Skip to 0 minutes and 5 seconds So good morning. I have with me Professor Federico Lega from the Bocconi Business School in Milan, and we’re going to talk about the topic of organisational innovations in healthcare. Federico, why do you think the challenge of organisational innovation is so acute these days in healthcare systems around the world? Thanks, John for these questions. They’re interesting. I think there are several forces or several challenges that hospitals and health organisations specifically are nowadays facing. Some are very well known worldwide, the fact that we have an increase in chronic care condition of patients, so the epidemiology of patients that are treated by a healthcare organisation is changing.
Skip to 0 minutes and 50 seconds There is sustainability issues, the fact that we have a sudden imperative to become more productive and to use more efficient ways and resources. But also, there are some challenges which are likely less known. One will be the challenges of changing the skill mix among professionals, we have quite an increase in turf wars among different families of profession, whether they are clinicians or nurses, and so on, and there are opportunities for a healthcare organisation to improve the way they allocate staff and use their staff. We have a massive change in technology. We’re now moving to the robot era for certain surgery. We have new possibilities in diagnostics. We have intelligent, or what we call precision medicine.
Skip to 1 minute and 44 seconds So these are changing the way healthcare is delivered. And if you change the way healthcare is delivered, you also have to change the structure within an organisation supporting that delivery. And finally, I think we need to mention also the fact that we have an increased look at what we call outcome-based or value-based healthcare. And so the fact that we are looking at concentrating volumes and trying to find optimising the stuff, creating multidisciplinary teams, looking at product lines rather than disciplines when we look at how we organise healthcare.
Skip to 2 minutes and 21 seconds So a number of challenges that really make it a little bit of unfit the traditional model of how healthcare was organised, and requires a new look, a new perspective, how we organise healthcare organisations. That’s a great introduction. Thanks for that. I’m just thinking specifically, what do you mean by then organisational innovations? You mentioned the traditional model. How would that change? What we mean by organisational innovations in this context? Well, I usually frame this in three different lines or trajectories of change. One will be internal redesign of healthcare organisations, and specifically this is actually taking place in the hospital.
Skip to 3 minutes and 5 seconds We’re moving finally to a real definition or a real example of what we call a patient-focused or a patient-centered hospital, which means that we still have the discipline as the basis for organising professions. So we still have people organised around cardiology or orthopaedics and nephrology, and so on. But more and more, we’re looking at in certain transversal lines, or let’s say clinical lines or clinical service lines, including the design of the hospital. So I mean, multi-systematic teams, like in the case of oncology or like in the case of neuroscience, or like in the case cardiovascular disease, which are putting together professionals coming from different units based on discipline. And that’s actually…
Skip to 3 minutes and 53 seconds it’s an evolution of a process that’s been on for many years. But now finally we see that this is becoming the new structure, the new basic structure of hospitals in many cases. So they’re becoming responsible centres. They are becoming a business unit. They’re coming to a new, let us say, structure dimension. And the other thing is now we are optimising, we’re trying to optimise in as much as possible the use of resources allocated to the different professionals. And so there’s an evolution in what we usually call operational management into hospital. Operational management is becoming a dominant function right now in healthcare organisation, because we cannot have anymore waste in the way we use operating theatres, bad management.
Skip to 4 minutes and 42 seconds We are introducing new ways of managing discharge. Many hospitals are moving into creating discharge rooms or discharge areas to facilitate the flow of the patients, during the stay of the patients in the hospital itself. We have the introduction of iCare letters in between the intensive care unit and usual care. So in one word, I would say that there’s a revolution in hospital, and health organisation that is based on what is often level as patient flow logistics. So a lot of attention to patient flow logistics, and this requires a redesign, a reconfiguration of the internal organisation of a healthcare organisation.
Skip to 5 minutes and 34 seconds This is very similar to the sort of business process re-engineering concept, isn’t it, that you organise around patients, patient groups, common processes, rather than clinical specialisms? Exactly, exactly. That’s a point. Obviously, what happened in the industry has been a reference, a benchmark to make sense of what is now taking place in healthcare. There are similar techniques, but then there’s a lot of customised need when you apply these techniques to the specific setting of healthcare. You have to do this in a professional context, with all the [INAUDIBLE] dependency that that context asks. So I mean, it’s clear that these are radical changes. You’re questioning the whole basis on which hospitals have been organised and designed, around which clinicians traditionally work.
