Specialization erupts turf wars over body parts Fragmented healthcare
VOLUME 21
Synergy among healthcare practitioners Turf war in radiology The guerilla warfare One as a unit
They would have known that had a long history of allergies past episodes of pneumonia, therefore was at high risk complications.
she and and for
prescribe antibiotics for an already treated infection. Her son would have been involved upfront in treatment decisions.
Mrs. Nkiru Adamu would have been
A clear pathway with the arc of
encouraged to get up and out of
treatment known by all may not
bed right after surgery to help
have changed the ultimate
minimize her chance of developing
outcome, but it certainly would
pneumonia. Building up her
have felt more caring,
strength and focusing on her
compassionate, and responsive to
balance and nutrition would have
everyone involved. As Mrs. Nkiru
been priorities in order to improve
Adamu's case demonstrates,
her ability to walk with an immobile
providing integrated, personalized
arm and cane and reduce her
care is not a luxury; it's a necessity.
chance of falls. After she was discharged, in-home physical therapy would have helped her get from her bedroom to the kitchen and bathroom on her own. All her treating physicians would have been aware of what happened in the dierent facilities so that the o u t p a t i e n t d o c t o r w o u l d n' t
“The world has enough for everyone’s need, but not enough for everyone’s greed”. Mahatma Gandhi
Navigating today 's dynamic complex health and social environment requires conďŹ dence, vision, and innovative strategies that drive impactful results. Rova College designs structured and customized executive programmes that respond to today's real world organizational challenges to meet the demand for extra-ordinar y leaders and managers.
For those seeking an experience in healthcare leadership and management that challenges, stimulates and inspires.
We challenge our clients' assumptions, disrupt usual ways of operations and introduce innovative ways of thinking. O u r c o u r s e pa r t i c i pa n t s a re prepared for the next level of their choice career and taught to maximize every opportunity for growth.
Abuja, Nigeria.
rova_healthmgt@yahoo.com
+234 (0) 805 362 1816, (0) 805 608 1259
info@rovacollege.org
www.rovacollege.org
ParaSight An Enhanced Computer Vision Platform For Clinical Diagnosis Of Malarial
ParaSight
TM
Digital Cytometry Platform Revolutionizing Malaria Diagnosis
Contact Details
Sight Diagnostics Ltd, Jerusalem, Israel
HEAD OFFICE: Plot 1299, Funmilayo Ramsome Kuti Road, Area 3 Garki Abuja. Tel: 09-98701719, M: 08032658433, 08166717574, 08131334996, Fax: 09-98701834 PMB 690, Garki Abuja email: info@dcllabx.com dclmed@yahoo.com LAGOS OFFICE: Plot 5 Block 4, Etal Avenue, Off Kudirat Abiola Way, Oregun Ikeja, Lagos State, Nigeria. Tel: 09-98701719, 08032658433, 08166717574, 08131334996, Email: info@dcllabx.com
P/HARCOURT OFFICE: No 19 East West Rd Rumuokoro By Choba Rd beside St Jude Catholic Church, P.M.B 4394 P/Harcourt. Tel: 09-98701719, 08032658433, 08166717574, 08131334996, email:info@dcllabx.com, dclmed@yahoo.com, phoffice@dcllabx.com. BENNIN OFFICE 2nd Floorm Igbodaro Ehanre House 34 Akpakpava Road Bennin City GHANA OFFICE: Tel: 09-98701719, 08032658433, 08166717574, 08131334996, Secant Tower Office Building (3rd Floor – East Wing) Plot No. 398, 7th Lane, Osu RE, Accra. email:dclghana@dcllabx.com Tel: 09-98701719, 08032658433, 08166717574, 08131334996, email:dclghana@dcllabx.com
The Healthcare industry is in the midst of a transformation that has all the hallmark of a DISRUPTIVE CHANGE.
...POWERED BY INNOVATIVE TECHNOLOGIES
Disruptive Innovation
Rules are being REWRITTEN Industry boundaries REDRAWN Prevailing truths CHALLENGED
Endorsed by:
FEDERAL MINISTRY OF HEALTH NIGERIA
40 SPOTLIGHT
Synergy Among Healthcare Practitioners
Among Healthcare Providers
THE BOUNDARY WARS in healthcare
20 22
SPECIALIZATION erupts turf wars over body parts
FRAGMENTED
HEALTHCARE The case of Mrs. Nkiru Adamu
26 28
Turf Wars in Radiology
48
David C. Levin, MDa,b, Vijay M. Rao, MDa
“
“
The War of Words
The Guerilla Warfare
52
54
One as a Unit
Clinical and Service Integration
The Hidden Attitudes
Clinical Laboratory
From Ancient times through the 19th century
56
66
68
Support group
ACCESS
QUALITY
CHEM E
ENGAGEMENT
S CE
hfn
T H IN S U R A AL
N
TIONAL H NA E
The following organizations have demonstrated their commitment and support to healthcare leadership and management in Nigeria.
