Healthcare leaders facing three choices

Prof Alexandre Lourence, Coimbra Hospital and University Centre and Adjunct Assistant Professor, National School of Public Health, Portugal
Prof Alexandre Lourence, Coimbra Hospital and University Centre and Adjunct Assistant Professor, National School of Public Health, Portugal

There were three choices facing Healthcare Leaders – ignore innovators and hope for the best, call for increasing regulation to make it harder for innovators to enter the market or compete on quality and efficiency, disruptive though that might be, Prof. Alexandre Lourenço, Administrator, Coimbra Hospital and University Centre and Adjunct Assistant Professor, National School of Public Health, told the Conference.

He said one of the major challenges facing the health services in Europe, was that they  had 21st century technology embedded in 1950 style organisations, organised the same way as they were 70 years ago.

Over the last 70 years, new hospitals had given a new focus to our lives –  we were born, lived, and died in hospitals. Hospitals changed and prolonged our lives.

At the same time, the hospital services were more differentiated, medical professionals had  become more specialized and  medicines and treatments more precise, particularly for patients with multimorbidity and the aged.

“Contrary to other industries, healthcare has resisted  organizational changes and continues to be primarily organized as it was more than half a century ago, and it struggles to adapt and evolve to overcome those challenges,” he said.

“We talk about big data and AI, but we don’t even know how to use much simpler technologies or achieve interoperability.   We don’t know how to crawl, and we ask our organizations to run the marathon.

“Actually, the system is more and more detached from individual and population needs, ignoring that today’s needs are quite different from those observed in the recent past.“

“We have population needs, increasing needs in mental health and a system which is not able to meet them.  Even though our population needs have changed from acute to chronic care, we continue to try and work through acute care.

“There is also an increase in citizens’ expectations and fiscal constraints in the context of low economic growth.

“The emergence and re-emergence of infectious diseases, or even the digital society, pose new and essential challenges to a structurally inflexible and rigid health system.  

“We have a system that has proven incapable of promoting health and preventing disease, eliminating variability and inequity in access, and providing integrated care focused on people’s needs. It is a system based on inputs – the number of doctors, the number of beds, the number of nurses, the number of MRIs, the number of respirators.  It is a system of volume – the number of surgeries and the number of medical appointments, a system that loses receptivity and walks towards oblivion.

“The health system is typically dominated by healthcare traditional providers –  healthcare professionals that are organized in hospitals, primary care centers, clinics, etc.”

Prof Lourenço said we needed to improve operational decision-making in four areas.

  • PATIENT FLOW: Data-driven operational decision-support systems could provide valuable insights to aid in making triage, admission, and discharge decisions.  Machine learning and decision-support algorithms could also be used to predict the expected number of admissions, discharges, and transfers to and from the ward
  • STAFFING: Digital technologies could also help with the supply side when it came to better managing capacity. Take, for example, nurse staffing, which accounted for a significant proportion of hospitals’ costs. Instead of relying on phone calls, text messages, and spreadsheets to make ad-hoc staffing decisions that often changed at the very last minute, charge nurses and hospital administrators could utilize analytics to improve this process.  For example, algorithms could predict nurse absenteeism rates and the need for surge staffing, to pre-emptively determine the right number of float nurses to call in. Research in emergency department operations showed that both could be modelled, even in environments where demand was highly uncertain.
  • SCHEDULING: While many hospitals had moved to electronically capturing and storing patient records, the scheduling of various resources was still largely a manual process. This applied to the scheduling of surgical procedures in operating rooms, scans in radiology suites, and many others. This was another area where digital technologies could bring substantial improvements, not only by better predicting resource needs and effortlessly incorporating last-minute changes and cancelations but also by optimizing schedules based on the latest research. Machine-learning algorithms could be used to better predict the duration of each procedure such as the length of a surgery or an MRI.
  • SUPPLY CHAIN MANAGEMENT: Across many industries, digitally transforming the supply chain had been shown to reduce process costs by 50% and increase revenue by 20%; hospitals were no exception. By automating the process of collecting data, ordering, reconciling and paying for medical, surgical, and pharmaceutical supplies, hospitals could reduce supply chain and inventory management-related costs. Radio-frequency identification (RFID) technologies and internet-connected trackers could be used to better track and locate supplies in real-time and allow a better usage of equipments and consumables.

