The progressive patient-care model
In reference to the progressive patient-care (PPC) approach, we found only partial coherence in terms of the meanings assigned to this specific label and, as mentioned, different labels to indicate similar concepts. In particular, a number of studies assign different names to the organizational model in which patients are no longer pooled on the basis of their prevalent pathology (i.e. in specialty- aggregated wards and clinical directorates), but instead on the basis of their expected length of stay within the hospital or of the degree of assistance they are in need of. The term “progressive care”, on the other hand, is sometimes referred to “progressive care units” (or step-down units) [
30‐
33], intended as specific care units that lie in between intensive care settings on the one hand, and traditional clinical wards on the other.
Indeed, however, we have found a good enough coincidence in terminologies used across studies in order to be able to generalize our findings. A number of works described in detail how the progressive care model, intended as the progressive pooling system on the basis of the intensity of assistance required, has been implemented in specific contexts. For example De Pietro and colleagues describe how Tuscany (Italy) is a pioneer Region in the implementation of such an organizational model [
34]. Indeed, the Region has imposed the model by law to all of its public health care organizations (in this region hospitals mainly belong to local health units and therefore the adoption concerns indiscriminately both settings), constituting therefore the main pressure for change. Although 3 levels of care are identified at the regional level (level 1, high intensity; level 2, medium intensity; level 3, low intensity which should be cared for outside hospitals’ walls), and in line with the evidence of most studies providing guide-lines and indications for implementation, great autonomy in defining
how concretely the model should be developed and implemented is left to specific organizations. In turn, this could partly explain the wide range of ways of interpreting the model and of using enablers in order to achieve its desired effects.
A frequent decision is to re-organize hospitals in poles, i.e. aggregations of “old” clinical directorates in the intent of pursuing efficiency and quality of service. Such aggregation can take place on the basis of different criteria such as aggregation of “stronger” with “weaker” (in terms of revenue, for example) ones or complementarity of the activities carried out within departments [
35].
Another frequent choice has to do with the decision of sharply separating elective patients’ from unscheduled ones’ pathways and, in particular, from emergency cases. This turns out to be useful in order not to excessively delay elective cases because of emergency “intrusions” and to better understand patient flow variability (across the day, the week and the year) using typical variability indicators [
36].
Moreover, it is frequent to distinguish inpatient from outpatient (patients involved in ambulatory and day-activities) pathways, without the two categories ever “meeting” during their stay in the hospital [
37]. Again, the objective here is to speed up pathways, reducing queues and bottlenecks.
As a matter of fact, studies pose a great emphasis on the emergency department, often considered the hub of change. Indeed, this seems to be the “engine” and the driving force of new organizational models. Understandably, the sustainability of horizontal, swift, and patient-oriented processes have a lot to do with a correct triage activity and the recognition of the appropriate pathways to be followed. In particular, with the new progressive care model, the emergency department becomes responsible of correctly assigning patients to the “different levels of care” within the hospital, and is therefore the main responsible of possible admissions in inappropriate settings.
To overcome possible mismatches between demand and supply of beds, hospitals can often count on a number of “pool beds” that are set aside to accommodate patients that, for different reasons, are outside the different pipelines (for example, patients that were admitted to a week-surgery but, for some reason, need to stay in the hospital more than 5 days) [
13].
A final frequent organizational innovation has to do with the decision to centralize as many functions and services as possible. Usually these include the sterilization units and the operating rooms, as well as all the activities related to pre-admission testing [
13].
In reference to the most adopted drivers to implement change, we found examples of Local Institutional Authorities explicitly requiring procedures designed on the new settings in order to exert clinical activities on behalf of the public system [
34]. In concrete, this correspondence seems to consist in the adoption of Integrated Planning, Budgeting and Control Systems such as, for example, the Balanced Scorecard (or similar tools) which, if correctly implemented, require a fair negotiation of goals and key (critical) performance indicators with many hierarchical levels [
6]. In concrete, however, managerial accountability tools (such as, for example, budgets that are still assigned to clinical wards) are usually not aligned to the new organizational model [
34].