issuu.com/hmr.e-copy rovacollege.org @rovahmr www.facebook.com/rovahealthmgt www.linkedin.com/in/rovahmr
EDITOR IN CHIEF Emmanuel C. Abolo SENIOR EDITORS Godwin Odemijie Moji Makanjuola INTERNATIONAL AFFAIRS BUREAU CHIEF Jeff Flint DIRECTOR - EDITORIAL OFFICE
Oluwakemi Lawanson STAFF GRAPHIC DESIGNER
James David Harrison Ukweh SCRIPT EDITOR
Moses Datoegoem HMR ADVISORS
Prof. Rowland Ndoma-Egba Prof. Femi Adebanjo Prof. Okey Mbonu Dr. Ibrahim Wada Dr. Emmanuel C. Abolo (Jnr) Dr. A Dutse Dr. Kabiru Mustapha Barr. Charles Okei CREDITS Erik Eckholm Pharm. Ahmed I. Yakassai David C. Levin Natasha Curry Chris Ham Dr Wael Barsoum Darlene Berger Chadwick L.R Chung The Kings Fund UK Cleveland Clinic Florida Pharmaceutical Society of Nigeria
14B, Thaba tseka Street, Off Ademola Adetokumbo Crescent, Wuse 2, Abuja - Nigeria. Tel: +234(0)805 362 1816, 808 750 4372, 703 617 0225. E-mail: info@rovacollege.org, rova_healthmgt@yahoo.com, Website: www.rovacollege.org
Editorial
Managing “Turf Wars” in the Healthcare Space
T
he craft model and fragmentation of actual delivery of care has its roots in medical tradition when practice was less complex and more individualistic.
Silo walls should function more as semipermeable membrane than concrete walls so information and resources can flow to foster overall system function.
The continual influx of the knowledge for health care both allows and in fact forces an ongoing redefinition of who is to use that knowledge and how it will be used; through revising the participants' capabilities, rights, responsibilities and roles.
It is a matter of reframing what constitutes the health system, the relationship between components, the overall paradigm of system purpose.
Moreover, not only do current practitioner role need to be specified relative to the new care processes and operating systems, but entirely new roles (perhaps system architecture for example) need to be developed and reimbursed. Roles require as much attention to design as all other aspects of operating systems for care delivery and learning.
This edition provides a timely insight into managing the relationship of professionals in the healthcare sector and a frame work for structured dialogue to foster collaboration and dismantle dysfunctional culture in the health system
These revised roles are an important input into the design of operating systems. And because both how the scientific and organisational knowledge for care will evolve, and which new health problems will develop, remains uncertain, these roles may change repeatedly. Managing the 'turf wars' does not require tearing down the silos. In fact, silos have important functions. Training, practice, professional advancement and new knowledge skills occur in centres and specialised environment of the silo.
EMMANUEL C. ABOLO Editor-in-Chief
Are we walking away from ďŹ gh ng the right war, ...in order to win the wrong war? PAGE Healthcare Management Review
018
Volume 21
What is the wrong war? What is the right war? Healthcare Management Review PAGE Volume 21
019
What I see most often is disagreement on a very small 5% of theory/practice, while many ignore the 95% that we all have in common.
PAGE Healthcare Management Review
020
Volume 21
In many cases, collaborative care is absolutely necessary for the best outcome for the patient. Wouldn’t we be better off if we all could find a way to work together based on our common goal of helping the patient? If we can get out of the FEAR mode, and realize that our healthcare system is largely broken and best put back together through collaborative efforts, we all stand a chance of thriving. Let’s strive to educate the public about what we do really well as PT’s instead of slinging mud at perceived enemies. Let’s start supporting all PT’s who do their best to provide Evidence Informed care, regardless of whether we agree with the specific techniques they use. Let’s all start playing nice in the sandbox.
Healthcare Management Review PAGE Volume 21
021
THE BOUNDARY WARS IN HEALTHCARE PAGE Healthcare Management Review
022
Volume 21
E
very healthcare professional will be confronted with threats to her current position by economic forces,
advancing technology, changing patient expectations and the need to remain knowledgeable in a world where the doubling time for knowledge is approaching three years. Sustainability is clearly tied to adaptability. Technology will change and economics will change. This is true of all professions and all industries.
Healthcare Management Review PAGE Volume 21
023
Key Questions: · What factors have affected the traditional role of health care practitioners and patients? o …what were the traditional roles o …what is the implication to quality? o …what are the new roles, responsibilities and relationships? o …what is shifting out of fashion? o …what is shifting out of traditional boundaries? o …what are the new boundaries o …what is the new landscape for engagement? ·
How prepared are we for these new roles? o …how do we accommodate the new profile in care design for the benefit of the patient? o …what does a healthcare professional have to be good at doing when working in conjunction with other practitioners, caregivers, and organisations that cure patients' diseases and relieve their suffering?
· ·
What are the underlying socio-cultural, economic and political issues How will the leadership of the various healthcare professions foster and sustain collarboration What are the impediments to team work?
·
PAGE Healthcare Management Review
024
Volume 21
Evolving knowledge of care allows and forces important new roles for health care practitioners. Key in the redesign process is Integrated Practice Unit (IPU) Ă˜ It is a multidisciplinary approach to diagnosis, treatment and disease management that creates value for patient and not created by a single intervention or single speciality but is the collection of outcomes of the entire process of care for medical condition Ă˜ The fundamental organisational unit in health care delivery should be IPU
Healthcare Management Review PAGE Volume 21
025
SPECIALIZATION erupts turf wars over body parts
Credit: Erik Eckholm The New York Times Archives
T
he brain surgeons are jousting with the bone surgeons, the dermatologists are rubbing plastic surgeons the wrong way, and the radiologists are fighting with nearly all of their medical colleagues. Turf wars among doctors are nothing new. But now, as a growing supply of
PAGE Healthcare Management Review
026
Volume 21
highly trained specialists confronts a stingier flow of fees, competition for the right to perform -- and bill for -lucrative medical procedures is growing more intense. The arenas of conflict are proliferating along with new technologies for inspecting or repairing the body.
