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Changing work structures in healthcare settings

The Economist Intelligent Unit

- Healthcare

- Oct 31 2014

How can traditionally cash-strapped and risk-averse healthcare institutions adapt work structures and ultimately improve patient outcomes?

Global healthcare systems are confronting a period of dynamic change, which is forcing governments and health systems to look for operating models that promote greater efficiency, while at the same time improving outcomes for patients. This combination of evolving healthcare structures and cost concerns is having an impact on the way human resources are deployed across healthcare systems.

New incentives

From the US to China, there is a wider effort to roll back so-called “fee for service” remuneration, in favour of paying doctors a set price for treating patients during the course of an illness or operation, or tying payment to outcomes, such as the reduction of hospital readmission rates.

Medical professionals have welcomed the trend towards salaries in exchange for more comprehensive and integrated care management systems that give physicians greater autonomy. Such systems are part of “enabling people to do the job they trained for,” according to Dr Murray Ross, director of the Institute for Health Policy at US health provider and insurer Kaiser Permanente.

A World Bank study has found that the use of performance-based remuneration can be an especially effective way of retaining public sector health staff. The study, which focused on developing countries, showed that output-based contracts led to an increase in salaries for 80% of physicians in a Romanian pilot project; the researchers also found that salary increases were more effective when tied to performance goals1

Meanwhile, some health systems are looking at improving other aspects of the environment in which their medical staff work, in an effort to reduce both occupational stress and staff attrition and enable them to attract top talent. In 2000, the UK National Health Service (NHS) introduced Improving Working Lives, an initiative designed to offer flexible working, access to childcare and carer support and other programmes designed to encourage health and wellbeing at work.

Flexible workers

Those health systems with most nimble workforces are likely to be most successful at deploying resources efficiently in the future. This will mean doctors collaborating both with one another and other healthcare professionals, such as physiotherapists and nurse practitioners.

Coordinated care can create cost savings by reducing uncertainty and catching some health conditions earlier. In the case of a breast cancer patient who has a group meeting with a breast surgeon, medical oncologist and radiation therapist within 24 hours of diagnosis, team-based care can also save valuable time as well as money, observes Dr Thomas Lee, the former chief executive of PartnersHealthCare, a US-based healthcare provider.  “The advantage is that there are no mixed messages; when people walk out of the room, everyone knows what is going to happen next,” he says. 

Such initiatives can lead to greater engagement on the part of healthcare workers, which in turn can contribute to greater job satisfaction and improved patient care, US researchers have found2. Yet it is also important for health systems to maintain an open dialogue with their employees in order to avoid the morale problems that can undermine workforce change. The UK National Health Service (NHS) has conducted an annual staff survey for the past 12 years: its 2013 survey found that although 79% of NHS employees reported overall satisfaction with the support they receive on the job, just 41% said they felt the organisation valued their work

Redefining roles

For such integrated care models to work well implies a redefinition of professional roles, whether between nurses and doctors or between direct health providers and team managers.

At Kaiser, physicians retain full responsibility for medical decision-making, which aligns professionalism and commitment, according to Dr Ross . “Because our health plan and medical group collaboration is at the organisational level, our physicians have substantial autonomy and they answer to their peer groups, not the health plan,” he explains.

Similarly, UK-based health provider and private insurer Bupa  conducts in-house medical reviews with its own teams of physicians to determine appropriate treatment, a factor that helped 4,500 of its patients avoid potentially unnecessary surgery from May 2011 to May 2013, according to Dr Paul Zollinger-Read, C.B.E., chief medical officer at Bupa.  

While more flexible and integrated health workforces can help medical teams work more efficiently, however, there is less evidence so far that they can compensate for the staff shortages, one of the biggest stresses facing hospital workforces. One article looking at nursing staffing shortages in the US compared “short-term” strategies, such as the use of internal agencies to meet temporary staff shortages with “long-term” strategies such as investments in nursing education and changes in roles. The study found that short-term solutions were not likely to be sufficient on their own to reduce employee stress levels3

Many health providers are already adjusting their care models to this new environment. Those that fail to adapt could face a bumpy ride in the future.

1Vujicic, M., “How you pay health workers matters : a primer on health worker remuneration methods,” World Bank, September 2009.
2See Peltier J. and Dahl, A., “The Relationship between Employee Satisfaction and Hospital Patient Experiences,” Forum for People Performance Management and Measurement, Northwestern University, April 2009.
3May, J. H., Bazzoli, G. J. and Gerland, A. M., “Hospitals’ Responses to Nurse Staffing Shortages,” Health Affairs, Vol. 25, No. 4 (July 2006).

This article is part of a series managed by The Economist Intelligence Unit for Sodexo.

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