from Leadership Medica n. 284/2011
A pursuit of best management and best practice. The experience of "Fatebenefratelli" in Milan
Since June 2010, the General Surgery Unit of Fatebenefratelli and Ophtalmological Hospital in Milan has begun a process of reorganization. What once were in fact the departments of Surgery I and Surgery II have been merged into a single complex structure of general surgery. Surgeons and Health Department, together, are working to give a new look to the department, principally for the benefit of patients. It began a process of total reorganization that involves surgeons and nurses, with the consent of the Strategic Management Department, in an effort to achieve not only excellence in professional practice but also in the organizational and managerial sectors.
In recent years, health has been the sector of the public administration that has received increased attention and the adoption of legislative measures that often overwhelmed the existentt reality. This process of change seems far from over and reorganization dictated by a new culture, should mainly be implemented and be consolidated at the base, that is, with regard to a hospital, sharing all the operators with those management systems capable of meeting the highest quality standards.
It is in this context that we undertook the reorganization of the S.C. General Surgery of the Fatebenefratelli Milano.
Analysis of the S.C. General Surgery
The S.C. General Surgery of the Fatebenefratelli Hospital in Milan has 40 beds for hospitalization, while for the Day Surgery it can count on the availability of 45-50 admissions per month at the dedicated multi-specialized department.
The activity consists of over 1,500 surgical operations per year, much of which is major surgery. An extensive experience has been developed in minimally invasive laparoscopic surgical techniques, thoracoscopy and oncologic surgery. The minimally invasive techniques are routinely used not only in cholecystectomy, appendectomy and hernia of the abdominal area but also in major abdominal surgery (in particular colon-rectum and spleen), in thoracic surgery resection and in support of neurosurgeon colleagues for the surgery of the thoracic spine. Due to the many years of experience,these methods are increasingly used also in the urgency. The outpatient services unit exceeds the 8.000 patients over the year, it is characterized by minimal waiting time and is almost entirely diversified based on the pathologies. About 500 specialist visits are sent to the other units of the hospital. There are at all times surgeons on shift in the Emergency Room-DEA and a "senior " general surgeon is available in the hospital 24 hours a day that together with an on call surgeon are dedicated to emergency surgery.
The medical staff is composed of 18 medical directors, as well as of the Director, and the nursing staff is composed of a nurse coordinator, 20 nurses, 5 medical social workers and 2 technical auxiliary workers. The hospital has an arrangement with the Postgraduate School of General Surgery, University of Milan and is responsible each year for the professional training of three interns.
Our mission is to provide adequate responses to requests from patients about the management (prevention, diagnosis, care and treatment) of surgical diseases, the principles of sound science and quality with the objective of maximum efficiency, allowing to obtain the best efficiency and maximum attention to the relational aspects of a more humane relationship with the patient.
Reorganization of S.C. General Surgery
We have taken this reorganization path, aware that the quality of care is a major problem for health services and do not depend only on the competence and skills of individual professionals, but the end result of several factors - clinical governance, rational use of available resources, control of technological innovations, channeling professional behavior toward effective and appropriate diagnostic and therapeutic choices-.
The available data in the literature show how difficult and complex it is to ensure a good quality of health services, regardless of the degree of professionalism and technological sophistication achieved. According to an estimate made in the USA about 40 per cent of patients do not receive effective treatment, while about 25 per cent would be inappropriately treated.1 Improving the quality of care is made possible through coordinated and consistent actions: the continuing education of professionals (lifelong learning), monitoring of care processes (clinical audit), the management of clinical risks related to health care (risk management). 2 3 There are two main obstacles when carrying out these actions, which correspond to the implementation of clinical governance in the context of welfare: the possible lack of resources, especially in terms of people and time to evaluate and monitor the quality of care, and the need for a change in organizational and professional culture.
The reorganization of our business unit is primarily addressed, as mentioned above, to the enhancement of quality of care provided and is schematically characterized by three measures:
- A new methodological approach to the activities;
- The division of activities in relation to professional competence;
- A new work schedule for the ward aimed at improving the appropriateness and user satisfaction.
This organizational approach is designed to facilitate the efficient management, to release suppressed energy, to encourage participation, boost the unit to the stated objectives and is based on the adoption of a system for collecting quality indicators. Quality indicators have been identified and defined for hospitalization, for day surgery and for outpatient services (Fig.1). With this detection system of quality indicators it is possible to constantly monitor the three "dimensions" of quality (managerial, technical and perceived) and therefore better understand the activities and be able to undertake a process of continuous improvement. In practice the set of quality indicators for the hospitalization and the Day Surgery should help us to redefine the processes of the diagnostic and therapeutic paths interpreted according to the most current guidelines suggested by the scientific literature, and secondly they will indicate re-engineering processes (organizational and clinical care pathways) where necessary and appropriate. It seemed more appropriate to adopt a system of quality indicators such as to investigate the existing and select the "best practices" rather than designing a priori ideal paths, far from the real context of existing constraints. A further instrument is essential for the roadmap: internal audit. Only through a planned program of auditing, the analysis of quality indicators and the subsequent detection of critical events which can generate appropriate corrective procedure (redefinition of the diagnostic and therapeutic process re-engineering)is possible. Not to underestimate also that the audit establishes good conditions to facilitate sharing, participation and collaboration among professionals.
