HLB

Critical Review of ‘MN’ Community Rehabilitation Centre – A Systems Thinking Approach.

Introduction

Within the dynamic landscape of the global health industry, development of an interconnected health system has become essential for improving health outcomes, as adaptions made to components of the system can foreshadow improved efficiency in the provision of holistic care (De Savigny et al., 2017). This is particularly pertinent in the allied health industry, where disciplines often collaborate to deliver care in a multidisciplinary team (MDT) model to enhance evidence-based, client-centred practices.

‘MN’ Community Rehabilitation Centre (MNCRC) provides an allied health focused day therapy program (DTP) for geriatric Australian’s requiring slow-stream rehabilitation following a Queensland Health (QH) hospital admission. Given the vulnerability of geriatric Australians requiring rehabilitation prior to discharge, it is essential that this health system operates efficiently to improve the health and safety of this population. Systems thinking promotes the strengthening of health systems by analysing the complex relationships between system components and subsequent outcomes (De Savigny et al., 2017). The MNCRC system and its outcomes are influenced by a multitude of stakeholders and contextual elements. As such, a systems framework will be used to implement a systems-thinking approach to critically review the key inputs, throughputs, outputs, outcomes and impacts of the MNCRC health system (Appendix).

Inputs

There is a plethora ‘building blocks’ or inputs which intricately shape the MNCRC health system. These will be discussed as broad input areas, however in reality, they interrelate with significant complexity (De Savigny et al., 2017).

Firstly, as a QH subsidiary, MNCRC funding is provided by the Government via the State Healthcare Budget, in addition to Medicare funding through the Public Healthcare Funding Model. Resultantly, the system is volatile to political changes and dependent on budget decisions which prioritise community allied health care for continued service provision (Foo et al., 2021). Funding is distributed between the wards and DTPs, to sustain high-quality and equitable resources, infrastructure, and workforce. This foreshadows spending limitations for high-cost medical technology such as Telehealth, limiting the provision of equitable allied health care across Queensland. Whilst the correlation between funding and healthcare quality is weak, it influences the efficiency and accountability of the workforce which directly impacts care quality and health outcomes (Peters et al., 2021). Limitations in technological advancements foreshadows impaired clinical skill development, whilst also creating accessibility and equity concerns for rural consumers.

Secondly, the workforce has significant influence on the MNCRC health system. Retention of highly skilled allied health clinicians is essential for MNCRC to provide best practice care given the complexity of geriatric presentations admitted. MNCRC requires employment of medical staff and a diverse array of allied health clinicians to service the two components of the facility. The recent Covid-19 pandemic has significantly impacted healthcare staffing with statistics predicting significant nurse and allied health clinician shortages over the next decade (Peters et al., 2021). Kenny et al., (2016) supports this, citing that increased stress, safety concerns, workload, and unrealistic management expectations were primary reasons to change professions. Workforce constraints are amplified by the absence of Telehealth services, as clinicians are denied the opportunity to further develop their skill sets and progress into associated leadership positions.

Finally, the consumer, encompassing the diverse array of socio-economic statuses, cultural backgrounds, places of residence and health literacy form a significant system input. Providing care which addresses these elements is essential to maintain positive consumer outcomes (De Savigny et al., 2017). Canfell et al., (2021) supports this, stating that consumer-centred care facilitates improved quality of life due to the emphasis on goals, supported by best-practice care. While MNCRC comprehensively addresses consumer-centred care through their individualised approach to rehabilitation centred upon impairments and goals, their lack of technological advancements negatively impacts outcomes due to inequities in care delivery. This is exemplified through their discharge protocols, where the lack of Telehealth availability to track and predict trends in consumer outcomes is impaired, impacting rural consumers.

Throughputs

The throughputs of MNCRC health system include factors such as delivery of services, accessibility, quality, and safety which directly influence overall outcomes (De Savigny et al., 2017). MNCRC provides targeted rehabilitation for geriatric Australians to address impairments and functional deficits in conjunction with individualised goals to achieve safe discharge (WHO, 2021). Consumers are admitted into sub-speciality wards based on their clinical presentation where they receive 24-hour medical management. Consumers partake in an intense DTP, where they complete an individualised impairment-focused program collaboratively designed and delivered by an MDT. As such, the system requires robust partnerships with QH clinicians to acquire specialised allied health practitioners to collaboratively address the diverse array of medical presentations.