Underused cardiologists and cardiac surgeons ďŹ ght for the right to insert pacemakers. Gastroenterologists, who reďŹ ned the art of peering into the upper and lower digestive tracts with scopes, now watch in dismay as surgeons begin to do the peering themselves. These same two groups are also arguing over control of the
new laparoscopic technique for removing gall bladders without open surgery. Specialists are in oversupply in many parts of the country, in the view of many experts. Expensively trained hands and minds will not remain idle.
Healthcare Management Review PAGE Volume 21
027
The Turf Wars The areas of conict are prolifera ng along with new technologies for inspec ng or repairing the body
PAGE Healthcare Management Review
032
Volume 21
Unfortunately, her experience is still the rule rather than the exception in the Healthcare system. This is the result of a system that's still largely focused on the historic way clinicians deliver care (by sites of care and by specialty) rather than by how people should receive care (centered around each person, their individual conditions, where and how they live, and the family and friends who support them). The fundamental challenges of optimizing care delivery across clinicians in independent silos persist. All too often, having a complex condition still requires the patient, the family, or both to become de facto project managers — a job for which they have no formal training — at a time of incredible emotional and financial stress. Ask almost any cancer survivor who coordinated his or her care — navigating between the primary care physician, surgeon, oncologist, radiation oncologist, nutritionist, and physical therapist, all while organizing rides, meals, and time off from work. The vast majority will answer that they — or their husband, daughter, or best friend — did the
job. There is a better way: integrated care. The pioneers in this realm have proven that it can be achieved: ·Integrated multi-specialty care models have been used for the better part of a decade for conditions such as headache, lower-back pain, joint pain, shortness of breath, and chest pain. These models can reduce waiting times, increase delivery of evidence-based practice, improve patients' experience of care, and reduce costs (mainly by reducing visits and decreasing the use of expensive diagnostic tests). ·Integrated breast cancer clinics and palliative car models are growing at numerous institutions throughout the country and are producing better results (e.g., reduced delays in care and improved experience of care for the former and improved symptom management, experience, utilization, and in some cases extended life for the latter). We believe it is time to optimize the integrated-care model and accelerate its adoption more broadly and deeply across the
Healthcare Management Review PAGE Volume 21
033
health care system.
position.
The measures needed to make this happen are clear:
Re-engineer processes.
Align payment with integrated care. Systems receiving a lump sum or capitated payment for treatment based on the quality of their transparently reported outcomes would have meaningful incentives to provide high quality, integrated care. In Mrs. Nkiru Adamu's case, the orthopedist, pulmonologist, infectious disease doctor, hospital were paid separately. Paying a lump sum for an 85-year-old woman with a broken elbow would incent the individual actors to collaborate. The vast majority of clinicians want to provide the best possible care for their patients and would welcome the alignment of payments with this desire and their professional beliefs and ethics. Kaisier Pamarante physicians frequently cite the capitated-payment model as one of the key reasons they chose to join the system, and is a main reason Kaisier Pamarante has 10 applicants for ever y open physician PAGE Healthcare Management Review
034
Volume 21
In the 1970s in aviation, pilots were the king of the cockpit; their word was law. Each pilot did things the way he felt was best, which meant each did things in a dierent way. For plane crews, that variation resulted in unclear expectations and roles. The result: a crash every ďŹ ve days with over 2,300 worldwide deaths in 1973. Standardizing work, clarifying roles, using checklists, and system design has dramatically improved safety and reliability. Major crashes are now rare. Atul Gawande made an eloquent argument to apply these principles to patient safety in The Checklist Manifesto. Standardized processes (with allowances for patientdriven, individual variation where needed) has been regarded as counter-cultural to medicine. But this is changing. Over 200,000 students have taken over two million courses on the Institute for Healthcare Improvement's Open School, a virtual online school for these improvement methods.
Our healthcare should invest in developing physician and staff capabilities not only in clinical medicine but also in process improvement.
Our healthcare should invest in developing physician and staff capabilities not only in clinical medicine but also in process improvement. Create universal electronic health records (EHRs). The lack of a single health record for each patient that clinicians from all specialties can access in both inpatient and outpatient settings is an obstacle to integrating care. In addition, patient privacy protections inhibit the sharing of health information, creating both perceived and real hurdles. If Mrs. Nkiru Adamu's family doctor had known she had recently had C. diff in the hospital and that her pneumonia had already been fully treated, he would not have prescribed a new course of antibiotics. She may still have died but would have likely suffered less. Kaiser Permanente has an EHR that is shared by primary care doctors and specialists who work in hospitals and offices and is also used by nurses, pharmacists, physical therapists, and nutritionists. Their ability to collaborate electronically with patients in their homes
and with each other using tools such as electronic consultation has fundamentally changed the way medicine is practiced at KP. Other medical groups have gone even further, making the entire medical record transparent to their patients through Open Notes On the horizon are opportunities for patients to help create their medical record by contributing family and social history, allergies, and care goals.