Evidence was found in terms of the emergence of new professional roles and a general reassignment of responsibilities among individuals and professions. Indeed, the trend seems to converge towards new multi-disciplinary roles with nurses covering more and more managerial and coordination tasks. For example in Tuscany old specialty-aggregated clinical directorates are replaced by “functional areas”, which are directly in charge of beds, staff, technologies and resources in general. Concretely, these resources are managed by the areas’ “nurse coordinators”, who are now responsible of their appropriate and efficient use. In general, nurses (or other health professionals) are often asked to cover a range of new managerial roles such as [
13,
32,
34]:
-
Admissions coordinator: in charge of the pre-recovery process and of the admission procedures;
-
Hospital rounds coordinator: in charge of the coordination of the visits to the ward by the different specialties;
-
Supply coordinator: in charge of managing the logistic flows of goods (pharmaceuticals, medical devices, and other materials) to the different wards;
-
Operating room coordinator: in charge of assigning and controlling the use of the operating theatres;
-
Bed manager/facilitator: in charge of establishing efficient patient placements in the different inpatient settings;
-
Clinical directorate coordinator: in charge of the general coordination of activities within clinical directorates;
-
Quality responsible: in charge of coordinating and controlling quality management activities;
-
Training and Education coordinator: in charge of coordinating and evaluating nurses’ formation;
-
Nursing tutor/case manager: in charge of “following” a patient through all of his/her pathway and of correctly coordinating all the activities and professionals involved in it, as well as providing constant guidance and support to the patient himself and to his/her family.
It is not only through the achievement of new managerial roles that nurses assist to a deep change in their profile. Actually, also those nurses (who are the majority) who keep on providing clinical assistance face drastic changes in their jobs as a consequence of the new organizational model. Indeed, they must achieve the ability of working in new multidisciplinary settings in which their competencies and clinical knowledge is likely not to cover the vast range of pathologies and case mixes treated in the new horizontal platforms. Moreover, nurses who carry out triage activities in Emergency Departments assume a great responsibility in correctly allocating patients in the various “levels” innovative hospitals now hold on. Also, some new coordination roles cannot be carried out without an ample knowledge on various clinical fields. For example, bed managers collaborate with the medical staff to assess patients’ needs and appropriate placement of individual patients. Therefore, they are required to use operational and clinical judgment on a daily basis to prioritize bed assignment and reassignment.
Organizations have usually met this challenge by organizing training activities for specific settings (not rarely required by the professionals themselves) and efforts have been made in order to allocate nurses who had been working in either medical or surgical wards in coherent settings [
34]. Moreover, nurses with a recognized experience on specific specialties or pathologies are usually assigned to specific settings, in order to guarantee within them the presence of some highly specialized figures.
Physicians also seem to face deep changes in their professions. Again, as is the case for nurses, they are sometimes called to cover new roles such as, in the first place, heads of new organizational settings (i.e. High Care, Week Surgery, Week Hospital, Urgency Medicine and Post-Acute Care) [
13]. Moreover, medical tutors/medical case managers become responsible of the whole medical pathway the patient follows, as well as being the reference point he/she as well as the family can rely on at any stage of the pathway [
32].
All these evolutions, together with the always critical necessity to manage individual skills, push for a gradual adoption of a competency-based model for HRM (through a competency-based model it is possible to manage all the competences discussed above, ranging from the more technical/clinical ones to the managerial and organizational ones). Moreover, hospitals and their sub-units (horizontal settings, clinical directorates, specialties, etc.) need to design and develop career paths and, therefore, appraisal systems in order to manage promotions along the professional line or the managerial line. Finally, it is felt that the evaluations of individual and team performances cannot be limited to sporadic events, nor can they be carried out by a single role. On the contrary, it is held to be important to enhance a multi-source and 360° feedback system, with evaluations expressed by many actors such as, for example, the chief of department, the chief of nurses, the manager of specialty, ward managers, peers, collaborators, patients. It is believed that this approach is better accepted by professionals and more likely to orient behaviors towards the organizational goals [
6].
Finally, implementations of the progressive care model highly rely on innovative ICT tools which enable a swift and accurate communication among actors. In particular, the most frequent tools adopted are integrated electronic health records, to be jointly used and updated by physicians and nurses [
34].
