5 key features of a successful hospital

 An article in the Economist this week describes the 5 key things a hospital needs in order to outperform the rest: 

• Competition: having 10 or more choices available to patients predicted better management practices, which in turn correlated well with survival from heart attack (a standardised measure of hospital success)
• Larger size:  bigger hospitals performed better than smaller ones
• Private ownership: higher scores
• Clinicians in managerial roles is good: the UK is relatively poor with only 58% of managers having a clinical background.  In Italy, all managers must have clinical backgrounds, in Sweden it’s 93%; US, Canada and Germany, 71-74%; France, 64%.
• Managers given autonomy fare best. 

These findings appear to correlate in the NHS.  The Hammersmith Hospital in London is considered one of the best in the country and fulfils most of the criteria.  “Big, professional, autonomous, mostly independent and ferociously competitive: elite universities seem to offer all five important characteristics for saving lives.”

Sea change?

 

We know that the world population is getting older and sicker, but did you know that by 2030, India and China will each have more cases of diabetes than the US? Infectious diseases, too, can spread rapidly; TB knows no bounds and is increasingly drug-resistant. You could call this the ‘globalisation of disease’. 

World-wide, more and more is spent on healthcare, yet returns, in terms of better health, do not correlate well with expenditure. 

Solutions will include:

• Personlised healthcare, e.g. mapping an individual’s genome to predict disease and nip it in the bud
• Telehealth, e.g. keeping people out of hospital and maintaining wellness
• Bigger public health projects, e.g. safe drinking water

A key requirement will be leadership and collaboration.   How can we create a compelling vision of better, affordable, global healthcare?  Comments?

Wrong Site Surgery

My hospital has recently installed a new Theatre Management System (TMS).  It is not a CSC system.  On two occasions in the last month, the wrong patient has been brought to my anaesthetic room.  The errors were quickly noticed and the patient redirected correctly.  This is the first time, in 20+ years’ practice that I can recall this happening, though it is a well-known cause of wrong site surgery. 

There are ongoing root cause analyses, but I suspect an underlying factor is that we have no reliable way of identifying the patient or the location. 

RFID technology exists that could address this issue.  Perhaps if the patient had been wearing an RFID bracelet, and there were sensors in the doors, such a mistake would not occur.  If such a system were linked to the TMS, maybe it would be foolproof? 

You will be a patient yourself one day and your safety could depend on it!

Hands-on patient care versus recording

In clinical practice (and by that I mean hands-on care), there can be a conflict between doing the task, e.g. putting a patient to sleep, and recording what you’re doing.  Sometimes, the record can be done retrospectively.  Surgeons, for example, do the operation and then write up what they’ve done.  Anaesthetists, in contrast, divide their attention between looking after the unconscious patient and recording their activity in ‘real’ time.  This is always a source of stress for the anaesthetist as it involves juggling the urgent versus the important.  In the old days, i.e. when I started 20 years’ ago, there was no contemporaneous recording, rather, like the surgeon, you simply wrote down what you’d done afterwards.  No need for recording the vital signs, and machine status every 5 minutes.  However, the norm nowadays is to record more and more data items, more or less simultaneously.

Theoretically, some of the recording can be captured automatically, e.g. the output from monitors and machines.  However, in reality this is rarely done as it requires ‘interpretation’ by the anaesthetist.  For example, if your ECG lead becomes disconnected for a few seconds, a ‘flat line’ is produced.  Clearly, the patient has not died, but how does the ‘dumb’ monitor now that?  Hence, most anaesthetists prefer to record patient and anaesthetic machine information manually, and slightly retrospectively, so that unimportant anomalies can be ironed out.

At present, we note down on paper with a pen, the blood pressure, heart rate, oxygen saturation, end-tidal CO2, etc, etc, every few minutes.  In addition, a record of drugs given, timings, doses, intravenous fluids, etc is kept.  It would be very difficult to do this electronically if it meant keying-in data and using a mouse; your attention just wouldn’t be where it should be – on the patient. 

But, a mobile touchscreen, that you can pick up and put down, allows you to replicate what you’re currently doing manually, only better, quicker and more accurately.  What’s more, and most important, is that it can all be done, ‘in the line of sight’ of the patient.  There are other benefits too.    Legibility and data handling afterwards are much easier.  And, as is becoming mandatory,  anaesthetists can have a digital record of all their activity, so productivity and experience can be logged.

So, no more conflict between competing tasks.  The patient can sleep safely with their anaesthetist watching over them!

What about the future?  Perhaps the ultimate ‘black box’ recording is real-time video.  Several surveillance cameras positioned in the Operating Theatre could record everything that’s going on (even a ‘head-cam’ for the staff?).  This, combined with outputs from monitors and machines, would provide a near incontrovertible record of proceedings, and remove the need for any other form of recording, allowing the staff to concentrate on their primary task of caring for the patient.  You can imagine what could be done with such videos!