Skip to 6 minutes and 25 seconds So this generates many challenges, doesn’t it? Which I suppose begs my next question, which is really can we think of some examples of this? Are we seeing these changes in the Italian context, for example? Yes, we have seen some of these changes. I would rather say we even have a couple of situations that could be very interesting worldwide, because they started earlier to introduce these changes. One of these is a hospital based in Milano, I will try to introduce a little bit of this. It’s called a Humanitas Hospital. It is a large hospital, 700 to 800 beds at this point.
Skip to 7 minutes and 9 seconds They introduced their operation management in the mid-90s, when they basically started to operate the hospital more like… sometimes they use the terms a factory, now they say we have a factory, this is the hospital, and then we have the professional, the intellectual capital that need to use this factory as best as possible. So to some extent they introduced in the Italian context the idea that one thinks is basically developing the professional side, and then you have to make sure that you have good clinicians, that you have good attention to outcome, and so on. But on the other side, you need to have a strong operation management of the facility and the resource allocation.
Skip to 7 minutes and 56 seconds And what they did, basically, they started to challenge the traditional model, in which beds, operating theatres, and everything else was basically allocated to the single discipline or to other departments, and they said, this is going to be managed centrally. Each discipline, each unit, each clinicians will have access to resources for the planning, and the use of the resources might have a variation according to the strategy of the organisation, according to the demands of the waiting list, according to the requests that may be done by the local authority, which is, let’s say, supervising the hospital, when it comes to setting the budget. We’re talking obviously of a national health system.
Skip to 8 minutes and 42 seconds So this hospital is a private hospital, but it still is accredited with the NHS, so it works in a regulated environment. So what basically they start to challenge is the idea that the physicians were dominating and controlling the dynamics of the hospital resources and say, you’re going to have them when you show that you’re going to use them in a proper way, in the most efficient way, an effective way according to a strategy that is set by the organisation to get the opposite of [INAUDIBLE] with the clinicians. And what really challenged that situation is the… I would say the engagement.
Skip to 9 minutes and 23 seconds So the real issue that they had is how to engage clinicians in the new model and making sure that they feel that this new model was built to make the facility, the hospital more fit to support the requests and the need of physicians, in terms of having the right resource at the right time in the right place. This must have generated massive human resource challenges, then. Are you talking about making coalitions work in different teams, interdisciplinary teams here? Yeah, exactly. Also, the organisation follow this model, so then now they have call centres. So they have the clinicians are in a sort of a metric system.
Skip to 10 minutes and 11 seconds So the same clinicians belong to a unit, let’s say a typical example would be a surgeon. And say, a thoracic surgeon, it would belong to the surgical unit, but also it would belong to the multidisciplinary teams based in the cancer centre, when it comes to lung cancer. And this obviously requires a readaptation of the organisation, a readaptation of the single clinicians in a new model, because these clinicians will have to bosses, the head of the surgical unit, but also the leader of the lung cancer unit or the lung cancer clinical service lines. How did they persuade the clinicians to buy into this model? Three major incentives. One is career.
Skip to 11 minutes and 4 seconds Creating the multidisciplinary teams increased the position to have a career inside the hospital, because rather than say escalating the rankings on the vertical side, so becoming the head of the unit of surgery, of the head of what you call a clinical directories, to give you an idea, some of the clinicians now can have an horizontal career, becoming leaders of multidisciplinary teams and having recognition and obviously even some financial rewards. So rewards, essentially. They have rewards. They get more visibility. OK? Because that is also promoted externally to the hospital, because all multidisciplinary teams or centres become a benchmark for the hospital. They’re basically the flagships, in terms of activity run by the hospital, so they are heavily promoted outside.
Skip to 12 minutes and 1 second And third, for the physicians, it’s an opportunity to develop professionally and become stronger and have in the future better markets for themselves. So they see that as an opportunity, basically. Well, thank you for that. Maybe perhaps just reflect on one more example. You mentioned is it the public health authority in Florence as another possible case? That’s an interesting case. The local authority of Florence, they… it’s a great or a large story, integrated delivery system. So it runs five hospitals and covers the health needs of a population of around 900,000 inhabitants living in Florence and in the metropolitan area of Florence.
