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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, as it was unacceptable to both patients and the hospital that quality should deteriorate and we realised that a shift in attitudes like this (which can be characterised as a paradigm shift) would be criticised. It was essential to us to prove that quality was at least preserved and hopefully improved.

We knew that the problems were deep-set in the system – indeed 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 deterioration 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. Also patients experienced insecurity and uncertainty, further diminishing their quality of life and health experience.
    
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 are partners and where the patients are responsible for their own health. This view actually has a deep impact on the way we are working, as the care team has to negotiate with the patients instead of ‘ruling’ over them. 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’, made up of their family and friends and support system, and the ‘medical team’, the staff 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 their life (see figure 13).

The first thing we realised in the analysis was that it was essential to change the patient monitoring system. The underlying principle had previously been that the healthcare system tried to monitor the patient’s health status through regular visits, instead of adapting the system to meet the patient’s actual needs. We realised 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 the right time to intervene was – this was when we realised that patients actually knew better than us when their disease was getting worse. This made us realise that we actually harmed some patients, as we could not deliver help at the time the patients actually needed care (partly because of an overcrowded system, the capacity of which was often used up in efforts that did not create real value for the customers). 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.    First, we decided to completely change our contact system. Depending on severity of the disease, need of monitoring AND the wishes of the patients, we stratified 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 – at scheduled visits, we often found patients had no obvious health problems. These visits took up a great deal of our time on the ward, did not create any real value to the patients 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, of course, have contacted us when flare-ups occurred, 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. Indeed, the very worst case can occur 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 – in this way, having a scheduled appointment will actually harm the patient.

Consequently, we moved to offering the group of patients with a stable condition (excluding patients on heavy medication, those with learning difficulties and those (few) patients who wanted to meet the clinician) an annual phone contact with a nurse and the opportunity 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, their 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 clinician 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 that half of the patients, 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 clinician. Even patients who desired to meet the clinician had a “traditional” follow-up, although actually only a few patients choose this follow-up, as the prime goal of most patients is to stay well – not to see a doctor.

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 have reversed the procedure. We invite each patient to come to our team room for a planning meeting, where we can put up the relevant charts, X-rays, etc. 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. What we do is actually to create a scenario which is designed for negotiation instead of top-down prescription.

This creates an experience of responsibility, power and control over their health and their disease, factors that are necessary if they are to keep the disease under better control and which give them the confidence to recognise when to contact us in the future, if they have concerns.

We also realized that we were holding daily discussions on cases where it really wasn’t appropriate – e.g. where there was an ongoing course of treatment with no sign of any problems. To monitor the patient’s progress more appropriately, we started to use a “process control chart” – a white board with coloured magnetic dots, indicating where patients were in the treatment process and where it would be appropriate to have a planning meeting.

About this case study
Main Contact

Dr. Jörgen Tholstrup
Chief Medical Officer
Highland District County Hospital
Eksjö, Sweden

email:
jorgen.tolstrup.rasmussen@lj.se


Dr. Jörgen Tholstrup provided Governance International  with this case study on 30 March 2010. The case study was updated in June 2014.

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