BUILDING SYSTEMS OF CARE, PART 2
By Jason Grady, NRP | SEP 3, 2020
All systems of care, whether STEMI, stroke, trauma, or other specialties, have the same goal: complete patient recovery.
From first medical contact, as the patient moves through the system, rapid, seamless diagnoses and treatment is critical by all stakeholders. Efforts to standardize systems of care have fallen short as they seek to create a "cookie-cutter" approach to solving the process issues. One of the first organized and successful STEMI systems in the United States was created in Minneapolis, MN by Dr. Tim Henry and his team who famously says “Once you’ve seen one STEMI system, you’ve seen one STEMI system.” Systems are unique in ways such as geography, resources, and obstacles and any attempt to “solve” these issues in general ways will leave systems frustrated and unable to make the progress they hope to achieve. Systems of care are just as the name describes; systems. Within human anatomy, systems must work together to sustain life. The components of each system must work together in perfect coordination from structures like the heart and brain down to the individual cell and everything must work seamlessly for life to exist, any breakdown of communication or lack of function is incompatible with life. Systems of care throughout healthcare have been difficult to establish and maintain. Some of the more common obstacle are the issue such as many moving parts, stakeholders do not work for the same organizations, lack of resources to, coordination, and reporting of data. All of these are important and legitimate obstacles and if a system is unable to identify them, implement a plan and adjust as outcomes dictate, systems will not survive.
System development is difficult and arduous if we try to take big bites out of it, however when we look at the components of what makes up a healthy system and understand that a system is a living breathing organism that must be built and evolved it makes it easier to start.
The five basic components of a system of care are:
Building and Maintaining Relationships with Stakeholders
Reporting Results, Educating and Adjusting
Ask anyone in direct patient care about what is needed to treat patients seamlessly and they likely would come up with novel ways to get the job done. Front-line providers are often the people who go to conferences to hear from experts and discuss the latest evidence of how to best assess and treat patients only to be stalled by administrative leadership who do not see the value in supporting the training, education, equipment or accountability to implement or
“…Give us the tools, and we will finish the job.”
it is derailed by a physician who refuses to “practice that way”. Far too often EMS rapidly assesses, diagnoses, and begins the necessary treatment only to have their patient sit in the ED while everything is being redone and figuring out what the physician on call that day happens to want. In a 1941 radio interview Winston Churchill said it best: “We shall not fail or falter; we shall not weaken or tire. Neither the sudden shock of battle, nor the long-drawn trials of vigilance and exertion will wear us down. Give us the tools, and we will finish the job.”
"…it is more important to have a protocol than to have the right protocol"
Protocols can be difficult to write and often take a large amount of collaboration with many people with their many opinions. There is research, best practice, evidence-based content, worrying if they are correct or what the lawyers think about them. Protocols too often are seen as a prescriptive algorithm that must be adhered to when treating a patient with a specific finding. Protocols are a planning tool that is used to guide treatment however, they must be put in the hands of competent providers that can understand how and why to use them and how to adjust when needed. The development of protocols should be done with the best evidence available however it is more important to have a protocol than to have the right protocol. Protocols should be vetted and established with the system in mind and how each item that is suggested will affect the patient at the next stage. We can get so bogged down with what is the “right” protocol that we never truly implement it and patients suffer. If an administrator or physician leader is uncomfortable pressing the envelope on something like medications, then start with a protocol to establish efficiency standards like scene time, communication, diagnosis accuracy, etc. If your protocol looks the same year after year, you are doing something wrong. Protocols must be measured and adjusted.
College football in the South is not just something that people are involved with, it invades the very fabric of our existence. More than one fight has broken out over who is the best team in the SEC and people lose their minds when you disagree whether or not they deserve to be in the playoffs. If I say the Georgia Bulldogs are one of the best teams in college football because they went 12-1 with a strength of schedule that rivals all top 10 schools and won all their games by a large margin, I make a legitimate case to be in the playoffs. If the Blue Mountain State Mountain Goats go 0-13, never play a top 25 team and lose every game by 50 points, they do not have a case to say they should be in the playoffs. Regardless of how loyal the fans may be, regardless of how long you have been a fan and regardless of how you “feel” about the school, the results have been measured and speak for themselves. Once protocols are established they must then be measured to ensure their validity. Any profession will likely agree that the worst part of any job is the paperwork, it takes a long time to complete and few people understand it's importance. Companies like Google, Facebook, television networks, and the like spend billions of dollars a year collecting data on unsuspecting users for one reason; to measure the effectiveness of advertising. They know our habits, time usage, and search history better than we know it ourselves and all because they measure what we do. If it is important for them to know and adjust immediately based on those results, we too should understand the importance and consider doing the same. As results are measured and identified, the protocols can be re-evaluated and real discussion can then take place on how to evolve them based on real data.
