Recently I had occasion to spend time in a busy community hospital in order to deal with my apparent adverse drug reaction. Happily, full recovery ensued but the time spent in the Emergency Department (ED) and ward left a strong impression on me.
When my wife and I arrived in the early morning, the ED was notably calm. Upon mentioning this observation to our nurse, she ironically demurred, presumably unwilling to tempt fate and bring on ensuing chaos.
There is little doubt that her fears are real. Overcrowded EDs, stressed staff and concerns about patient safety are problems witnessed more often than any health care professional would wish. I wondered then, as I do now, if the chaos may be largely preventable -- if only the appropriate systems and staffing that enable professionals to provide high quality care were put in place.
A key systemic change we could make to our healthcare system would be to implement the often acclaimed, but infrequently achieved, continuum of patient-centred care.
The continuum of patient-centred care could include a consistency of health care professionals familiar with a patient's case and who are buttressed by the flow of relevant patient history and investigations. Patient centredness by the professional care-giver would target care, communication and common ground or a shared understanding between those receiving the care and those providing it. Such an approach would not only keep patients and families fully abreast of management details but also dramatically reduce the incidence of orphaned or overlooked patients.
No longer need individual people languish in a twilight world of waiting and uncertainty.
The best concept I have encountered to accomplish these goals is that of the case manager who can become a constant for an individual's care. The role could be filled by a family physician, nurse practitioner or other health care professional. The key concept is to ensure continuity of care.
It has been done before, but now we need to replicate the success across the country and across healthcare services.
A good example is trauma care, which was provided on an ad hoc basis in Ontario until 1976 when the first comprehensive program of trauma care was created at the (now named) Sunnybrook Health Centre. The cooperative regionalized program included a continuum of care from paramedics and helicopter transport through all the steps of trauma resuscitation, operating rooms, Intensive Care Units, ward care, rehabilitation and community care. The result was nothing less than substantial improvements in patient outcomes provided cost-effectively.
Another example of patient-centred care comes from Ontario's Cardiac Care Network formed in 1989, which has demonstrably improved care and outcomes for cardiovascular patients in Ontario. For example, major surgeries are entered into a registry documenting procedures, outcomes and adverse events. Should any concerns arise, the information is available (with appropriate security in place) to the relevant practitioners or for quality control to third parties. Untoward events or trends can be readily evaluated and corrective action taken if needed.
Some might object that these models are for a narrow scope of highly specialized problems and are too expensive in the present funding climate. Others, rightly, would emphasize prevention which has been integrated into these successful programs.
The truth is that the healthcare system cannot afford the less efficient systems currently in place.
A recent stellar example of patient-centred care comes from the Alberta Bone and Joint Health Institute (ABJHI) which now provides seamless delivery of care across diverse health care professionals and systems of delivery, including community care, out-patient and acute care. The institute deals with major joint replacements but also addresses chronic diseases such as arthritis. Better care is delivered more cost-efficiently by including both primary and secondary prevention which are integrated into the program. The result is that wait times have been effectively reduced while simultaneously controlling costs and also yielding higher patient and professional satisfaction.
What then are the barriers to progress elsewhere in the country?
Unfortunately decision-makers seldom respond to evidence provided by best practices -- less than they should, in any case. Perhaps a new mind set is required across the healthcare system -- a mind-set that incentivizes innovation and embraces progressive change.
In the end, patients, healthcare professionals and decision-makers all need to work together and demand and deliver better care. I believe the answer lies with all of us.
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