Reduce dependence on specialty care. While increasing the number of primary care physicians has been linked to lower mortality rates, increasing the supply of specialists has not. The reimbursement system, professional lifestyle, and our beliefs about expertise reward specialty care physicians over primary care, creating a perverse incentive to create more specialists. Creating deep but narrow expertise can lead to health care professionals feeling accountable for a slice of a patient's individual condition but rarely makes anyone clearly accountable for a whole person's Healthcare Management Review PAGE Volume 21
035
health. Patient-centered medical homes, accountable care organizations, and integrated delivery systems are all designed specifically to address this issue. Integration is particularly crucial during periods in our lives when we really need health care the most: “health care moments” such as birth, death, the diagnosis of cancer, or the need for surgery. These are moments marked by pain, suffering, excitement, confusion, and concern. They are endured individually and by whole families and communities. They involve frequent visits to hospitals and clinics and interactions with a range of providers. These are the moments when patients and families crave a system where the funders and providers are working together to offer whole-person and wholefamily care. To address this need, all health care systems should work to optimize the health care moment from the “customer's” perspective. This entails the following: Recognize and respect the caregivers. The integrated-care model should provide service not just to the patient but to the PAGE Healthcare Management Review
036
Volume 21
family and all other caregivers who support that patient as well. If the patient gives permission, they should be included in developing and implementing the care plans. Make the journey clear. The period leading up to a seminal health event such as a birth, an operation, or death can be lengthy, but in many instances it is predictable. Ensuring the patient, family, and caregivers have clear expectations regarding the clinical care, the impact on life (Will I lose my hair? My appetite? How do I keep up my strength?), and the impact on family finances can make the journey slightly less hard. Making this more predictable for the person living through the health care moment can remove some of the avoidable suffering caused by a reactive health care system. Each individual's journey can then be customized to meet his or her needs and desires. For example, moms and families can choose where their babies will be born (home, hospital, etc.) and how (with or without an epidural) without compromising care quality or service reliability. This co-production and
DISAPPEARING COMPARISMS
With the increase in specialisation, boundaries collapse
HYPER CONVERGENCE
Silos of all descrip on are collapsing ...un-meshable disciplines are becoming meshable
customization of the care pathway can help organizations provide mass-customized, highly-reliable care. Minimize disruption to the patient's life. In the hospital, patients are asked to lie in bed, swallow unidentiďŹ ed pills, eat food that arrives on trays, and ring a call button for assistance to get up and do the most basic of human functions. They are expected to be passive receivers of care and depend on the dedication and hard work of the expert nurses and doctors. It should not be surprising that when patients go home, they are confused about their medications, uncertain about what foods to prepare, and shaky on their feet when they walk to the bathroom. What if we
changed all of this by revamping care systems to teach or train patients in hospitals to participate in, rather than passively receive, their care? Being prepared mentally, physically, and socially can help minimize the disruption caused by a health care moment and optimize the patient's and family's autonomy, dignity, and respect. Aim for health: Every system is perfectly designed to get the results it is getting. Our health care system produces health care, not health. If we start to measure and reward health outcomes and health improvements (Did you feel better, have less pain, and enjoy a higher quality of life after your interaction with the health care system?), we can shift the system to focus on what we truly seek from our health care:
Creating deep but narrow expertise can lead to health care professionals feeling accountable for a slice of a patient's individual condition but rarely makes anyone clearly accountable for a whole person's health. Healthcare Management Review PAGE Volume 21
039
SYNERGY SYNERGY AMONG HEALTHCARE PRACTITIONERS
collaborated to achieve desired results for the patients. The question now is when are we going to realise that each of us needs all of us and all of us need each of us to
“
“
The bad news is for a very long time, we have not fully
take the healthcare delivery of our nation to great heights of achievements? I sincerely believe the time is NOW. We are the generation of healthcare practitioners that must change the narrative.
“
The good news is that it is not too late for us as
healthcare providers to join hands and work together to achieve better care for our patients knowing pretty well
“
that anyone can be the patient. Teamwork in healthcare
is vitally important to patient treatment, care and safety. Let us foster communication and create a better work environment.
PAGE Healthcare Management Review
040
Volume 21
Pharm. Ahmed I. Yakasai, FPSN, FNIM, FNAPharm, FPCPharm President, Pharmaceutical Society of Nigeria (PSN) 2015 -2018 Chairman/CEO, Pharmaplus Nigeria Limited
Benefits Of Synergy Synergy among healthcare practitioners provides benefits for the patients and the healthcare providers.
Dr, Francis Adedayo NMA President
Pharm Ahmed Yakassai PSN President
Synergy among healthcare practitioners is a must and not an option in achieving optimum safe quality care for the patients. When healthcare practitioners with different complimentary skills cooperate, come together and work hand in hand in the interest of the patients they always achieve better results for the patients.
PAGE Healthcare Management Review
042
Volume 21
To the Patient It promotes patient-centred care: The ultimate goal of the healthcare team is to provide patient with the best care possible. The patient is the epicentre of the healthcare. Providing best care for patient is easier to achieve when there is synergy among healthcare practitioners. Instead of having each practitioner take turns caring for them, patients have a team of experts on their side from the beginning; working together to provide the best possible care that has lasting results. It enhances better communication: Synergy among healthcare practitioners closes the communication gap and enhances inter-professional collaboration among the healthcare team. Healthcare providers are able to interact on a personal level, share ideas about patient treatment, outcomes and challenges as well as work together to maintain continuity in care.