Evidence suggests that the new organizational model has in many cases led to good results. There exist numerous examples of improved efficiency indicators such as reduced waiting times, reduced stockpiles, reduced bureaucratic procedures and duplicated information [
34,
35,
37], as well as reductions in average hospital lengths of stay, increased bed occupancy rates, increased hospital case-mix complexity, reduction in turn-over ratios, increase in patient inflows, that is, patients coming from different catchment areas [
13] although at times this occurs at the cost of putting more strain on employees [
35].
Moreover, results report an increased patient satisfaction [
13], especially in reference to the identification of a medical and/or nursing tutor (yet not in reference to the general stay in the hospital) [
34]. Patients are reported to no longer being “parked” in areas where they cannot receive appropriate care. Indeed, a multi-disciplinary approach seems to be strongly encouraged and collaboration between the medical and surgical staff seems to improve [
13,
32]. The logics of process management is further enforced and thus promotes the development of care maps and clinical pathways [
13]. However, there is a lack of evidence in terms of improved clinical outcomes.
Other reported unsolved problems have to do with: the definition of a more clear repartition of medical and legal responsibilities among medical tutor and other physicians, as well as between physicians that manage different platforms; the optimization of bed capacity exploitation, especially in reference to an effective and efficient allocation of patients coming from the ED; an effective allocation of nurses to different settings on the basis of the concrete intensity of assistance required by their patients; the implementation in EDs of trustworthy assessment tools which enable a correct evaluation of the degree of intensity of care required.
Open issues also have to do with the assessment of the desirability of medical day- or week- hospitals, given the general difficulty of predicting the expected length of stay of medical patients, and with the capability of actively involving professionals and of overcoming cultural barriers, especially on the physicians’ side [
13,
37].
The Patient-centered approach
Although broadly studied for decades, a clear definition of patient centered care (PCC), as well as an understanding of how specific PCC processes relate to patient outcomes is lacking [
38].
Yet we were able to find a relatively numerous set of documents in which the definition of patient-centeredness is (at least partially) coherent with the meaning we assigned to it. Indeed, most articles analyzed do intend PCC as the tendency to organize activities along and around the patient’s pathway, as opposed to an approach in which patients must go and seek the services they need in specific physical and organizational locations. However, in some cases, and mostly in reference to articles from the USA, PCC assumes a broader meaning and also includes the idea of enhancement of positive relationships between care providers and patients by promoting daily routines that are tailored to their life experiences, abilities and preferences [
39].
Moreover, the topic seems to be poorly explored within hospitals’ walls, and somewhat more studied within primary health care settings. In particular, and again especially in the USA, scholars’ attention is often focused on Patient Centered Medical Homes, intended as medical homes that ideally tailor and individualize health care services to patient needs by increasing access and managing all aspects of care [
40].
An exception has to do with the analysis of general process improvements within EDs, that constitute one of the most studied settings within hospitals. For example, a study suggests how important it is, in order to improve processes, to starkly invest in determining the “voice of the customer” – intended as patients' and staff’s perceptions- by using internal survey tools or external services [
41].
The importance of designing and managing smooth processes is confirmed by studies analyzing the effects of suboptimal ones. For example, a study explains that health care professionals encountering barriers within processes can choose to either engage in workarounds to get past the block, or potentially repeat work (rework). Both solutions are likely to cause waste and lead to safety concerns. In particular, issues related to information exchange tend to lead to rework, internal supply chain issues are more likely to lead to workarounds [
42]. Moreover, the causes of distorted processes and pathways often have to do with inadequate allocation of capacity as well as a lack of coordination between different pipelines and production units [
36]. Policy, it is suggested, should stimulate the provision of more coordinated services, for example, through integral cost prices for separate diseases (“case-mixed accounting”) [
43].
Anyhow, the most analyzed aspect of PCC is related to continuity of care among different settings. As a matter of fact, patients commonly experience a complete new set of caregivers as they progress from acute to subacute care settings. Managing continuity of care, as well as guaranteeing accountability for overall outcomes becomes challenging, and patients often feel abandoned by their primary caretakers. The most frequent response to this issue is given by the assignment of care coordinators or of rehabilitation liaison nurses, in charge of following patients from the acute to the sub-acute setting [
43,
44]. In other cases, nurse practitioner teams assess patients, co-manage syndromes, provide staff education, encourage patient self-management, communicate with primary care providers, and follow up with patients soon after discharge [
45].