A program of four audits per month on a weekly basis has been planned and each meeting will feature specific topics.
The first week meeting will cover the discussion of clinical cases and the identification of "best practices" , the second week, the audit will be devoted to organizational problems and objectives relating to the budget, the third theme will be the clinical governance ( quality and risk management), in the fourth week we will focus on everything related to vocational training and scientific production.
To these audits are invited colleagues from other units, nurses, and office quality management control whenever it is judged necessary for their active participation in a more comprehensive examination of the arguments.
In a second phase the detection system of quality indicators could also lead to the planning of a program of actions aimed at educating the patient and / or the General Practitioner, that is a program of so-called "social marketing". Figure 2 summarizes the connections and the effects that we expect from these actions.
Finally, indicators for outpatient services (Fig. 1) collected in a consistent manner and in real time can guide, if it becomes necessary, a reorganization of resources and / or other services so as to meet the service expectations on the part of users.
Reorganization by surgical activities and surgical skills
Understanding that the Medical Director of the S.C. General Surgery should be able to make in relation to their ability and experience, a range of surgical services such as "generalist" in the performance of particular activities and emergency department of emergency surgery, it is appropriate that each also be devoted to a specific area of the surgery so as to increase (or gain if he had not) super-specialized skills, necessary to achieve quality results and increase the attraction of users with the benefit of productivity.
The reorganization provides for the assigned business areas according to their skills so that continuous improvement will lead to the provision of safe effectiveness and appropriateness.
The areas of surgical activities were divided as follows:
- Breast Surgery
- Colorectal Surgery
- Proctological Surgery
- Surgical gastro-enterology
- Hepato-biliary-pancreatic surgery
- Thoracic Surgery
- Abdominal wall surgery
- Emergency surgery and trauma
- Day-surgery and week-surgery
These areas of expertise may be organized as a unit or simply refer to "professionals." The allocation of responsibilities among the medical directors reflects the mechanism of the "privileges" of U.S. hospitals: each surgeon presents his own surgery cases of the last five years and will be given the assignments on the basis of experience.
This mechanism also points out who can be regarded as appropriate to the activity of tutoring and then take on the professional development of surgeons who are not yet fully formed.
Reorganization of the care activities in the ward
For good quality of care are two essential needs:
- Ensuring continuity of care
- Ensure reliable figures of reference not only for patients but also for their relatives and colleagues of the services and other business units.
In departments of surgery such as ours, the turnover for emergency room shifts, shifts in the ward and the activities of divisional operating room often turns the doctor in an unrecognizable figure of reference for the medical care activity department.
This is frequently a source of discomfort in patients who see the succession of doctors as a discontinuity of their care and inability for the physician to establish an empathetic relationship with the patient.
The turn-over of doctors, sometimes even daily, has other considerable drawbacks: the possibility that the information given by doctors are perceived by patients and / or relatives as diverse and sometimes conflicting, misunderstood in communication with the services and / or other departments due to the alternation of doctors, possible disruption in the organization of the dismissal, considerable loss of time needed for deliveries between one doctor and another.
Based on these considerations, a change of work shifts has been implemented.
The new plan calls for two shifts of medical directors (one "senior ") dealing exclusively with the ward care processes for a continuous period of one week, in this period these two doctors will be exempt from any other activity (emergency room, interdivisional shifts, operating room, outpatient clinics) in order to dedicates himself exclusively to the patients.
This system, eliminating the drawbacks listed above, not only ensures the continuity of care but perfect uniformity in procedures and management of clinical problems.
This contributes positively to the image of the group, by improving the perception - which is not always easy - that individual problems are developed in accordance, in sharing and methodological uniformity.
If it is certain that one of the objectives for services and health systems is to ensure a good quality of services is equally certain that the modern health systems, even though their high degree of technological sophistication, are struggling to ensure good quality of their performance with the not infrequent possibility of generating public distrust towards them.
In this context our reorganization aimed at continually improving the quality of tools already widely known by (performance indicators and clinical appropriateness, audit, guidelines) and the building of relationships within the team of operators, which promotes a culture accountability for quality as an institutional duty.
Dott. Claudio Lunghi
Direttore del Dipartimento di Chirurgia Generale e Specialistica
A.O. Ospedale Fatebenefratelli e Oftalmico di Milano
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