多数临床医生的自然倾向是强烈支持他们的病人,这可能意味着让病人提前接受MRI检查或要求他们认为必要的手术。总的来说,这种倾向与大多数医院提供卓越护理的使命相一致。它也与病人希望得到照顾和提倡的愿望相一致。 然而,这种善意的行为从全系统的角度来看是有问题的,并导致系统性的反面--囤积。在临床领域,囤积可能采取的形式是将手术后的病人放在重症监护室的床上,这些病人的手术离完成还有几个小时。确保重症监护室床位可用的本能是可以理解的,但如果重症监护室床位空着,不能被另一个有迫切需求的病人使用,后果可能是可怕的。这种传统的孤立无援的决策是适得其反的,与临床同行的合作是不利的,每个人都在推动他们的病人到前线。 另一方面,系统思考者倾向于观察种群以及各种生态系统是如何相互作用的。他们关心这样的问题:“我们如何优化资源,以最好地服务于我们的人口?”“如果我在一个筒仓里采取行动,这将如何影响另一个筒仓的结果?”最终,系统思考者高度意识到,每一个行动都有可能是理想的或不理想的下游和上游连锁反应。 传统的临床心态是可以理解的,因为临床医生受到培训和激励,以任何可能的方式为他们的病人辩护。此外,历史上缺乏工具和最佳实践来向临床医生展示他们的资源请求如何影响更大的医院系统,并可能导致瓶颈和短缺,降低资源利用的整体效率。幸运的是,系统性使临床思考者能够采用全系统的思维方式,同时保持其临床培训固有的核心价值。 勾画出走向系统的道路 当临床医生对他们操作的更大的生态系统获得无摩擦的意识时,系统性就发生了,从而导致对整个组织最优的决策。系统化的路径始于快速将任何给定患者可视化为更大环境中的节点的能力。这使得临床医生能够内化他们个人临床订单之间的关系,以及这些订单可能对其他患者和临床医生产生的影响。通过模拟各种资源决策的结果,如开放浪涌单元,重新安排手术时间表,或将浮池工作人员分配到不同单元的能力,这一迈向系统性的旅程得到了进一步的推进。 在实践中,系统性可能使临床医生意识到,为一个不太紧急的病例推动更快地进行CT扫描意味着一个更值得的病人可能需要等待更长时间。如果有正确的工具,这是直观直观的,也可以向病人和家人解释,他们必须等到一天结束后才能进行非紧急测试。 现实世界中系统性的另一个例子是越来越不愿意为边缘病例开抗生素。大多数临床医生承认,通常给要求使用抗生素的患者开抗生素更容易,而不是解释他们的疾病更有可能是病毒性的而不是细菌性的。但是,越来越多的抗生素耐药性意识使医生选择了更困难的途径,即扣留药物,以延缓耐药性。这个例子表明,临床医生可以用循证工具改变他们的行为和扩大他们的认识。 实现系统性需要数据驱动的方法 将作战智能化、数字自动化、人与人相结合的数据驱动工具的出现,将系统性从理论概念变成了实实在在的现实。这些工具通过给临床医生一个医院的全局视图来实现系统性,这样他们就可以开发超越他们直接的病人或团队的情况感知。反过来,工作人员认识到他们的决定和组织一级的结果之间的相互联系,这最终导致更精简的业务,提高工作人员的满意度,并加强病人护理。 使用现代数据驱动操作软件的一个关键好处是推动临床医生采用一定程度的系统思维。这并不意味着放弃病人护理的首要地位或损害病人-提供者关系的完整性。相反,这意味着当两种选择在临床上等效时,临床医生选择操作效率更好的一种。 例如,通过数据驱动的洞察力,临床医生可以查看对重症监护室床位的实时需求,并有信心在患者需要的时候有床位可用。如果没有可用的床位,临床医生可以开始制定替代计划,如召集工作人员开放容量或安排PACU登机。数据驱动的洞察使床能协调,这意味着资源以最高效率使用,而不是囤积床,这降低了总体床的利用率。 最终,系统性允许医院从排他性决策转向合作性护理,从整体上造福于工作人员和病人。通过适当的工具和最佳实践,临床医生可以通过获得全系统的意识和做出优化患者结果和操作效率的决策来扩大他们对优秀患者护理的承诺。 照片:费奥多拉·基奥西,盖蒂影像公司

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