Healthcare
From STS Roundtable
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Healthcare System Fishbowl: Memphis October 2008
As part of our learning agenda for the 2008 event, a dialogue was initiated around the healthcare system using a modified fishbowl technique. A fishbowl conversation as defined by Wikipedia is – a form of dialog that can be used when discussing topics within large groups. Fishbowl conversations are usually used in participatory events like Open Space Technology and Unconferences. The advantage of a Fishbowl is that it allows the entire group to participate in a conversation. Four to five chairs are arranged in an inner circle. This is the fishbowl. The remaining chairs are arranged in concentric circles outside the fishbowl. A few participants either volunteer or are selected to fill the fishbowl, while the rest of the group sit on the chairs outside the fishbowl. In an open fishbowl, one chair is left empty. In a closed fishbowl, all chairs are filled. The moderator introduces the topic and the participants start discussing the topic. The audience outside the fishbowl listens in on the discussion.
In the spirit of our learning model – Inspiration, Internalization, Integration – the following process was adopted:
- Inspire
- The inner circle of the fishbowl acted as the larger community’s knowledge builders and sharers by conducting a mini environmental scan. Internal strengths and weaknesses with the healthcare system were first identified followed by external (global) threats and opportunities.
- Internalize
- Community awareness and application were engaged by one half of the inner and outer circles forming a working group to identify the healthcare system’s core competencies, which amounted to a marriage (or natural fit) between internal strengths and external opportunities. The other half of the fishbowl’s inner circle and audience identified the system’s major vulnerabilities, which emerged from the marriage of internal weaknesses to external threats that constituted this “double whammy.”
- Integrate
- The final step in the fishbowl process was for the entire community to respond to the question – “How can we apply our learning in this process to inform our STS-RT Discovery process (that is, theory and practice)?
The data compiled below is the output of the fishbowl process.
As mentioned above, once the fishbowl exercise was completed, the participants separated into two groups. One group focused on internal strengths and external opportunities. The notes below are from the group that focused on internal weaknesses and external threats to the healthcare system
Internal Weaknesses
- Shortage of primary care doctors
- Money goes to specialized care
- New horizontal care systems do not deal with integration issues and require coordination skills and capability
- Lack of coordination capability
- At community hospitals, staff is not coordinated and there are integration issues with major parts of the delivery system which, are also at times, at odds with the hospital
- The system is focused on doctors vs patients- the system is lined up to help maximize the doctors' productivity
- Complexity of the system goes to the patient to deal with
- One question is how to shift from doctor centrix to patient centrix?
- Hospital architecture is not designed for staff/patient
- Television medicine- the technical issues failed to consider the social issues. For instance, patients did not want to disrobe in front of a camera
- Policies are developed to address an issue with the physician- revolving around physicians
- Charting for nurses now focused on laws/regs vs. patient
- Tolerating poor social skills of the physician
- Work design is around the physician
- Homogeniation of care
- Shifting 'drunk tank' and other services to ER
- ER is now portal of entry but not funded that way
- JACHO- accreditating body dictates the standard of care - $$$ go to it
- Nurses' time to attend patient goes to non-value added work
- Huge learning curve to IT systems and much time is taken with them that needs to be freed up
- Staffing shortage of nurses and no way to 'grow' the population
- Current nurses are tired
External Threats
- Shortage of teaching staff in nursing schools and low pay- not sure if low pay is about teaching staff or nurses salaries or both
- Entire system is breaking down- increased population, paying system maxed out
- Huge discontent among buyers
- Hospital staff is already stretched thin and now asked to reach out and do more- adding more services but not more staff
- Specialized technical clinics - blow continum of care model
- JACHO- too much spent documenting
- Insurance industry
- Business model
Major Vulnerabilities
- Fundamental business model is broken- managing 'dying' business vs. keeping people healthy- hospitals will remain but patients will die
- Family system is broken and we have lost teaching of health care that used to take place within the family members. For instance,we now have breast feeding clinics to teach new mothers what their mothers and aunts used to teach
- Regulatory system does not fit social system's needs
- Hospitals are reactive
- Now health care crisis vs financial crisis
- Patient has to become the client
- Create like patient groups with nurses and paraprofessionals - put information into the hands of the patients
