Volume 189 - Issue 4
Health services under siege: the case for clinical process redesign
Authors: Tony J O’Connell, David I Ben-Tovim, Brian C McCaughan, Michael G Szwarcbord and Katherine M McGrath
Med J Aust 2008; 189 (4): 238-240. || doi: 10.5694/j.1326-5377.2008.tb02009.x
Published online: 18 August 2008
Published online: 18 August 2008
In reply: We agree with Wilson and Collins. Community-based or ambulatory alternatives to admission to an acute facility are essential adjuncts to the redesign and increased bed capacity referred to in our article.1 The capital costs alone will be prohibitive if our only strategy is adding bed capacity. We see a significant shift in capacity from the acute to community sector as eminently amenable to redesign methods: to map current constraints (as the issue is not just inadequate community services), engage clinicians in changing their referral and treatment patterns, improve awareness of alternatives, identify new processes to facilitate use of the community as a viable alternative, and embed these new behaviours through easily accessible redesigned pathways.
We chose the case study of the frail older patient deliberately, as it highlights how our current default option, hospitalisation, does not necessarily give these patients the best outcomes.
In response to Larcos, we are concerned that the frustrating complexity of our current system for patients and frontline staff alike has produced so many clinicians who, like him, are cynical about improvement. Good redesign activity does engage clinicians, and our best improvements arising from redesigned processes are those that have incorporated clinician and patient input. That is the practical everyday “evidence” on which good redesign is based.
Redesign does not ask staff to work harder. Significant leaps in performance can be achieved by redesigning to make an increased throughput easier to deliver. Good redesign eliminates the frustrating and wasteful steps in care that add no value to the staff or patient experience.
Finally, in response to Brand and colleagues, both delivery of evidence-based care and process redesign are required to improve access to services and, hence, equity, patient flow, and patient and staff experience, and to reduce wasted effort. There is mounting evidence that better flow processes are associated with better outcomes. An Australian study has shown that delayed progress through Australian emergency departments (EDs) is associated with increased mortality.2 Our own article illustrates a 30% reduction in statewide mortality in New South Wales EDs as flow improved, with a concomitant reduction in statewide hospital standardised mortality rate.1 When patient flow improves because constraints and disconnects are eliminated, then system efficiency improves; it is only when patients are processed with indecent haste that one might expect a deterioration in quality.
The improvements reported were not just measured in minutes from initial triage, but also in fewer hours spent in an ED before transfer to a ward, and in fewer days of waiting for tests and consultations as an inpatient before discharge.
The results provided in the supplement3 are for an entire state health system, the largest in Australia, illustrating a turnaround in state performance, and they therefore warrant serious consideration.
References
- O’Connell TJ, Ben-Tovim DI, McCaughan BC, et al. Health services under siege: the case for clinical process redesign. Med J Aust 2008; 188 (6 Suppl): S9-S13. 0_CBBEHECD
- Sprivulis PC, Da Silva J, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006; 184: 208-212. 0_CBBHFEAD
- Health services under siege: the case for clinical process redesign. Med J Aust 2008; 188 (6 Suppl): S1-S40. 0_i1091849