Rather than relying on patient's chart to review treatments and patient history which may not help them to make informed decision. Synergism creates a free ow of information among healthcare practitioners. This helps to avoid miscommunication about patient's needs and missed symptoms. It enables Comprehensive Patient Care: When there is synergy among healthcare practitioners it is easier to form a holistic view of patient needs and care. Each healthcare practitioner holds a piece of the puzzle. Bringing all these pieces together enables a better outcome for the patient. It creates better coordination of patient treatment plans: Synergy among healthcare providers allow for better coordination of patient treatment plans by dierent healthcare providers due to their mutual under standing and collaboration. Specialists, therapists and clinicians are
Healthcare Management Review PAGE Volume 21
043
Everyone wins when there is synergy among healthcare practitioners.
better able to make informed decisions for
To the Practitioners
the benefits of the patients as results of
It empowers team members: Synergy
increased trust, interaction, understanding,
among healthcare practitioners empowers
knowledge and mutual respects among
all healthcare practitioners experience,
healthcare practitioners in different
exposure, knowledge and skills. Exchange of
disciplines.
ideas and best practices openly and freely among healthcare practitioners boosts the
It minimizes readmission rates: With better
competency and confidence of the entire
communication among healthcare
team members to get results.
practitioners, patient centred care, better coordination of patient treatment plans and better care for the patients, outcomes become better. Synergy among healthcare practitioners combats ongoing patient care problems such as misdiagnosis; when patients are misdiagnosed and not properly care for it is just a matter of time for them to be back in the hospital, at a high cost to the patient and the healthcare facility, putting more pressure on the healthcare team. Synergy among healthcare practitioners helps patients to be effectively treated first time.
PAGE Healthcare Management Review
044
Volume 21
It promotes team mindset: Working independently put pressure on healthcare practitioners. By working as a team, healthcare practitioners support each other, breaking down the silos of different disciplines, enhancing each other mentality. This team mindset raises morale and improves confidence to get results for the patients.
We have the responsibility to move from disaggregated silos to collaboration based on: •
MUTUAL RESPECT
•
DIALOGUE
•
TRANSPARENCY
•
WIN-WIN NEGOTIATION
‌collabora on strengthens systems, decreases errors, and helps build a culture in which outstanding outcomes are norm
PAGE Healthcare Management Review
046
Volume 21
How to Achieve Better Synergy Among Healthcare Practitioners
S
ynergy among healthcare
For example, the Pharm Degree in Nigeria
practitioners starts with
provides. Pharmacists with specialised
interprofessional education. Medical,
clinical pharmacy training that focuses on the
Pharmaceutical and other healthcare
development of professional competencies
students should receive training on why,
and confidence in the provision of evidence-
what and how to work effectively as a team
based patient-oriented care.
with other healthcare practitioners during
Ÿ
Better manage the utilsation of healthcare resources
early years in healthcare institutions. This will prime them to collaborate with other
Ÿ
healthcare providers during their practice
Ÿ Promote wellness and disease prevention, all in collaboration with the healthcare team
years. It is also important to create an environment where medical, pharmaceutical and other healthcare students should be engaged in learning with, from and about each other.
Optimise medication related health outcomes
Ÿ Opportunities for participation in clinical research Ÿ Training in the analysis of clinical research emphasised Ÿ The need to expand and integrate approaches to teachings in pharmacotherapy With residency training programme to enhance
Joint trainings, seminars, and conferences among healthcare practitioners should be organized just like it is being done in other climes (e.g. Nigerian Association of Pharmacists and Pharmaceutical Scientists in the Americas (NAPPSA)/ Association of Nigerian Physicians in the Americas (ANPA). Consider various options on how to give healthcare practitioners the collaborative training they need to care for patients as a team.
pharmacist's ability to collaborate effectively
with other healthcare professionals. Pharmacists and other healthcare professional will improve preventive outcomes and medication interventions as a result of better accessibility to healthcare.
Healthcare Management Review PAGE Volume 21
047
Turf Wars in Radiology David C. Levin, MDa,b, Vijay M. Rao, MDa
“The proliferation of new imaging technologies has left radiologists especially vulnerable to professional poaching.� The radiologists have since lost monopoly on x-rays. They have faced more recent onslaughts with the spread of MRI, ultra-sound, nuclear diagnostics and others PAGE Healthcare Management Review
048
Volume 21
W
e in radiology generally believe that for a number of reasons, we are the ones who should perform imaging on patients. We are the only physicians who devote entire training periods of 4 to 6 years to learning imaging and image-guided interventions. Except for unusual circumstances (e.g., some interventional procedures), we are not able to self-refer and hence are in the best possible position to keep expenditures for imaging services under control. We are familiar with all imaging modalities and are thus able to
consult with ordering physicians and steer their patients to other studies that may be more appropriate for the clinical questions at hand. We are trained to detect incidental abnormalities outside the primary areas of interest on imaging studies. And last but not least, we are trained in radiation and magnetic resonance imaging (MRI) safety. Nonradiologist physicians who practice imaging cannot meet these criteria to anywhere near the same extent as
Healthcare Management Review PAGE Volume 21
049
radiologists. Despite the inherent truth and logic of this argument, many of our physician colleagues in other specialties do not agree with it. One need not look very hard to find abundant evidence of interest among other medical specialists in encroaching on the practice of radiology. For example, in July 2002, the American Medical Association's House of Delegates went on record in support of nonradiologist physicians' efforts to receive privileges to perform ultrasound (US) examinations at their respective institutions. The House adopted a policy that US imaging is within the scope of practice of appropriately trained physicians and that criteria for granting US privileges should be based on recommended training and education standards developed by each physician's respective specialty. The question of what constitutes “appropriately trained” was left unanswered. Thus, radiologists have waged turf wars with other physicians over various aspects of US, such as echocardiography, obstetrical US, prostate US, vascular US, and emergency department US. Similar battles have taken place over disparate procedures such as skeletal radiography, cardiac nuclear imaging, vascular interventions, urinary tract interventions, neurointerventions, musculoskeletal interventions, fallopian tube catheterization,
Although this list appears formidable and perhaps discouraging, it is worth considering the fact that turf wars exist in numerous other nonradiologic areas of medicine as well. For example, orthopedic surgeons and neurosurgeons compete over spine surgery; colonoscopy is performed by both gastroenterologists and colorectal surgeons; skin lesions are removed by both dermatologists and surgeons; and the list goes on. Thus, encroachment by other specialists on some areas of diagnostic imaging and imageguided interventions need not signal an inevitable defeat for radiologists. Quite possibly, an equilibrium will be reached wherein both radiologists and other physicians will continue to perform and compete for certain of these procedures. However, in an era when so many physicians in other medical disciplines are scrambling for new sources of revenue, it is clear that these turf wars are not going to disappear any time soon. If anything, they will intensify. To successfully compete, radiologists must adopt a forceful and multifaceted strategy. The guiding principles will be that patients are entitled to have their imaging studies and imageguided interventions performed only by those physicians who are properly trained to do them and that physicians have an obligation to our health care system to use imaging in an appropriate manner to eliminate or at least minimize unnecessary testing, costs, and radiation exposure.
