21 October 2021

Why we still build hospitals “like it’s 1999”

Hospital Technology

In three recent new builds of related hospitals in Victoria, there quickly emerged a problem with patients calling code blue alerts with alarming frequency.

In each false alarm it turned out the patients had thought they were switching on their bathroom light but they were in fact hitting the “staff use only” button designed to request emergency assistance.

Every bathroom in each of the hospitals had to be subsequently retrofitted with a specially designed Perspex panel over the alarm bell. Nursing leadership overseeing each hospital remain puzzled as to why the bell had been located in a position where you’d normally put a light switch for the bathroom.

“It’s not like it made any sense to put that bell switch there in the first place,” one nurse leader told Wild Health.

Another nurse leader we talked to said she’d seen the same problem in a new hospital build, but that was in 1996.

How did such a basic operational user interface error happen in three hospitals in such a major new build?

Meanwhile, in a hospital nearby, the midwives in the birthing unit were also having problems with their emergency alerts, not long after a new build.

Whenever the staff assist button was pressed in the birthing suite, the midwife in charge of the area received an alert to their phone – so far so good.  But the alert wouldn’t switch off and was blocking the ability of the team leader to use their phone to escalate the care and call the emergency response team if needed.

The problem had been occurring for some weeks but whenever it had been escalated to the health service’s ICT team, and investigated, the ICT team came to the conclusion that the problem was user error.

In order to get to the bottom of things, the Chief Nursing and Midwifery Information Officer (CNMIO) of the health service visited Birth Suite to replicate the problem with the team leader’s phone, videoing the sequence of events from acknowledging the emergency response alert on the device and the subsequent problem the staff member had when trying to use the call functionality as the alert notification continued. The CNMIO then took the video to the ICT team, which soon worked out it wasn’t user error after all.

It’s a common experience that can lead to a breakdown in communication and frustration for clinical staff who have reasonable expectations that technology tools and devices will not add to their workloads. Faced with the demands of clinical work, clinicians must prioritise patient care and are concerned that safety in the unit could be compromised because of impaired systems of clinical communication when the level of care escalates. ICT teams are often given initial or conflicting information about device issues, delaying their investigations and the opportunity to resolve health IT issues in a timely way.

Luckily, the hospital in this story had an overseeing CNMIO who could insert themselves in the middle of the problem and act as a form of translator between the clinical operational staff and the ICT and engineering staff in order to improve the processes in place in a way that supports collaboration before a critical event occurs.

This CNMIO is one of only 25 CNMIOs in Australia. Australia has nearly 700 public hospitals and almost the same number of private hospitals if you count the day-surgery facilities.

Is 25 CNMIOs enough for nearly 1,400 hospitals, given how rapidly digital technology is affecting everyday life in a hospital ward?

According to this CNMIO, who said she gets on well with the ICT team, and engineering and facilities management, it’s a typical situation of healthcare system complexity affecting  communication between departments where staff often work in silos, in different divisions but need to work in new ways to respect each other’s roles, and expertise to solve the challenges of contemporary healthcare effectively.

“It takes an extra level of energy to jump up and down, stay persistent and not always take no for an answer” when transforming ways of working,” the CNMIO said.

“If you think about nurses, their central status to all aspects of healthcare delivery and their experience of working with people, they deal with emotions every day, and they bring their authentic selves to their day-to-day problem solving.

“When things go wrong, the peripheral person in ICT or facilities management who is charged with investigating and resolving the issue may not understand the clinical context or the clinical impact. [And] the clinician doesn’t know the complexity of the technical issues faced, either network, software or hardware related.

“This is why the role of digital health nursing leaders such as CNMIOs is so important”.

Nurse call systems are just one aspect of a complex array of digital systems that have to be considered in a new hospital build. But they make for a very good example of how most Australian hospitals are designing more for cost than return on deeper digital integration in their design.

In the US, Europe and increasingly now in Asia, nurse call systems have evolved into  sophisticated and intelligent cloud-based communication platforms for many hospitals, encompassing far more than relatively simple point-to-point communications between the wards and nurse stations. The systems are also intelligent hospital-wide networks that monitor the whereabouts of particular personnel and resources that are relevant to multiple situations, which collect, analyse and report data to help optimise operations, and which often include AI to optimise communications and resource allocation.

Such systems are capable of delivering messaging to a nurse and clinicians individual handsets, co-ordinate messaging for a whole clinical team, talk seamlessly between a clinician, pharmacy and the hospital lab, monitor exactly where team members are for optimal response, collect and analyse team data for analysis of protocols, and so on.

But such systems aren’t cheap, and often do not achieve their full potential especially when they are put into a traditional design-and-build logistics chain for a new Australian hospital. The step that is missing is clinical workflow analysis, testing and implementation.

So, while increasingly you’ll see such systems throughout the US, Europe and Asia – Singapore’s latest new hospital build incorporated such a hospital-wide call platform in its build along with a lot of other well-integrated digital systems – you won’t see any of this sort of sophistication yet in Australia.

