Patient engagement is said to be the prerequisite to improve the European health system. With the rapid growth of aging population and cumulative costs for hospitalization, patients are expected to take over part of the burden by actively controlling their own health.

But practices in many European hospitals still contradict those brilliant intentions. As soon as you cross hospital’s threshold you are stripped not only of your personal belongings, but of your identity as such. You are no more an engineer, teacher or a musician. You are just a patient and a patient, according to etymology of the word “is the one who suffers”. It seems that the following basic rule of human behavior cease to work in hospitals: people are engaged with those whom they like and who sympathize with them. The majority of physicians, for sure, are accepting those norms outside of their professional milieu. So why is this culture not common in hospitals?

Indifference as a self-protection.

One can often hear from medical professionals: “If I sympathize with all my patients I will not be able to treat them”, “I am also a human and cannot break my heart over every individual”, “I am alone, and you (patients) are many”.

We can understand physicians: with a burden of responsibilities, often long exhausting hours of work, one develops a psychological barrier to protect her/himself from emotional distress and sorrows. With years one gets used to it. The self-protection turns into disengagement and finally indifference. Just another job.

When you arrive at a hotel, most often a receptionist will smile to you and a butler offers to carry your luggage. When you arrive at a hospital you may sit for hours absolutely neglected by the medical staff.

Listening and hearing others is the vital part of communication. Not in the hospital, not when you are already there. Often doctors’ rounds resemble a brief excursion through the Zoo, but with less excitement. The excursion is reduced to a mere five-minute (at maximum) demonstration of a patient to the chief physician surrounded by tacit assistants. The medical guru is sorting out notes with lab tests, hardly looking at the patient himself. The verdict will be delivered to the patient later in written. A simple handshake calling a patient by name or a question: “How are you doing today?” are obviously not yet the part of a standard procedure.

Hospitals are not the luxury resorts. But one will still expect care and not brute enforcement such as, e.g., exerted on a patient in a Munich hospital who was fiercely tied to the bed on the first night after a serious open heart operation. According to the Intensive Care Unit (ICU) nursing apprentices on duty that night, the patient attempted to take off the oxygen mask and thus could harm himself. Apparently they were not listening to what a patient was trying to tell them: there was no oxygen supply in the mask and he was simply suffocating. The two strong young trainees, assisted by a belligerent staff nurse who obviously knew nothing of the case but was a priori hostile to the patient, jumped on the half-paralyzed man knotting him to the bedside to interrupt his protests and to prevent him from pressing the emergency button. The subdermal injuries caused by fastening the patient were so hard and the bruises so deep that one of his hands was damaged forever.

Attracted by the noise in the middle of the night and attempting to help his roommate, another patient jumped out of his bed to call the police. He was running along the corridor with a rubber tube hanging from his side until he was caught be the alarmed nurses who ran after him with wild cries. One could imagine such scenes in the Woody Allen movies, should it not actually happen in one of the most prominent hospitals in Germany. Apparently the Chief of the Department was not shocked by the case: though impressed by extensive purpish bruises on the patient’s skin, he merely shrugged his shoulders explaining that he did not have enough money to keep professional nurses in ICU. The worst thing was that everybody wanted to hush up the case as soon instead of exploring the grounds for such outrageous behavior of the nurses.

Not listening to patients could be killing. In a different case a man was so depressed after an operation that he confessed to the nurse his intention to commit a suicide. The nurse consulted a physician, but the complaint was brushed off as a “just another post-operative syndrome”. Three days later the patient jumped out of the window. Should somebody at that time stopped to talk at least for a couple of minutes to a poor chap or just put a hand on his shoulder, maybe he would still be alive.

Healthcare as a business

Inasmuch as we like to think about healthcare as of a social responsibility and humanism, it is in fact a big business. Concerns about costs in Healthcare communities almost prevail over the discussions about patient’s safety. Complex logistics, transportation, suppliers, engineering issues, etc. are of course the essential part of the whole healthcare system. Not the least are the insurance companies, those brokers between patients and medical professionals that control huge chunks of healthcare funds. It is Health Insurances and not the medical professionals that too often decide what services should be delivered to patients and what shouldn’t. In Germany, according to AOK Health Insurance 2014 report which has provoked indignation among the physicians and hospitals alike, there were annually 19.000 preventable hospital deaths in the country [1]. For a comparison: car accidents took away the same year 3.290 lives.

One of the reasons for such appalling results (in particular, discussed in the German ZDF news program) was the amount of unnecessary surgeries performed in hospitals that expose patients to the risk of infection, collateral organ damages and finally death. According to the ‘Medical Experts Online’, a company that provides patients a platform for a second medical opinion, in 66% of cases the first recommendation in favor of surgical intervention was found inappropriate [2]. The situation in the US seems to be no better. In fact, unnecessary surgeries might account for 10% to 20% of all operations in some specialties, including a wide range of cardiac procedures [3].