The main enablers to implement PCC appear to include an effective leadership and management communication, with the necessary technical and professional expertise and creative/soft skills; a strong internal and external motivation to change (favorable perceptions from direct care providers about the priority of the innovation to the organization); a clear and internally consistent organizational mission; an aligned organizational strategy; a robust organizational capability; and a continuous feedback and organizational learning [
39,
46].
ICT tools should ideally be able to improve workflow through the prioritization of information and detection of individuals’ contextual situations, promote stronger inter-professional relationships with adequate exchange of information, enable interoperability and scalability between and within institutions, function across different platforms [
47]. This is particularly relevant for multi-morbidity patients’ care because there is a large number of health professionals in charge of patient care, and this requires to obtain clinical consensus in their decisions [
48].
There exist a few pioneer experiences in the implementation of innovative ICT tools. For example, a study reports the experience of the implementation of a Shared Care Platform within a hospital and two primary care centers to provide support in the continuity of care for multi-morbidity patients. This platform includes a social network component (the Clinical Wall) which contains a record where health professionals are able to debate and define shared decisions. Preliminary results suggest that such type of tool can indeed enhance communication effectively, having during its pilot implementation phase favored decisions about coordination for appointment changing, patient conditions, diagnosis tests, and prescription changes and renewal [
48].
ICT tools, anyhow, still appear to be rudimental if compared to their potential, as is testified by studies that explain how not only the information they deliver (through, for example, electronic health records) are often not exhaustive [
49], but also how they often fail to even identify numerous individuals involved in patients’ care, suggesting that electronic health records may not provide adequate tools for care team designation [
50].
In particular, it is suggested that “
the failure to view the hospital as a system has contributed to the practice of inefficient and ineffective clinical documentation. Rethinking IT in support of clinical documentation from a system-oriented perspective may help improve patient care and provider communication” [
49]. The suggestion is to design systems in which “
the clinician first enters the patient’s relevant problems and subsequently performs other actions in the explicit context of the single most relevant problem to which they relate. The problem thus drives the care and (…) an interdisciplinary problem-oriented view would keep all providers focused on the whole patient and defragment clinical care” [
49].
The most relevant challenge communications systems seem to face has to do with a switch from hospital information systems to health care information systems, in coherence with collective decision-taking processes [
51]. The integration of Information Systems seems indeed to be essential to support shared care and to provide consistent care to individuals – i.e. PCC [
52].
Although
liason figures seem to be appreciated and effective in enhancing communication among professionals (in a study a majority of physicians (75%) and support staff (82%) interviewed reported interactions with a care manager [
40]), in general evidence about the effects of PCC on clinical outcomes seem to be very limited. Some studies found significant relationships between specific elements of PC and outcomes [
38,
53], others between a patient-centered approach in general and a reduced ED utilization, due to an improved care coordination and reduced delays in care [
54]. Another study suggests that
liason activities are associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care [
45]. In general, however, evidence seems to suggest no significant and universally recognizable relationship [
38]. Improved continuity of care, anyhow, as well as transdisciplinary teams’ shared resources, have been found to increase patients’ satisfaction through a gained sense of support throughout the continuum of care [
44].
All in all, tools to identify the concrete degree of patient centeredness implementation are rare, although a few attempts have indeed been made, such as, for example, the Patient-Centered Medical Home Assessment tool, aimed at stimulating and monitoring progress among primary care practices interested in transforming to patient-centered medical homes [
55]. This sort of experience, however, was not detected in hospital settings.
The lean approach
Vast research has been dedicated to the implementation of lean methodologies within healthcare systems, often suggesting their benefits in resource utilization and patient care [
56‐
58]. There seems to be agreement on the factors that determine the extended array of improvements reported. In particular, factors such as standardized work and reduced ambiguity, new connections between people who depend one form another, enhanced uninterrupted flows through processes, and empowered staff to investigate problems and to develop countermeasures using a “scientific method”, seem to be the keys to success [
59,
60]. Moreover, process mapping, leadership support, staff engagement, and sharing performance metrics are felt to be keys to enhancing efficiency [
61].
