Dr Massimo Castoldi is Medical Director at the private multi-specialty hospital Humanitas Gavazzeni e Castelli.
One of our reports on the quality of life in healthcare organisations shows that healthcare professionals draw their energy and find their motivation in their relationships with colleagues and patients, while the real problem seems to be the confrontation with the management structure. How could it be useful to act to try to remedy this problem?
Speaking from my own experience, I think it is inaccurate to confuse efficiency with a sense of belonging to a hospital or an organisation. I try to explain this concept: it is clear that it is important for us to maximise the use of resources, such as beds and operating theatres, so that they are fully utilised when allocated to a surgeon, avoiding inefficiencies. This, in my opinion, is a point to be taken into consideration. If we continue to limit funding for the National Health Service, and the main costs are personnel, technology and facilities, it is clear that we will not make these resources as efficient as possible.
Otherwise, if we fail to ensure the efficiency of facilities, technology, and personnel, we will inevitably waste resources, because we will not be able to invest in innovative technologies, increase personnel, or renovate facilities. It is essential to agree on this. For example, there are many hospital facilities in Italy that do not comply with fire regulations, so concerted action is needed.
Doctors and nurses complain about overly tight deadlines that take time away from care. How can you try to counter this tendency towards exaggerated efficiency?
Can efficiency be considered a defect? I would say no. However, efficientism, like all ‘-isms’, can be a problem, on that I agree. But when does it become a problem? When we consider that our health workers, whether they are nurses, doctors or technicians, play a monotonous role, be it visiting, operating theatres or other activities. This is an objective fact. We have to imagine that within our organisation we involve all operators in strategic projects. This means taking the time to communicate our directives to them, to train them, to measure and discuss quality targets, not just quantity targets.
As an example, in my hospital we have implemented a mortality and infection monitoring system in the operating theatre, along with all other relevant standards that we discuss with the doctors during monthly team meetings or in case of deviations from the expected standards. What I am emphasising is that within an efficient system, it is necessary to provide dedicated time for these types of activities, which indirectly contribute to the production of results.
For example, during our budget meetings this year, we will not only focus on quantitative targets, because we achieve them every year. Rather, we will focus on qualitative targets. It is important to assess not only the number of operations performed, but also the customer satisfaction of our operating unit, as well as the quality of the protocols followed. It is on these issues that we focus, and here we return to the subject of efficiency.
Of course, efficiency implies not only ensuring adequate operating time, but also devoting time to quality management and patient relations, which can be difficult to reconcile. However, I believe it is this balance that establishes a good relationship between professionals and management. It is clear that if we treat our professionals as mere executors, without taking into account their skills and their importance in the decision-making process, tensions inevitably arise.
How would you describe your team of health professionals with a metaphor?
Are you familiar with the history of piracy? Pirates were indeed bandits, but in a way they were also instrumental to the system. In fact, they were called privateers because they had a sort of licence issued by the state of the nation they were referring to. Some of them even became nobles in England, such as Sir Francis Drake, who was allowed to attack Spanish ships.
This situation can be compared to a complex system like that of a hospital. There are professionals who mainly perform production tasks, concentrating on their duties, and then there are professionals who are involved in the organisation of the hospital, running the whole thing as if it were a well-oiled machine. Both models have their merits, but I personally believe that the second model, managed by the medical management, is more effective. This model is able to structure and sustain the organisation to high standards and be attractive to patients.
However, it is important to strike a balance between these two approaches. In the real world, we all know that there is a crisis of medical personnel, especially in the most critical areas such as the emergency room and emergency medicine. Often, young professionals prefer to do only outpatient work, and specialisations such as emergency medicine remain understaffed, while other departments, such as ophthalmology, are always crowded. Organisations that manage to dialogue with both types of professionals can gain the most benefit.
There is a difference, especially in purpose, but the tools available are the same. Let us move on to the crucial point. If an organisation involves professionals in a project that focuses on quality as well as quantity, I believe it is doing what it has to do. It is crucial to ensure a solid relationship between the management, which explains the project and implements the tools, and the healthcare professionals at all levels.
How do you act concretely to avoid these conflicts between doctors and management? What is your experience from this point of view?
What I have said so far is clearly reflected in the place where I work. If we look at the rankings published by Agenas for 2022, Humanitas Rozzano is in first place in Italy with the Ancona General Hospital for quality of care, Humanitas Gavazzeni is in third place, and Humanitas Castellanza is in fourth place. These evaluations are not made by us, but by Agenas, the health services agency. This is because perhaps the model to follow is a good one. It is a combination of efficiency, effectiveness and quality that is measured through the assessments provided by Agenas. Efficiency is measurable, but anyone who thinks that quality is not is wrong: either quality is measured or it is not quality. Here we measure efficiency, we measure the effectiveness that determines quality and we also measure various other indicators. This is where, in my opinion, the right relationship with the professionals lies. I have to ask them for both quality and quantity.
I mean that organisations, in my opinion, if they perceive that an organisation requires both, then they feel involved, otherwise they feel exploited. Our environment is not a paradise on earth, so we also need collaboration and face difficulties. However, the way forward is this: you have to demand efficiency, effectiveness and quality. If the organisation does this, in my opinion it has a good cost-benefit ratio, because it is not just about pursuing numbers, but achieving a higher quality standard. And this is where physician satisfaction also comes into play.
To clarify, what I talked about concerns the tools I use. Every month I organise a meeting with all the medical managers to work together as a team. During these meetings, I give them their measurable quality standards, as mentioned earlier. Each of them gets to read their performance and we discuss it together.
Each year, we set different quality targets. This year, we are introducing PROMIS [Patient-Reported Outcomes Measurement Information System] in some operational units, i.e. measures based on patients’ perceptions of the service they receive. It is necessary to create a system in which a satisfactory relationship is established. It is clear that we also lose staff, as other opportunities may be more attractive to them. If the projects we propose include development, implementation of new standards and efficiency in production, then management will not seem so unreasonable, nor focused only on production or theory.