So why insurances are spending money on procedures that are not only unnecessary, but harmful? The more money insurances spent, the more likely they receive additional funds or increase member contributions (the “premiums”) the next year. On the other hand, hospitals are rewarded with a bonus for each operation. Considering that each surgery costs in average about 40K euro, this is quite a lucrative business. The only unhappy creature is a patient who ultimately has to cover everything with his own health and money.

Under such a model, patient satisfaction is one of the last KPIs a hospital is concerned about. Patient has no choice: her or his clinical pathway was predetermined by Insurances.

Can patient satisfaction make healthcare prosperous?

One of such examples was a hospital in Torrevieja, Spain, a private and public partnership between Torrevieja Salud (the health system of Torrevieja) and the Government of Valencia. Dr. Barcia, at that time the Chief Executive Office of the hospital, had a difficult challenge: according to his agreement with the Government of Valencia, he received 571 euro per patient from the Government compared to 898 euro spent in average by a Public hospital in Spain. Should he nevertheless get a surplus through effective management, it could be reinvested into the hospital and his staff. Dr. Barcia staked on reducing excessive administrative costs and attracting more patients, e.g., out of 600.000 tourists that are coming annually to Valencia. The deal was strict: if a patient was not satisfied with care in Torrevieja and moves to another hospital, Dr. Barcia had to finance her/his full treatment in a new institution.

The challenge was not only to design an economic formula with effective care, but to make it repeatable as an accountable standard procedure. The first task was to cut on routine administration costs such as due to registration and numerous files filling. By 2007, this hospital was already fully automated.

Every morning Dr. Barcia was checking the “barometer” of his clinic. In 10 minutes he could get an overview of the hospital’s “Rhythm of Business” through Florence, the hospital management system designed by Miguel Ortiz, CIO of the hospital, together with his 8 team members.

Among 400 Key Performance Indicators (KPI) the patients’ satisfaction was among the highest priorities. Each patient‘s complain was registered and analyzed by the system. Doctors, not squeezed with the limits of standard protocols, were focusing on the outcomes: the effective cure and the ultimate patient satisfaction. The system captured the best clinical practices focused on individuals vs. a commonly adopted standard “average” patient.

The reception area was no longer a place for endless frustrating waiting. Patients were able to book their appointments via the patient portal. The system could automatically recalculate the waiting time letting them know when exactly they have to arrive. Such services have been available at airports for a long time. Why not in the hospital?

Doctors were no longer spending hours reading patient charts prior to visits: they could access the system from the comfort of their homes. As a result, the waiting time in Torrevieja was 50% lower than in other Spanish hospitals.

Effective management supported by IT saved 327 euro per patient. The difference Dr. Barcia reinvested in cutting-edge equipment as well as in trainings and incentives for his personal. Thus, the average income of the medical staff in Torrevieja was 40% higher than across the region. That attracted skilled physicians from all over the world. Patients from private hospitals nearby were often considering moving to Public Hospital of Torrevieja.

The efficiency of Torrevieja management was reflected not only by numbers. One could actually spot it the moment you were in. Suddenly you noticed a doctor talking to a nurse about a patient case – an unusual picture indeed. Observations made by the nurses were an integral and indispensable part of the care process under Dr. Barcia’s management. In the pediatric department I saw a farther sitting next to his child. A nurse came in asking the father if he may need something to eat or drink. In many hospitals I was visiting, relatives were most probably considered as camels: nobody cared if they eat or drink at all. A doctor dropped by to say hello to his patient. No formal round: just to cheer him up a bit. In many European hospitals medical professionals are working in teams: every day a new physician will see the same patient, so at the end both patient and his relatives are confused: who is really responsible? Whom can I talk to?

After one year Torrevieja Hospital under Dr. Barcia management was recognized as the best middle-size hospital in Spain. The hospital management formula based on patient satisfaction proved to be economically and professionally effective.

Florence, the IT management system, was later transformed into Green Cube, fully automated patient-centric IT system offered now to other hospitals together with the management consultancy.

Somebody would say that the heart of Dr. Barcia’s success were talented people, others would attribute the Torrevieja Hospital performance to an excellent IT system. Both are right. But nothing would have worked without the initial question: what can I do better for my patients? To make our Healthcare system better medical professionals should at least care and sympathize with their patients, regarding them as individuals and not as a mere collection of organs, although the latter view is presumed professional.

References:

1. http://www.finanzen.de/news/14942/aok-krankenhaus-report-2014-rund-19000-tode-wegen-behandlungsfehler
2. http://www.atelier.net/en/trends/articles/doctors-20-online-second-opinion-verifies-need-surgical-operation_430159
3. http://www.usatoday.com/story/news/nation/2013/06/18/unnecessary-surgery-usa-today-investigation/2435009/