What seems to make the difference is that management assumes a subordinate role when it comes to solving flow issues, adopting a “bottom-up approach”, by allowing the frontline staff to identify problems and come up with appropriate solutions. The risk, otherwise, is to face reluctant staff, who feels forced to institute top-down process improvements, with a perception of being monitored [
59,
60].
Once again, experiences are often referred to lean projects within EDs. In a Swedish pediatric Accident and emergency department, for example, lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving led to improvements in waiting and lead times (in the order of 19-24%) which were sustained in the 2 years following change [
60]. In two different EDs a Quality Improvement project that included lean principles improved the self-estimated patient safety culture, mainly due to team-work and communication openness [
62]. In a further ED in which lean techniques were implemented through a six-step process of Lean education, ED observation, patient flow analysis, process redesign, new process testing, and full implementation, patient visits increased by 9.23% and, despite this, length of stay decreased slightly. Moreover, patient satisfaction increased significantly without raising the inflation adjusted cost per patient [
59].
Evidence about the application of Lean and Six Sigma methodologies within operating rooms (ORs) and across surgical suites have also been reported. A study, for example, reports substantial improvements in on-time starts and reduction in number of cases past 5 PM, as well as substantial gains in non-operative time, staff overtime, and ORs saved. These changes, in turn, resulted in substantial increases in margin/OR/day [
61].
In an outpatient setting, a 3-day value stream analysis and a 5-day rapid improvement event were able to shorten the patient cycle time and the time to initial assessment [
63]. In another outpatient service a lean process improvement project brought to a 27% increase in service capacity to intake new patients and a 12% reduction in the no-show rate [
64].
Some successful experiences are also referred to transversal patients’ pathways across different settings (within the hospital and across structures). In five European hospitals, for example, there was a 59% reduction in the average time to diagnosis and a 75% increase in diagnostic yield in response to the implementation of a structured Lean Six Sigma based methodology to pathways for syncope management. Moreover, a marked reduction in repetitions of diagnostic tests and an improved prioritization of indicated tests were also recorded [
65].
A statistically significant reduction of 5% and 9.3% was noted in the 30- day and overall mortality, respectively, after implementing ‘Lean thinking’ in the management of hip fracture patients in a hospital trust. Further improvements were also reported in door-to-theatre time, use of trauma beds and early discharge from hospitals [
66].
Despite numerous examples of successful implementations of lean techniques, literature does not fully agree on their degree of success within the healthcare sector, often finding inconsistent the evidence about their contribution to higher organizational performance. For example, a recent study suggests that “
a progressive managerial philosophy has a stronger impact on healthcare performance than the adoption of practices from any particular managerial approach” (including lean). It argues that the most successful adaptations occur when employees manage the steps that produce value as a whole, rather than in bits or silos, with the organizational implications that productivity measurement should be carried out at the system level rather than by unit. This approach however is rare and there are no lean implementations across an entire hospital [
67]. Therefore it is suggested to interpret evidence with extreme caution [
68].
As a matter of fact, a further study that analyzed the effects of an ED process improvement program based on lean methods found that although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared to control sites that had not implemented the program but had been exposed to system-wide initiatives such as public reporting and pay for performance. Again, the suggestion is to further evaluate the effectiveness of lean methods before spreading out its implementation [
69].
In particular, despite a relevant number of successful implementations of lean projects is reported, lean is often felt to be “
a constellation of disjointed and poorly connected activities (…) which tends to involve the application of a narrow range of specific tools or techniques (…). Leaders tend to understand Lean as a collection of stand-alone, operational tools, rather than as a broader system-wide improvement philosophy” [
70]. Approaches such as ‘kaizen blitz’ or ‘rapid improvement events’ seem to have dominated the healthcare sector’s scenario, leaving sporadic experiences in terms of fully re-designing, in a holistic perspective, the whole set of processes that constitute pathways across organizations [
70,
71]. In other words, “
while a project management implementation methodology may make many gains initially, sustaining the gains relies on the project’s integration and identifying what is needed for any changes to become routinized” [
72].
