On the way to agile care structures

It's 9.30 a.m. in Neurology 6, Head Clinic at Heidelberg University Hospital. Everyone is there: senior consultant, ward doctors, chaplains, nurses, physiotherapists, psychotherapists, trainees - all professions gather every morning in the ward room. It gets crowded, but everyone knows: If you arrive too late, you're out of luck. This is the fixed time for daily communication. "Punctuality here is a question of respect for others from the outset," explains ward manager Robin Krüumlger, who has been in charge of the ward from the very beginning and helped to set it up. „The senior consultant is also on site at 9.30 a.m.“ Then all patient-relevant topics that are on the agenda that day are discussed in a condensed form in a maximum of 30 minutes. „This alone gives the individual professions more time to work on and with the patient. And less information is lost on the way from the nurse to the doctor to the therapist or counsellor," reports the trained health and nursing professional. He says that questions can be asked straight away if something is unclear, and everyone knows their tasks for the day.

The team also takes a quick look back every day to see what didn't go so well and where there is room for improvement. To ensure that agile interprofessional working functions well, the paths on the newly established ward, which is aptly named „Innovation Room Nursing“, are short. The doctor's room is next to the nursing ward room. This means that what needs to be done can be clarified quickly and directly on site.

explains project initiator Krüger.

Project „Innovation Room Care“

The Heidelberg University Hospital has set out to align work processes more closely with patients, reduce hierarchies and create flexible working time models. The idea of the nursing innovation room was born. Initially, eleven nursing staff worked on the newly established Neurology 6 ward with eight beds. There are now 16 beds and 19 nursing staff, three ward managers and two senior physicians. Nursing Director Edgar Reisch has been enthusiastic about the idea from the outset and said at the time of the opening in 2020: "A ward under nursing management creates the right space to easily integrate innovations into everyday nursing care, to test them and to evaluate them scientifically." An advanced nurse practitioner works as a specialist manager on the ward and supports the multi-professional team as well as therapists and other service providers in the acute hospital. The ward is also used to train interns, trainees and students. Patients with rare neurodegenerative diseases are cared for here. The employees have the creative freedom to come up with innovative ideas and implement them in everyday ward life.

Another important building block for promoting agile care is the lean management concept. Lean management is very important to us here at the hospital, and we set out early on to give medical and nursing staff more time for treatment and care. In our department, every team member can initiate, work on and implement projects,

says Krüger, explaining another special feature of the Heidelberg pilot project.

One key to an agile hospital is therefore patient-centred and open communication. However, agile care also means that the profession takes on more responsibility and is allowed to organise itself, for example. Robin Krüger's ward is also a role model here. „An important, major organisational structural project was and is the autonomous duty roster design“, reports the ward manager. What was previously only possible for the nursing staff in the Springer pools will in future also apply to the nursing innovation room thanks to an internal ward project. The nursing staff write their own duty rosters, individually and on their own responsibility. A measure that also increases employee satisfaction, Krüger knows. „And if the employees are satisfied, this in turn benefits the patients.“

New Work in nursing

What some call new work or innovation is already a reality for others. These approaches are already increasingly being used in care for the elderly, especially in the European context. Buurtzorg should be mentioned here as an example of self-organised care based on flat, transparent and self-organised structures.

Buurtzorg

Buurtzorg is the Dutch word for neighbourhood care. It refers to an outpatient care company from the Netherlands that is based on self-organisation and works exclusively with autonomously organised care teams. Jos de Blok founded Buurtzorg in the Netherlands in 2007. It promotes the autonomy and decision-making skills of carers and actively involves patients and their relatives. The increased say and responsibility on the part of carers has a positive impact on the profession. In Holland, Buurtzorg is one of the most popular employers and is now the largest mobile care service provider. Over 15,000 employees decide on their own work processes, rosters, recruitment and training, without the need for HR management, marketing or a CFO.

But back to Germany: New Work – a buzzword that is currently everywhere. But what does it actually mean? First and foremost, it describes the workplace of the future – in most professions with a focus on hybrid and mobile collaboration. This is only possible to a limited extent in nursing. Nevertheless, this profession is also considering what the nursing care of the future could or should look like. After all, change does not stop at nursing care. New healthcare companies are entering the market, Lauterbach regulations need to be implemented and medical technological innovations can make many things easier. Some things require a political framework, others can be initiated by clinics and facilities themselves. Namely, how they need to change in order to react quickly to new market conditions or internal changes, but also to position themselves as an attractive employer - just like the Kopfklinik in Heidelberg. In addition to a corresponding mindset, formerly known as a mission statement, this also requires a rethink within the company.