breast biopsy, myelography, and bone densitometry. PAGE Healthcare Management Review
050
Volume 21
Today, virtually no more coronary angiograms or percutaneous coronary interventions are done by radiologists. There are a number of reasons why this occurred: Ÿ
Cardiologists controlled the patients.
Ÿ
Most radiologists lacked training and expertise in electrocardiographic interpretation, cardiac hemodynamics, the use of cardiac drugs, and other clinical aspects of coronary artery disease.
Ÿ
The cardiology board examinations required catheterization laboratory training, whereas the boards in radiology did not.
Ÿ
Most of the research on coronary disease and imaging of the coronary arteries was done by cardiologists; and a manpower vacuum developed because few radiologists were willing to undertake training in coronary disease and cardiac catheterization techniques, and that vacuum was quickly filled by cardiologists. Some of these conditions existed (and still exist today) in other areas of radiologic practice.
Healthcare Management Review PAGE Volume 21
051
The War of Words Rule No. 1 of the turf wars: All salvoes must be fired in the name of patient welfare.
Another important area of encroachment, Dr. Moorefield said, involves use of ultrasound, especially by obstetricians with machines in their offices. Fees range from $100 to more than $300. "I am sure there is a lot of unqualified work going on," he said. "Not to say every one, but very many obstetricians have acquired these instruments with little or no training." The danger, he said, is that correctible conditions in the fetus, or hazards for the mother, will be missed.
"When doctors are as busy as they ought to be, they are much less inclined to do things of marginal medical value, or to seek patients for elective, cosmetic services," said Dr. Arnold S. Relman, former editor of The New England Journal of Medicine.
PAGE Healthcare Management Review
052
Volume 21
Undoubtedly there are unqualiďŹ ed obstetricians conducting fetal ultrasound, said Dr. Richard L. Berkowitz, chairman of obstetrics at Mt. Sinai Hospital in New York. But many more have excellent training and experience in fetal sonography. "Just because you're a radiologist doesn't mean you are well trained in this either," he said.
To experts in medical economics, the battle for patients indicates more than a redivision of the money pot. If too many specialists have been trained, then resources have been wasted. And if they have to search for things to do, they may promote the costly overuse of procedures.
"There are many neurologists reading M.R.I. scans who shouldn't be," said Dr. James M. MooreďŹ eld, a radiologist in Sacramento and chairman of the American College of Radiology. Neurologists involved in reading scans reply that they have obtained the requisite training and that their personal interpretation of scans is vital to good care.
Plastic surgeons complain that other specialists are horning in on the performance of rhinoplasties, better known as nose jobs. The debate follows Rule No. 2 of the turf wars: Any surplus must be in someone else's specialty.
"Since there are not enough neurosurgeons, the orthopedists, who produced too many, began doing neurological procedures," said Dr. Pevehouse, a past president of the American Association of Neurological Surgeons. In many regions, he explained, there are too many orthopedists in relation to the number of broken bones that need setting or hips that need replacing, the standard work of orthopedists. And so, like Dr. Christ, the plastic surgeon, he described how interlopers are creeping across the h u m a n b o d y, i n va d i n g o n e neurosurgical site after another. First, orthopedists started doing peripheral nerve work, on the arms and legs. "Now they think their scope of practice should include disc problems a n d n e r v e r o o t p a r a l y s i s , " D r. Pevehouse said. "Some even want to do spinal tumors." This is bad news for patients, Dr. Pevehouse said (Rule No. 1). "Orthopedists are not trained to the same extent to handle nervous tissue." Orthopedists, of course, beg to dier. Healthcare Management Review PAGE Volume 21
053
The Guerilla Warfare
T
he proliferation of new imaging techniques has left radiologists especially vulnerable to professional poaching. They long since lost their monopoly on X-rays, as more doctors put machines in their oďŹƒces. They have faced more recent onslaughts with the spread of magnetic resonance imaging, or M.R.I., ultrasound, nuclear diagnostics and other methods.
PAGE Healthcare Management Review
054
Volume 21
One major dispute concerns who can interpret, or "read," M.R.I. scans. Guerrilla warfare over this is simmering around health care professionals, mainly between radiologists and neurologists, since M.R.I. is often used for brain and spinal disorders, but also between radiologists and cardiologists as methods for scanning the hear t are developed. Healthcare Management Review PAGE Volume 21
055
One as a Unit
Clinical and Service Integration
O
rganisational integration alone is unlikely to deliver better outcomes and effort must focus on clinical and service integration. Action is needed at the macro, meso and micro levels, and multiple strategies should be pursued at all three levels. General practice commissioning offers a platform on which to develop integration provided that practices involved in commissioning consortia are encouraged to commission and provide services in collaboration with clinicians in community health services and secondary care. Policy-makers should encourage the emergence of clinically integrated groups and integrated provider networks based on patient choice wherever possible and linked through contractual integration.
