THE SCIENCE OF HEALTHCARE DELIVERY

The symphony

Gurrit K Sethi, Strategic Advisor, Global Health Initiatives

Communication and Information (C&I) forms the base of care delivery, and, many times the outcomes of situations. This is true for any healthcare service organisation. The patient communicates problems and medical history to the doctor, the doctor communicates the condition and treatment plan to the patient and communicates orders to the nurses / RMOs, the orders for medication / investigation are communicated further, the results and effects are communicated back to the doctor, and to complete the loop, the patient condition is tracked. This loop continues till the patient is well again. What if this loop breaks or becomes a Chinese Whisper…?

The construct of healthcare delivery is a complex maze and an interesting one — this science involves various industries come together, like the tunes of many instruments in an orchestra —-to name a few the pharmacy, the IT, the hotel experience — all come together with medical services to create one hospital! When not in harmony the beautiful tunes turn into a cacophony of sounds. The same happens in healthcare service delivery as well when these different parts do not function in harmony. And worse when the wrong cords are pulled.

Picking up again on the construct of healthcare organisations (refer last article in Issue 44), like all structures, a good plumbing system is critical to the flow — of information and communication. In the last issue we looked at the Patient / Family experience. Now let’s examine the scene behind the scenes. The physician and the support that is critical to the medical delivery of outcomes expected.

Imagine this situation: The family stood at the admissions counter. It was almost thirty minutes. The receptionist sat at her desk trying to punch in furiously. The system, read – Hospital Information System (HIS), was running slow. The receptionist was too involved in getting the computer to respond to make the family comfortable and offer them a seat since it was taking time.

The nurse rushes across the nursing station in the morning to fetch the patients’ file as the surgeon walks across to meet the patient on his morning round. The reports of the investigations ordered the evening before have not arrived. The patient and family eagerly await to be told of the patients’ progress and prognosis.

The doctor ordered medications scribbled across the sheet. The nurse sent the request to the pharmacy. The pharmacy did not have the medication. An alternative was suggested, cross checked for doctors’ approval and ordered. The dosage got delayed. The doctor had ordered a medication which was not part of the formulary.

The surgery was scheduled. The patient was prepared. The Nurse refused to shift the patient. The surgery consent form was missing / incomplete. The family needed to be explained the risks and agree to those.

The patient was to be wheeled into the operation theatre at 9 AM. The first case got delayed. The patient was rescheduled for surgery at 2pm. The nurse got into action to keep the patient hydrated via IV while the patient demanded water and food… she felt bad for the patient but this has to be…

Recent policy changes made by the government on consumable pricing and chargeability had the respective companies pull back certain products. Many patients who preferred and could afford these supposedly better products could not use the discretion to avail the opportunity for better care.

The expensive consumables required by the surgeon were not procured and this delayed the surgery causing inconvenience to the patient and the staff. The internet connection was out and the indents for the items could not be received in time therefore the timely purchase was not possible.

The patient was on the table in the Cathlab. The doctors were all scrubbed and huddled around him about to begin the procedure. The patient then wanted to pass urine. However, the general duty attendant was missing. Also no one could find the urine pan. The doctor had to de-scrub and catheterise the patient and then continue with the procedure.

Three patients were lost in an OT post the surgery while weaning off the patients from anaesthesia. The scientific team much later realised that this happened because of the exchange in gas pipelines of oxygen and nitrous oxide.

The patient went into a shock. The nurse was given a verbal order for 14 units of insulin, the nurse interpreted it as 40. The sound alike drug and dosage orders need to be interpreted correctly and should be written.

The doctor meant x units of IM to be administered but transcribed as IV. The nurse administered as IV and the patient went into an anaphylaxis shock.

The patient was allergic to nuts and was a diabetic. He was served a sweet dish with nuts.

The Endocrinologist reconciled the insulin dose as per the blood sugar of an operative patient. The RMO missed transcribing this to the drug chart. The nurse administered the continued dosage and the patient went into hypoglycaemic coma.

The patient was in the hospital for over ten days and waited eagerly for the doctor to come. The senior consultant however remained busy in the OPD and then went to the OT.

The patient was verbally advised for discharge by senior doctor, the junior doctor / nursing forgets to mention the same in the progress sheet and the patient stays in the hospital wondering why is he made to stay back.

Such are the results if communications go haywire in hospitals. Thus the lengthy documentation procedures that teams have to follow. And the strong need for everything to be ‘protocolised’. This ‘protocolisation’ helps manifold. It helps work as a reminder for various pathways to follow by way of forms to be filled out. It supports reliability, repeatability and replicability – in the way care is delivered, the outcomes and the way of work. This predictability oils the system in a way that various different moving parts come together at the right time in the right way to do the right thing.

For the general masses who question the costs of healthcare, it is what does not meet the eye that largely accounts for quality of outcomes, and which is what we pay for. The process of hygiene, infection control, treatment protocol, along with and over and above the communication & information, calls for intensive training of care delivery teams across the spectrum. The intensive training requirement is not limited only to medical and paramedical teams. Rather for the required support from the Food & Beverage teams, the house keeping teams and others, the training needs extend across. Availability of medicines and consumables while maintaining the temperature and storage requirements through the supply chain, ensuring the right food is prepared for the patients and provided timely, the hygiene care for the patients keeping them tidy and infection free and ensuring the same for the environment, encompasses and defines the medical care environment and the outcomes of it.

For care givers, these misses on symptoms through a proper history taking, misses on investigations for various reasons and more specifically misses in treatment protocols and documentation land many in trouble along with the institutions. The protocols are meant to aid in care and serve as tools to support good care and outcomes. These go a long way to also support the physicians in case of legal consequences should they arise. Care giving itself is a very complex process. While largely the two key players are the patient and the doctor but the delivery itself is through the nursing teams largely supported by other para-medical teams as well as non-medical teams. The attendants, and or the family, also plays a vital role in the delivery and the decision making. So educating these key stakeholders also become an important part of the care delivery system.

For other stakeholders this provides an opportunity to build a predictable business steeped in a common goal of proving good patient care.

A proper flow of communication and information helps build a bridge of trust between care givers and care takers (patients and family). When things go haywire, which many times they will, as after all doctors are not Gods, it is this trust that will save the day and the SYMPHONY.

--Issue 45--

Author Bio

Gurrit Sethi

Gurrit K Sethi, Hospital Chief Operating Officer, Care Hospitals; Strategic Advisor for Global Health Services, Global Strategic Analysis, contributes to healthcare by helping providers build and better business efficiencies and concept development, also strives to contribute socially through the Swiss Foundation, Global Challenges Forum as Strategic Advisor, through conception of sustainable health initiatives. She started her career from the shop floor working her way up to lead and set up different healthcare businesses. In her words, her significant achievements have been in bringing to life different SMEs and SBUs signifying a change in the Indian healthcare scenarios, as the opportunity paved the way along the healthcare growth curve in the country. With over 18 years in healthcare under her belt, across different healthcare verticals, she has carried transformational changes in the projects she has led, four of those being early stage start-ups. Gurrit is an avid traveller and voracious reader of varied genres, attributes which she says, provide her with incisive insights about people and systems and what drives them.

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