“The health system is typically dominated by the healthcare traditional provider – hospitals, primary care centers, clinics, etc and pharma and medical devices industry.

“A third party is emerging. Primarily as technological partners of legacy providers, pharma, and medical devices industry.   New technological players are primarily influencing the previous two. We see its influence on Bigdata, remote monitoring, etc. If primarily they rely on conventional providers, they now venture themselves to solo initiatives: remote physical therapy, teleconsultations, etc., disrupting the way care is being provided.

“In my opinion, the most significant disruption will come from alternative players. The individual health providers. The primary technology companies are investing in health prevention. They have the capacity and resources to influence healthcare, as we don’t see it yet. The ability to detect prediabetes, fever, arrhythmia, and provide meaningful advice.

“With telehealth quickly becoming more prevalent, clinicians’ roles may evolve in some unexpected ways. As more patients begin accessing care through video connections, it is not hard to imagine a pathway toward lower-cost care providers. The first wave could involve price shopping in a patient’s local community. That could be followed by price shopping in different communities or worldwide. And once we are conditioned to getting our care through a computer screen, could software-controlled, animated chatbots of some kind be that far off?

“Although the need for the health professions is not going away, it is likely to fundamentally change. While technical expertise may not distinguish care providers the way it once did, relationship expertise will become far more important.

“A new world is around the corner. We know, that due to institutional forces and professionalism and limited management, the healthcare system tend to status quo.   Most industries have evolved from bureaucratic principles to market relations in the past decades, where the customer knows best in opposition to classic professionalism in which ‘the doctor knows best,’ or bureaucracy, where clients are seen as dehumanized objects.

“We can ignore the need for transformation or lead transformation. During the covid-19 crisis, we have witnessed that professionals and managers worked together and redesigned care. Are we using this experience to transform healthcare or choosing to ignore the need for change or prepare for transformation?

“Many still insist on the past solutions, promising more funding, hospitals, or doctors, without understanding that the current model is approaching obsolescence. It is at this point that managers need to lead health systems to change configuration and perform complex functions. From the relation between the concern for the transaction and patient-centeredness, the grid shows five positions –  Laissez-faire provider. Efficient provider, Pioneer model of care, The ‘good life’ model of care and a sustainable reconfigured model of care.

“Vertical movement requires transformational leadership, horizontal movements require transactional leadership.  Both the framework and the care configuration grid are novel contributions to the theoretical understanding of patient-centered care under organizational theory, providing guidance to policymakers and managers on positioning their organization. Moreover they enable the identification of the priority issues to address when implementing patient-centered care.

“I hope you know the meaning of the safety car — the pace car. It enters  when a major incident occurs. Everyone slows down and gets ready to restart the race. This is how I hope that we look at covid-19, a major incident that will allow us to rethink the healthcare system. After all the crisis we had in the first 20 years of this new century, we cannot afford to lose this one, to not evolve the health system.”

Alexandre Lourenço is a hospital administrator at Coimbra Hospital and University Center and Adjunct Assistant Professor at the National School of Public Health, who performs public duties in various institutions of the Portuguese Ministry of Health. He is also a consultant at the World Health Organisation (WHO) in the areas of financing, health systems strengthening and health services delivery. Alexandre also coordinates the Postgraduate Program in Management of Health Institutions at ISEG – Lisbon School of Economics and Management, and is an Associate Member of the NOVA SBE Health Economics and Management Knowledge Centre. He holds a PhD in Management from Nova School of Business & Economics, Lisbon. He is a Specialist in Hospital Administration (MHA), postgraduate in Primary Health Care Management and Master in Health Management (MSc) from NOVA NSPH. Former President of the Portuguese Association of Hospital Administrators, presently he is a board member of the  European Association of Hospital Managers and Treasurer of the European Health Management Association.