I
t follows from this definition that integration is concerned with the processes of bringing organisations and professionals together, with the aim of improving outcomes for patients and service users through the delivery of integrated care. Many advocates of integration see it as a potential solution to fragmentation,
PAGE Healthcare Management Review
056
Volume 21
defined as the breakdown in communication and collaboration in providing services to an individual which results in 'deficiencies in timeliness, quality, safety, efficiency and patient. Integration is a 'frameworks of care' that reduce fragmentation and duplication of health care, which can lead to poor patient outcomes, inefficient services and
wasted resources. Fragmentation is often the result of organisations, professionals and services operating independently of each other, with adverse consequences for service users. There are different degrees of integration, ranging from linkage through co-ordination to bringing together services into one organisation. Linkage involves organisations agreeing to collaborate to improve outcomes; coordination entails organisations putting in place defined structures and processes to overcome fragmentation; the most radical form of integration involves establishing new programmes and units in which resources are pooled and information shared. Whatever the degree of integration, 'the primary purpose of integrated care should be to improve the quality of patient care and patient experience and increase the cost-effectiveness of care. As such, integrated care is provided with both a rationale and a common basis for judging its impact'.
Integration is a coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors. The goal of these methods and models is to enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients with complex, long term problems cutting across multiple services, providers and settings. The result of such multipronged efforts to promote integration for the benefit of these special patient groups is called 'integrated care'. Healthcare Management Review PAGE Volume 21
057
Fulop’s typologies of Integrated care ¶
Organisational integration, where organisations are brought together formally by mergers or through ‘collectives’ and/or virtually through co-ordinated provider networks or via contracts between separate organisations brokered by a purchaser.
¶
Functional integration, where non-clinical support and back-oce functions are integrated, such as electronic patient records.
¶
Service integration, where direct clinical services provided are integrated at an organisational level, such as through teams of multi disciplinary professionals.
¶
Clinical integration, where care by professionals and providers to patients is integrated into a single or coherent process within and/or across professions, such as through use of shared guidelines and protocols.
¶
Normative integration, where an ethos of shared values and commitment to coordinating work enables trust and collaboration in delivering health care.
¶
Systemic integration, where there is coherence of rules and policies at all organisational levels. This is sometimes termed an ‘integrated delivery system’.
Systemic integration
Organisational integration
Functional integration
Integrated care to the patient
Service integration
Clinical integration
Normative integration
T
he relationship between organisational integration and care co-ordination is illustrated in Figure 2, which indicates that organisational integration in itself may be insufficient to overcome fragmentation of care. It also suggests that high levels of care coordination can be achieved both within integrated organisations and between different organisations working together in networks. This brings out a further important distinction, relating to the level of care that is
PAGE Healthcare Management Review
058
Volume 21
the focus of integration. As discussed in more detail below, integration may be pursued at macro, meso and micro levels. Care coordination is one way of achieving integration at the micro level by ensuring that service users experience seamless care. Care coordination depends less on organisational integration than on clinical and service integration, because the experience of service users is influenced more by the nature of team working and the adoption of shared guidelines and policies than by the nature of organisational arrangements.
“When an en re industry architecture is transformed, it is not only who does what that changes, …it is also who takes what” Michael G. Jacobides, Associate Professor of Strategic and International management at the London Business school
THE CENTRE OF GRAVITY HAVE SHIFTED”
“ A man ‘s got to know “
his limitations.
Harry Callahan
“
Care co-ordination depends less on organisational integration than on clinical and service integration, because the experience of service users is influenced more by the nature of team working and the adoption of shared guidelines and policies than by the nature of organisational arrangements.
”
A distinction can be made between horizontal and vertical integration. Horizontal integration occurs when two or more organisations or services delivering care at a similar level come together. Examples include mergers of acute hospitals as well as the formation of organisations such as care trusts that bring together health and social care. Vertical integration occurs when two or more organisations or services delivering care at different levels come together. Examples include mergers of acute hospitals and community health services, and tertiary care providers working with secondary care providers. Both horizontal and vertical integration may
be real or virtual: real integration entails mergers between organisations, whereas virtual integration takes the form of alliances, partnerships and networks created by a number of organisations. Virtual integration may occur along a continuum, ranging from formalised networks based on explicit governance arrangements at one extreme to loose alliances or federations at the other. Virtual integration is often underpinned by contracts or service agreements between organisations, as in the supply chains found in many manufacturing industries. It can therefore be seen as a form of contractual integration rather than organisational integration.
Healthcare Management Review PAGE Volume 21
061
Levels of Integration and Evidence of Impact The macro level is one at which providers, either together or with commissioners, seek to deliver integrated care to the populations that they serve. Examples include health maintenance organisations such as Kaiser Permanente and Geisinger Health System, and integrated medical groups. Common characteristics of these integrated systems contributing to their performance include multispecialty group practice, aligned incentives, the use of information technology (IT) and guidelines, accountability for performance and defined populations, a physician–management partnership, effective leadership and a collaborative culture. Ñ
The meso level is one at which providers, either together or with commissioners, seek to deliver integrated care for a particular care group or populations with the same disease or conditions, through the redesign of care pathways and other approaches. Examples include initiatives to integrate care for older people in North America and Europe, disease management programmes, chains of care and managed clinical networks.