Building and Maintaining Relationships with Stakeholders
Perhaps you have been summoned to a team-building exercise at work and participated in exercises like trust fall, human knot, or trivia. While these activities may seem ridiculous and uncomfortable at the time, team cohesiveness and dynamics are often superior to team competency. This collaboration allows for transparency and outside the box thinking with a common vision and goals within the entire system.. For many years there have been conversations from hospital leaders about assumptions of the level of EMS education, scope of practice, and protocols. Additionally, EMS assumes what happens in hospitals, the processes they follow, and how they report outcomes. For both of these I would ask; "Have you ever sat around a table with the people providing each stage of care and looked at a single patient and what each brought to their care?". When stakeholders are brought together and egos are put aside, discussing the good, the bad, and the ugly becomes nonjudgmental and beneficial to the individual patients and the system as a whole. Stakeholders are more than just managers and directors who control the logistics and processes, they must include those who come into contact with the patient as well. Patient care providers will bring problem solving to the table more than any other stakeholder and with bidirectional transparency and communication issues can be identified and solved all with the same group and the decision will be supported at all levels.
Reporting Results, Educating and Adjusting
In 2006 the D2B Alliance published recommendations on reducing door to balloon time with one of these recommendations being real-time feedback1. In 2020, ask most EMS professionals the answer they get when attempting to follow Ask most EMS professionals the answer given when attempting to follow up on a patient they treated and transported and the standard answer given is "We can't tell you about that patient, it would be a HIPAA violation". Our interpretation of HIPAA and the unreasonable and overbearing parameters we put on it is one of the most damaging things in medicine. Our unwillingness to share real-time information, or any information for that matter, with all stakeholders involved, prevents us from
moving forward and saving lives.
In medicine we have moved from the Hippocratic Oath: "First, do no harm" to the HIPAAcratic Oath: “First, share no information”.
In medicine we have moved from the Hippocratic Oath: "First, do no harm” to the HIPAAcratic Oath: “First, share no information”. Hospitals demand EMS to give a radio report, bedside report and leave their written patient care report and then refuse to reciprocate sharing the outcome of the patient. HIPAA regulations are quite clear on who has access to patient information, including outcomes.
HIPAA 45 CFR § 164.506 - Uses and disclosures to carry out treatment, payment, or health care operations states: A covered entity may disclose protected health information to another covered entity for health care operations activities of the entity that receives the information, if each entity either has or had a relationship with the individual who is the subject of the protected health information being requested, the protected health information pertains to such relationship…
EMS is a covered entity and had a relationship with the patient and so are entitled to all protected information. Imagine if when hospital staff are ready to hear from EMS either by radio report or transferring care, were told they could not be given any information because it would be a HIPAA violation. Results and outcomes must be shared as soon as possible and be transparent and bidirectional if we truly care more about the patient more than our egos.
A hallmark of a true professional is the self-drive to be a life-long learner. All stakeholders should share in this task initially so everyone understands the level of each stakeholder and identify where the gaps in knowledge may exist. This may be in a specific modality or something the measured data highlights. A successful system will have all resources necessary to educate at any level provider. Education works best in when those providing definitive care and who perhaps have the most specialized knowledge, share their expertise with those providing care at each stage. Along the way new educational opportunities will arise and the system must ensure those needs are met and remeasured.
None of the above matters if a system is unable or unwilling to adjust based on the results obtained from each patient and each cohort. When data is gathered, reported, analyzed and discussed, little by little progress can be made. Outcomes must continually be assessed and adjusted as needed and then reported, analyzed, discussed and adjusted. Protocols must continually be assessed and adjusted as needed and then reported, analyzed, discussed and adjusted.
System components may be easy to understand and agree upon however, this is not where the real work is. Based on the uniqueness of each system, there are virtually an unlimited number of variables that make up each component and these must be monitored and coordinated in real-time. System components should not be viewed as linear from start to finish. In a system of care, there is no finish, only continuous improvement. These components are not mutually exclusive, they are dependent on each other and should be seen as circular with each as one as crucial any other.
If we are willing to work within a patient-centered system, putting egos and finger pointing aside, we will make an impact on the people to whom we have dedicated our careers, because that is who we are.
| Jason Grady, NRP | Sep 03, 2020
1 Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction Elizabeth H. Bradley, Ph.D. et al. N Engl J Med 2006;355:2308-20 https://www.nejm.org/doi/pdf/10.1056/NEJMsa063117