Due to the specificity of the DTP, the facility only accommodates for seventy clients at maximum capacity, therefore accessibility is an ongoing issue secondary to public waitlists. Whilst there are other inpatient rehabilitation facilities in Queensland, MNCRC is the only public geriatric centre which places significant demand on the organisation. Consumers who are denied admission remain in hospitals or are transferred to less specialised facilities, impairing consumer satisfaction and outcomes. Furthermore, admission timeframes are variable due to the array of clinical conditions admitted. Admissions range from 2-10 weeks, dictated by the achievement of discharge criteria. MNCRC allocates weekly sessions for collaborative MDT meetings with consumers, and key stakeholders to facilitate the provision of goal-oriented care to ensure safe and efficient discharge. Collaborative staff culture is an integral aspect of successful healthcare systems, instigating the cohesion of team and client goals to address impairments (Canfell et al., 2021). Strömgren et al., (2016) supports this, stating that relationships with MDTs and stakeholders directly influences care output and overall consumer satisfaction through individualised care provision. Targeted rehabilitation delivered by MDTs directly correlates with improved consumer outcomes, accelerated recoveries and reduced chronicity development (Canfell et al., 2021). Providing client-centred care can assist in reducing public waitlists, as clients achieve discharge criteria more efficiently.

The absence of Telehealth technology is a major issue impacting service delivery and accessibility due to the large rural population travelling to metropolitan Queensland for health services. Telehealth technology allows clinicians to extend service provision to rural locations without the burden of travel-time and costs. Li et al., (2022) supports the use of Telehealth in community settings, highlighting that outcomes are just as effective as inpatient rehabilitation. Once discharged, clients are expected to attend review appointments at monthly intervals for three months, to monitor outcomes and performance data. Whilst rural consumers still benefit from completing the program, long-term consumer satisfaction and performance data is compromised without a structured Telehealth system. MNCRC has proposed Telehealth technology, however funding has been rejected due additional resource and training requirements.

The quality and safety of MNCRC services is monitored by the National Safety and Quality in Health Service Standards (NSQHS) which assesses key elements such as the delivery of timely and affordable care, patient acceptance and health literacy. The NSQHS is a quality assurance mechanism implemented to ‘protect the public from harm and to improve the quality of health service provision’ (Australian Commission on Safety and Quality in Healthcare [ACSQHC], 2019). Provision of high-quality and safe healthcare in alignment with the NSQHS standards is essential to achieve positive consumer outcomes. This is evident through the prioritisation of patient safety and goals, and the use of KPIs to obtain positive healthcare outcomes. These KPIs are directly related to the services provided, to ensure safe patient outcomes, and efficient resource usage.

Outputs

The outputs of MNCRC health system are centred upon consumer outcomes, with financial and budgetary outcomes and clinical performance data closely monitored. Efficient health systems prioritise continual consumer and service improvement through value-based care delivery in the short to long-term (Peters et al., 2021). MNCRC measures outputs through analysis of admissions and discharges to monitor efficiency considering the high demand for the service. Prior to the Covid-19 pandemic, approximately 85 clients were discharged monthly, with an 87% 12-month success rate (indicating nil readmissions) (Personal Communication). During this period, MNCRC had a 1:2 clinician to client ratio, which contributed to efficient discharge statistics. The 2021 data however reveals that only 45 clients were discharged monthly. This correlated with clinician retention issues, indicated by the 1:3 staff to client ratio (Personal Communication). This indicates the importance of individualised care provided by specialised allied health clinicians to achieve outcomes and maintain efficiency. MNCRC evaluates other KPI criteria, including clinical incident investigations, consumer feedback mechanisms, multidisciplinary collaborative care, and lengths of stay to ensure that high-quality care remains centralised in practices.