Skip to 12 minutes and 48 seconds So what they did, they saw that they have the necessity to optimise again to use all resources on one side, and to build clinical networks among the physician, the clinicians belonging to the different hospitals with the different other healthcare setting, managed by the local authority. So on one side, they identify what they call six pipelines. So they say, we need to optimise the pathway or the logistics, the tension flow logistics of the elective surgery, of the urgent surgery, of the complex clinical patients. And so the chronic patients with a multi pathology, for instance. The outpatients, the outpatients flow.
Skip to 13 minutes and 40 seconds You have an increase of offer, in terms of base service and other kinds of complex procedures in health patient settings, so the need to optimise this. And then the birth pathway is another anti-oncological pathway, because these have their specificities. So what they did, they took six engineers. They put the six engineers in charge of the six pipelines, and they started to standardise and optimise the way that patients were treated in the different settings of the local authority in a different hospital, using lean techniques and all kinds of improvement techniques. On the other side, they group together the clinicians, again in the similar… they call these poles, similar to centres. So they have the cardiovascular centre, so the neuroscience, the orthopaedics.
Skip to 14 minutes and 37 seconds And they group together the clinicians belonging to the different units situated and located in a different hospital in teams, and make sure that the leader of the team will define the standards in terms of clearing of pathways, in terms of the protocols that would be applied through the system. So now the physicians belong to the unit in the specific hospital, but also to the team which is part of a clinical network, which is run by the organisation level. And has this initiative continued? I mean, has there been resistance? Yeah. It’s still going on.
Skip to 15 minutes and 18 seconds There’s been quite a bit of resistance at the beginning, as you can imagine, because this really was challenging the professional autonomy and some of the discretion that physicians thought they had about how to manage, both from a clinical and organisational viewpoint, the patients. It took almost a year and a half to basically run the change process, which means that actually they had a number of sessions with clinicians, to engage them in the process. They… well, nothing, I say nothing new, but it was a massive effort. So they have a really, really… I would say thousands of hours of training in workshops and so on with the clinicians, to make this happening.
Skip to 16 minutes and 8 seconds But because the general management of the local authority is really, really strong on this, they succeeded. And when the physicians started to see the benefits of this, which means that actually now they have the guarantee that the pre-operation management the patient will be done in the same way, in any place. If they have a shortage of operating theatre in one hospital, they can use the operating theatre time in another hospital and move across, so they have an event team that move around the five hospitals. The nursing team or the nursing staff will use the same protocol when they assist patients in one side and on another side.
Skip to 16 minutes and 48 seconds The standardisation actually produced some benefits in the physician when they saw this, actually, to jump in and say that’s fine.
Improving healthcare through organisational innovation
Here we explore the issue of how organisational innovations in the design of hospitals might have positive impacts on the quality of care and patient outcomes. Please watch the video with Professor Federico Lega from Bocconi University, describing examples of organisational innovation in the Italian national health service.
Professor Lega explains how, over the past 20 years, hospitals in most countries have been forced to review their organisational structures in response to new environmental pressures. These pressures have arisen, in particular, from population ageing, with more elderly and frail patients, increases in chronic diseases and comorbidity. These pressures have called into question traditional forms of hospital organisation based around a rigid demarcation between clinical departments and specialisms with demands for greater collaboration. This, in turn, has led to new innovations in organisational forms, moving towards a new paradigm which Professor Lega terms the care-focused organisation. This model seeks to re-structure hospitals away from the traditional physician-centred view (discussed in Week 2) and prescribes instead a hospital organised around the particular needs of patients or the ‘intensity of cure and care’. The modern hospital is expected to shape its structure and the organisation of services according to the changing intensity of care required by the emerging cohorts of patients.
Professor Lega highlights two recent examples of this kind of organisational innovation in the Italian NHS. These include the Humanitas hospital in Milan and the public local health authority in Florence. The latter is also been widely acknowledged as a success story in lean implementation.
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