systems thinking

Transitions of Care, or Improving Your Health At Home

When explaining the role and importance of public health to my colleagues, I like to jokingly point out that, ideally, patients spend most of their lives outside of the hospital. Though my tone is sarcastic, my sentiment is honest. Most of what happens to people that keeps them healthy or makes them sick happens outside of the hospital setting. One’s habits, lifestyle, home and work environment, level of education, and financial means all influence one’s trajectory of health more strongly than most hospital-based care can. These social, behavioral, and structural determinants of health often make the difference between a person whose health will maintained outside of the hospital and a person who will require repeat hospital visits.

The structural determinant of health that I will discuss in this post is one that I have confronted on a daily basis in the hospital – that of continuity of care, or barriers thereto. The fragmented nature of our healthcare system and the game-of-telephone-like way that information gets passed from one link in the healthcare chain to the next is a major reason that patients’ health and healthcare suffers from systemic discontinuities between hospital, rehab, clinic, and home or facility.

http://www.healthy.ohio.gov/~/media/HealthyOhio/ASSETS/Images/heart%20disease%20and%20stroke/stroke%20diagram.jpg

The hospital is just one part of the health care ecosystem.

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The Checklist Itself Doesn’t Matter

Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence.…We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.” – Chapter 8.

I just finished reading Atul Gawande’s The Checklist Manifesto, which was first published in 2009 and spent some well-deserved time on the New York Times Bestseller List. Written by an attending general surgeon at Brigham & Women’s Hospital in Boston, this book tells the admittedly “unsexy” story of how a simple tool such as a checklist can improve the quality and consistency of outcomes in a wide range of fields: aviation, building construction, venture capital, and (even) medicine. All of these fields are complex systems – involving many moving pieces and players, and an inherent unpredictability of conditions, materials, personnel, and complications. In addition, these arenas assume a certain level of skill and require a high standard of consistency and safety, but errors and complications still plague us. We have reached a point in many fields where the problem isn’t ignorance (we do understand a lot about the world around us) but rather ineptitude (we fail to apply the knowledge that we have consistently and correctly). A checklist can help us improve our “eptitude.”

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