For the care profession, however, it is perhaps better to speak of „agile care“ rather than New Work. This is because it is primarily about a different form of collaboration that is no longer based on the complex management structure in clinics and the polarised distribution of roles: away from the old hierarchical responsibility and decision-making power towards more self-organisation in the teams. It is not surprising that more and more hospitals are moving towards agile care. After all, word has got around that, in addition to the health-promoting safeguarding of specialist staff, a sense of community is also created that is conducive to overall organisational development and can improve the quality of care.

In addition, an agile way of working makes the clinic attractive and interesting for new employees.

However, the obstacles seem to be particularly great in the healthcare sector, because hospital organisation is still almost immune to rules, and there is an extreme silo and competitive thinking between the professions and also between the wards and departments. Until now, hospitals have not needed agility because they have been centralised, privatised, outsourced, etc. However, the task of hospital management in the coming years will be to improve the most internal processes - and this requires agility.

Calmness, health, community

Karin Probst, certified business coach and Scrum Master, who has already helped many clinics on their way to becoming agile hospitals, knows that agility only works with an attitude. „I am usually called in when there is enormous employee dissatisfaction“, she explains. This becomes apparent when there is an increase in team conflicts or typical workload errors occur, such as employees mixing up a medication or hitting a car because the driver is working against the clock under constant stress. The reasons for switching to agile management are obvious, but what does that mean in day-to-day care work?

Probst explains that this includes a daily, disciplined exchange on the so-called Kanban board, which visualises the work steps“. Each employee has assigned tasks, there are clear structures and controllable work steps. Everyone keeps an eye on this with the daily meeting. „Of course, more mistakes occur in the initial phase. This is also due to the fact that employees are motivated to address errors in the group," explains Probst. However, the targets set are small and manageable. „That's why they quickly experience success, which is celebrated“, she continues.

Core of Agilität

• Agilität relies on small, autonomous and interdisciplinary teams.
• These teams are customer- and patient-centred. They are allowed to make more decisions because they will implement them later. The employees are actively involved in the decisions.
Agility in practice is based on small steps towards change within a manageable period of time, which are also communicated transparently to everyone.
• Agility differs from the usual hospital organisation. Now it means communicating transparently, making decisions and working together, trying out small steps, correcting them and creating and celebrating joint successes. And the whole thing is interactive!
• Agility is based on continuous learning and regular, open feedback.
• Agility requires management to provide a clear framework for goals, values and individual decision-making.
• Agility also needs to be organised.

In addition to the added value of being able to reduce stock levels, for example, by organising stock across all stations, resulting in less waste and lower costs due to out-of-stock goods, flat hierarchies also increase the quality of collaboration. The team can focus on its core tasks, improving both the quality of care and interprofessional collaboration. As a result, work peaks are also eliminated at the end of the process and daily routines are regularised," continues the coach. This is not easy, but most of the time you can't see the wood for the trees, „because carers in particular are too exhausted by the excessive workload“. Nursing staff often criticise the fact that it is no longer possible to work to a high standard due to the immense workload.

And that crushes and demotivates“, says Probst.

In addition to the daily short meetings, there are larger meetings every two to three weeks at which the IT department and, for example, the management are also present - which is also the case in Heidelberg. „It is precisely this close interdisciplinary co-operation that is valuable for the employees and for the patients,“ explains Krüger. And Probst also confirms that decisions are always made where they occur. Lean management and digitalisation are also two pillars without which the transformation process would not work. Probst reports on a hospital that she accompanied through the transformation process to become an agile clinic: Within two weeks, the fixed structure and standardised work processes meant that the number of kilometres walked daily by nursing staff on one ward was reduced from 270 to 150 kilometres. A benefit for the employees - as well as uninterrupted break times. This has resulted in a cost reduction of 27 per cent for the clinic. The digital patient board supports the healing process and empowers patients to take charge of their own health. In the end, everyone wins.

Source: kma Klinik Management aktuell - kma online from 27/01/2023