Outcomes

Health care leaders at MNCRC are responsible for analysing outcomes for continual evaluation and revision of service provision. This encompasses perspectives from MDT members, relevant stakeholders, and consumers, encapsulating quantitative and qualitative data to gain insight into staff culture, community engagement and internal operations. This guides continual service revision in alignment with evidence-based practice (Li et al., 2022).

Consumer and community engagement data is collated upon discharge, with face-to-face reviews conducted in the subsequent three months following discharge. Online questionnaires at six- and twelve-months post discharge are also conducted. During reviews, allied health team leaders use specific criteria to assess progression since discharging. In these meetings, modifications can be made to individual home programs with input from the MDT for continual adaptations following discharge. This is supported by the anonymous online questionnaires to assess overall satisfaction and integration back into the home environment. In 2020, questionnaire data revealed that 78% of consumers felt ‘extremely satisfied’ with their rehabilitation, with a further 87% of this group indicating that their function twelve months following discharge was beyond baseline (Personal Communication). The data also indicates that consumers from rural locations who were unavailable to partake in review consultations following discharge were less satisfied with their overall outcome due to lack of progression once assimilated into their home environment (Personal Communication).

Impacts

Whilst MNCRC’s foundational strengths fundamentally guide geriatric Australian’s to improved health outcomes through individualised rehabilitation delivery, there are inherent weaknesses within system components which impair the long-term benefits. Exposure to an intense, MDT-focused rehabilitation program centred around goal-achievement, directly correlates with improvements in health literacy and empowerment. This reduces readmission rates, relieving the ever-present burden on the public healthcare system.

Opposingly, consumers who are denied access due to capacity and workforce constraints achieve sub-optimal outcomes, due to increased lengths of stay in hospital or less specialised rehabilitation services delivered at generalised facilities. This impairs consumer satisfaction and foreshadows longer-term issues such as increased prevalence of chronicity and readmission, ultimately reducing the likelihood of discharging home (Canfell et al., 2021). Furthermore, rural consumers, who account for 40% of total admissions are disadvantaged without Telehealth services available to partake in review consultations following discharge (Personal Communication). This creates inequities in care accessibility, foreshadowing sub-optimal outcomes and satisfaction. Program modifications are not completed for consumers who cannot attend review consultations, which increases the likelihood of poor adherence, incorrect technique and underloading, leading to comparatively poorer outcomes compared to regional consumers.

References

Australian Commission on Safety and Quality in Health Care. (2019). Infection Control and Prevention. https://www.safetyandquality.gov.au/our-work/infection-prevention-and-control

Canfell, D., Burton-Jones, A., Littlewood, R., & Sullivan, C. (2021). Digital health and precision prevention: shifting to consumer-centred health. Australian Health Review, 46(3), 279–283. https://doi.org/10.1071/AH21063

De Savigny, D., Adam, T., & Blanchet, K. (2017). EBOOK: Applied Systems Thinking for Health Systems Research: A Methodological Handbook. McGraw-Hill Education (UK).

Foo, C., Downie, S., & Maloney, S. (2021). Funding clinical education in allied health. Australian Health Review, 45(4), 523–524. https://doi.org/10.1071/AH20363

Kenny, P., Hall, J., & Reeve, R. (2016). New Graduate nurse satisfaction. Nurse Education Today, 36, 230-235. https://doi.org/10.1016/j.nedt.2015.10.023

Li, M., Davis, M., Kim, N., & Sussman, S. (2022). Leading Change in Healthcare. Journal of Healthcare, 67(1), 13–24. https://doi.org/10.1097/JHM-D-20-00299

Peters, M., Butler, A., & Marnie, C. (2021). Delivering safe staffing in aged care. International Journal of Nursing Studies, 119, 103943-103943. https://doi.org/10.1016/j.ijnurstu.2021.103943

Strömgren, M., Eriksson, A., Bergman, D., & Dellve, L. (2016). Capital among healthcare professionals. Journal of Nursing Studies, 53(January), 116–125. https://doi.org/10.1016/j.ijnurstu.2015.07.012

World Health Organisation (WHO). (2021). Decade of healthy ageing: Baseline report. Summary. World Health Organisation. https://apps.who.int/iris/rest/bitstreams/1348996/retrieve

Appendix:

Components of MNCRC health system.

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