Empowering patients to need less care and do better in Highland Hospital, South Sweden

Change Management

Given the waiting lists in 2001, we decided to undertake a fundamental review of the values behind the relations between our patients and the healthcare system. In particular, we analysed our service from a patient perspective. This analysis suggested to us that we needed to redefine the roles of the patients to give them greater personal responsibility for their health. As we redesigned the unit, we also had to find a way to monitor quality in a convincing way, as it was unacceptable to both patients and the hospital that quality should deteriorate.

We knew that the problems were deepset in the system – indeed, physicians and other involved staff were just as frustrated as patients themselves, who were understandably dissatisfied at having to wait for treatment. Moreover, making patients wait probably had adverse effects on their health, sometimes resulting in detoriation of their condition and causing worse flare-ups and longer hospital stays than would have occurred if care could be delivered at the proper time.  Furthermore, staff felt that some of the procedures we were using did not actually have any particular value for the patients and, in some cases, might actually be harming their health.

The first thing we realised in the analysis was that it was possible to change the patient monitoring system. The underlying principle had previously been that the healthcare system  forced patients into its way of doing things, instead of adapting the system to meet the patients actual needs. We realized that we were actually doing too much for some patients, and doing too little for others. At the same time, we were unable to guess when was the right time to intervene - this was when we realized that patients actually knew better than us when their disease was getting worse. We therefore redesigned the unit to set up a team-based healthcare delivery system in which all participants,  including our patients,  put their individual competences to use in a proper way. This immediately helped us to cut out some of the inappropriate work which had previously been done even though it had not produced any real value for the patient.

We realised that, traditionally, meetings between the physician and the patient, were, by their very nature, repressive. The physician was the ‘top dog’, his/her views were considered to be the central element of the process. Both the patient and the other staff were simply seen as being supportive to this central process. We decided that this had to be changed  - we had to create a setting where the team and the patients would actually negotiate what would be the proper treatment for each patient. So we designed a team where all participants,  including the patient,  would be involved, using their individual competences. We wanted each participant to feel in charge of at least part of the process. The patient is actually in the middle of two teams – the ‘community team’ of their family and friends and support system, and the ‘medical team’ here in the hospital. The hospital team’s role is to support the patient in his/her “real” team, where the patient expects to be a well functioning individual with full control over his life.

First, we decided to completely change our contact system. We stratefied patients into several groups, each of which would be treated differently, rather than forcing all of them into the same system, as we had done previously.

We were aware that many of the annual visits were of little use – we found nothing wrong with the patient but these visits took up a great deal of our time on the ward and, of course, were stressful and disruptive to the patients. Moreover, most of the  flare-ups of the disease took place during the rest of the year - patients should therefore have contacted us at those times but we didn’t have appropriate routines in place to encourage that (nor the time to deal with such contacts, given that we were constantly dealing with the well patients who had come in for their regular check-ups). Consequently, patients’ flare-ups were often more serious  than they would have been if they had been picked up in time. The worst case is where a flare-up occurs when the patient has already made an appointment for some time in the future and decides to wait for that appointment, rather than contacting us – this will often allow the flare-up to become worse – i.e. having a scheduled appointment will actually harm the patient.

Consequently, we moved to offering the group of patients with stable inflammatory bowel disease a phone contact with a nurse and asked them to contact the surgery whenever they felt they wanted to discuss their condition. Instead of coming in to the ward once a year for a check-up, patients are asked once a year to send in a blood test and to fill in a short form asking quality-of-life questions (using the SHS – Short Health Scale). Then  a nurse contacts them on the phone for a detailed conversation, covering their overall health condition, any troubles since the last contact, potential need for prescriptions and any other issues the patient wants to discuss. They are offered a visit to the doctor, if they want it. However, they are encouraged to get in touch with the unit immediately if any signs appear that the disease is getting worse or if they become worried for any other reason. When patients make these unscheduled calls,  the nurse can recommend self-care, where it is suitable, or offer an appointment to see the physician at the hospital within three days. (Patients can also contact the clinic via e-mail, if they prefer).

Of course, this approach wasn’t appropriate for all patients – it applied to those patients, the majority, whose disease was in a stable condition but it wasn’t suitable for patients who were receiving treatment for an unstable condition with immunosuppressive drugs or for patients who could not be considered responsible for their own actions – these were asked to make their traditional follow-up visits to the physician. 

A further change we made was in the way we worked with in-patients. We realised that we seemed to apply a different set of values in the ways we treated in-patients compared to out-patients. Instead of the medical team ‘doing the rounds’ every morning, and inspecting each patient in their bed, discussing their case ‘over their heads’, we reversed the procedure. We invited each patient to come to our team room for a planning meeting, where we can put up the relevant charts, X-rays, ect. relevant to their case. Here they can interview us about what has changed since our last discussion, how they feel, what they are worried about and what we are suggesting might be done.