Indeed, research seems to suggest that the implementation of lean within the sector is often difficult and risks providing disappointing results if not sustained in time. In particular, organizational readiness, an adequate organizational culture, effective leadership (given the difficulty of effectively enrolling staff in the change agenda) and the availability of adequate resources and communication strategies appear to be fundamental for its success [
57,
72,
73]. Moreover, lean must overcome important lines of resistance, which often see clinicians apprehensive about the motives and legitimacy of change as well as concerned about the validity of theories suggesting benefits for patients due to changed working practices [
73]. Evidence suggests that lean is often poorly understood by who has to implement it and can be felt as a threat to personal freedom and autonomy, with the risk of being perceived as a pressing form of control on one’s work [
60]. The “bottom-up approach” mentioned above, therefore, seems not to be fully implemented in concrete.
Further factors that may have impeded a greater improvement seem to include a mismatch between job tasks, and discomfort with inter-professional collaboration [
60], suggesting that multidisciplinary formation should be improved, in order for professionals to feel more comfortable in actively collaborating with other professions.
Table
2 presents a summary of the main evidence reported by scientific literature in reference to the progressive patient care organizational model, the patient-centered approach and the lean approach, as well as the drivers of change necessary to effectively implement them within hospitals.
Table 2
Main evidence reported by scientific literature
Progressive patient care model | In some contexts implementation by law (e.g. Tuscany) Great autonomy of organizations on how to implement model Forms of implementation: poles; separation elective/unscheduled/emergency patients; distinct inpatient/outpatient pathways; emphasis on ED; pool beds; centralization of functions | Integrated Planning, Budgeting and Control systems (e.g. BSC) In concrete, however, MA tools not aligned to model (e.g. budgets still assigned to clinical wards) | New professional roles and a general reassignment of responsibilities (nurses and physicians) Need for: Competency based model; Separate professional/managerial career paths; Multi-source and 360° feedback system | Integrated electronic health records, to be jointly used and updated by physicians and nurses | Improved efficiency indicators Increased patient satisfaction (medical and/or nursing tutor) More coordination between medical and surgical staff Better implementation of clinical pathways Lack of evidence in terms of improved clinical outcomes | Effective allocation of nurses to different settings Correct triage activity in ED and efficient allocations of patients Desirability of medical day- or week- hospitals Involving professionals and of overcoming cultural barriers Definition of clear repartition of responsibilities among professionals |
Patient centered approach | The most analyzed aspect of PC is related to continuity of care among different settings (poorly explored within hospitals) An exception: analysis of general process improvements within EDs | | New professional roles in hospitals (e.g. liason nurse) | ICT tools should ideally: prioritize information and detect individuals’ contextual situations, promote stronger inter-professional relationships with adequate exchange of information, enable interoperability and scalability between and within institutions, function across different platforms. Few pioneer experiences (e.g. Shared care platform) ICT tools still rudimental if compared to their potential | Significant relationships between specific elements of PC and outcomes, or between PC approach in general and a reduced ED utilization. Liason activities are associated with slightly higher (not significant), quality care transitions. Greater patient satisfaction Improved communication among professionals General evidence about the effects of PCC on clinical outcomes very limited | Poor attention of literature to PC within hospitals Necessary switch from hospital information systems to health care information systems Non exhaustive information Individuals involved are not traced Lack of tools to clearly assess PC |
Lean approach | Application of various features of lean such as new employee roles, staffing and scheduling, communication and coordination, workspace layout, process design etc. Application of lean tools within settings (EDs, ORs, outpatient settings) Only few examples of lean applied to pathways | | Staff empowerment and “bottom-up approach”, by allowing the frontline staff to identify problems and come up with appropriate solutions | | Many examples of improvement in efficiency indicators Fewer examples of improvement in clinical outcomes A number of studies find inconsistent the evidence about lean’s contribution to higher organizational performance | Lean is often felt to be “a constellation of disjointed and poorly connected activities” Lack of “system-wide” improvement philosophy The “bottom-up approach” is not fully implemented in concrete and barriers to implementation persist Need of more formation for inter-professional collaboration |