Ñ
The micro level is one at which providers, either together or with commissioners, seek to deliver integrated care for individual service users and their carers through care coordination, care planning, use of technology and other approaches.
Although we have distinguished between these three levels for the sake of analysis, in practice they are often used in combination; this is in recognition of the fact that changes at the macro level, on their own, are limited in their ability to make a difference for service users and also to address the weaknesses of care fragmentation.
PAGE Healthcare Management Review
062
Volume 21
HIGH Single provider, weak internal co-ordination
Single provider, strong internal co-ordination
Siloed providers
Multiple wellconnected providers/ clinical networks
Extent of organisational merger
LOW Co-ordination of care
WEAK The relationship between organisational integration and care co-ordination is illustrated above, which indicates that organisational integration in itself may be insufficient to overcome fragmentation of care. It also suggests that high levels of care co-ordination can be achieved both within integrated organisations and between different organisations working together in networks. This brings out a further important distinction, relating to the level of care that is the focus of integration. Integration may be pursued at macro, meso and micro levels. Care co-ordination is one way of achieving
STRONG integration at the micro level by ensuring that service users experience seamless care. Care co-ordination depends less on organisational integration than on clinical and service integration, because the experience of service users is influenced more by the nature of team working and the adoption of shared guidelines and policies than by the nature of organisational arrangements.
Credit: Natasha Curry & Chris Ham (The King’s Fund)
Healthcare Management Review PAGE Volume 21
063
“
Our patients reap the rewards of this focus on
value - based medicine coordination of care and patient safety, all of which form the basis of our ranking as the top hospital in southeast florida as ranked by US News & World Report.
“
We owe all of this to our immensely dedicated team of physicians, nurses and healthcare providers who validate this mission, earn the esteem of our patients and focus on delivering quality healthcare every day.
PAGE Healthcare Management Review
064
Volume 21
Dr. Wael Barsoum, CEO and president, Cleveland Clinic Florida
Healthcare Management Review PAGE Volume 21
065
The Hidden Attitude Credit: Chadwick L.Chung
Inter professional disputes have been associated with the traditional approach of teaching professionals in silos.
PAGE Healthcare Management Review
066
Volume 21
Deep-rooted prejudices and professional “territoriality” challenge successful integration of disparate views and represent a significant barrier to inter professional collaborative care.
I
nter professional collaboration in health care is believed to enhance patient outcomes. However, where professions have overlapping scopes of practice (eg, chiropractors and physical therapists), "turf wars" can hinder effective collaboration. Deep-rooted beliefs, identified as implicit attitudes, provide a potential explanation. Even with positive explicit attitudes toward a social group, negative stereotypes may be influential. Deep-rooted prejudices and professional “territoriality” challenge successful integration of disparate views and represent a significant barrier to inter professional collaborative care. Enhanced patient outcomes are expected to result from successful collaboration between health care providers. However, collaborations are as complex as jurisdictional boundaries, historically associated with turf wars and by team members attempting to reach common goals. Of particular concern is a growing body of evidence indicating that some of the unnecessary error in patient
management can be attributed to poor communication between health care professionals. Inter professional disputes have been associated with the traditional approach of teaching professionals in silos. This information has led to an evolution in health care education, with movement toward an inter professional curriculum in an attempt to improve collaborative practice. Unfortunately, results of such programs to date do not appear to have had the longitudinal effects that can be expected to translate into changes in behaviour, since change in attitude has not been observed in some research. Solving the challenges posed by the evolution of inter professional care requires a clear understanding of the magnitude of the issues involved. Scant quantitative research has been dedicated to understanding the complex relationships between professions. Rather, the majority of studies have used qualitative methodologies to understand the issues that surround various collaborative ventures. Healthcare Management Review PAGE Volume 21
067
Clinical Laboratory From Ancient times through the 19th century By Darlene Berger, former MLOeditor (1998-2000)
From tasting urine to microscopy to molecular testing, the sophistication of diagnostic techniques has come a long way and continues to develop at breakneck speed. The history of the laboratory is the story of medicine's evolution from empirical to experimental techniques and proves that the clinical lab is the true source of medical authority.
PAGE Healthcare Management Review
068
Volume 21
T
hree distinct periods in the
physicians could observe with their eyes
history of medicine are
and ears, which sometimes also included
associated with three different
the examination of human specimens.
places and, therefore, different methods
The ancient Greeks attributed all disease
of determining diagnosis: From the
to disorders of bodily fluids called
th
middle ages to the 18 century, bedside
humors, and during the late medieval
medicine was prevalent; then between
period, doctors routinely performed
1794 and 1848 came hospital medicine;
uroscopy. Later, the microscope
and from that time forward, laboratory
revealed not only the cellular structure of
medicine has served as medicine's
human tissue, but also the organisms
lodestar. The laboratory's contribution
that cause disease. More sophisticated
to modern medicine has only recently
diagnostic tools and techniques—such
been recognized by historians as
as the thermometer for measuring
something more than the addition of
temperature and the stethoscope for
another resource to medical science and
measuring heart rate—were not in
is now being appreciated as the seat of
widespread use until the end of the 19
medicine, where clinicians account for
century. The clinical laboratory would
what they observe in their patients.
not become a standard fixture of medicine until the beginning of the 20
The first medical diagnoses made by
century.
humans were based on what ancient
Healthcare Management Review PAGE Volume 21
069
th
th