When a traditional nurse call system needs to be replaced in Australia, what you usually see is a tender to simply upgrade an old system to a new system with the same specification for functionality. In other words, the people overseeing the replacement of an ageing nurse call system, are not aware of a more functional integrated communications platform as they aren’t tasked with that.

Why do we still design, build and upgrade Australian hospitals with such backward-leaning thinking?

According to Bruce Pedersen, principal of one of Australia’s leading specialist healthcare and digital health consultancies, Australia is suffering from quite normal issues of legacy institutional momentum that exists when there is so much expense, regulation, complexity and time involved in design and build.

Pedersen says that there is a lot of good input these days from clinical advisory groups in a typical new build, and that can include input from a CNMIO. But typically, the digital component of a build is still treated as an item of cost, such as lighting or plumbing, not something that is dynamic and which is likely to save costs if implemented the right way. 

He points out that things are changing for the better but that there is still a significant disconnect between the needs and wants of the clinical team, who see the potential of new digital technology, and the need to meet certain budget constraints.

“There is no point in putting together a strategy which you can’t afford, but at the same time you can’t just have the builders and infrastructure people make the final determinations because that is an old process that isn’t taking into account the potential of digital to return to the system,” Pedersen told Wild Health.

It is apparent that the problem is higher than the level of the specifying clinical team, and the people doing design, build and construction.

One issue that may have held Australia back is that in most of the major states, governments set up e-health units with a view to getting escalated momentum and agility in the delivery of important digital programs such as the introduction of EMRs, improved interoperability between hospitals and single health records for each state.

While this has worked well in most states in achieving singular digital program objectives, it has also led to e-health divisions of state governments becoming more isolated from the divisions mainly responsible for the design and construction of hospitals.

In some ways, the legacy thinking of state policy-makers persists in the separation of departments into e-health and Infrastructure. That e-health isn’t considered part of “infrastructure” in some states possibly says most of what this problem is about: digital is still considered separately and within a fixed cost framework, not as something dynamic that can transform a patient and clinician experience, and deliver exponential improvements in access, safety and experience.

The NSW government has committed almost $11 billion over the next four years to build new health infrastructure. Yet, Health Infrastructure NSW, which oversees digital budgets and implementation, describes itself as a capital works group mainly.

Pedersen points out that things are changing, and specialised digital health consultants are now often engaged. However, there can still be some conflict with the traditional view of spending, which is classified as an information and communications technology (ICT) spend and which invariably ends up in a new hospital build at around 3 per cent of the total build.

Whereas once fixing the cost of IT at 3 per cent for all builds may have made sense, given the dynamics of cloud-based communications platforms for hospitals, and the interoperability potential of such systems, fixing the cost at an amount thought universally to cover “computing” doesn’t make sense these days.

“Historically, the group considering ICT in a build will be told they have 3 per cent of the total and that’s it,” says Pedersen.

“This is the wrong way to be looking at digital.

“Yes, if you want you can spend an entire hospital budget on digital, and that’s problematic for sure, but these days you need to consider digital in a much broader framework of delivering efficiency and safety, before you mark it down for a fixed and traditional percentage of a total build.”

The other issue in play of course is a cascade of vested interests, even when you do have a good process of clinical advisory groups leading the start of the process.

It’s the Tasmanian Hydro Electric Commission (HEC) paradigm. By the time of the controversial Gordon Dam project in the 1970s, the HEC was mostly a dam building organisation, not an electricity utility. Asking its senior managers to question whether continuing to build dams was the right strategy for Tasmania moving forward was only ever going to result in one answer.

In the case of hospital builds, there are layers of vested interests that the policy people need to work out how to engage.

What clinical group is going to recommend that, all things considered, they probably could have a smaller hospital overall, with fewer beds, if they implemented an effective hospital in the home strategy?

What engineering, design or building firm is going to put digital capability into the same context and start designing smaller, more agile hospitals that are highly interoperable with the primary care and allied health networks in their region?

What state government is going to even do this, given that they aren’t responsible for delivering primary care and if you really implement hospital in the home, you are going to need to engage primary care?

Although everyone understands now that digital technology could enable a connected network from hospital through to primary and allied care, which would revolutionise the potential of virtual care to manage more people more effectively in the community and within the aged care ecosystem, and ultimately save billions in wasted tertiary care infrastructure, it is also a political reality that states run hospitals and the federal government runs primary care. And that creates artificial, usually political barriers to increasing efficiency across the whole system.

The potential for such efficiency is already evident in cases where healthcare systems are in one management line and more vertically integrated. It can be seen in some of the Scandinavian countries, particularly Denmark, and somewhat ironically in some of the better-run HMOs in the US, where, seeking only efficiency in patient care as a goal, some HMOs are of course reducing the number of hospitals in their networks with much better preventive infrastructure in their system.

In both cases, there is a trend to decreasing hospital beds, and in some cases, actually closing down some hospitals as management of patients in the community becomes significantly more a part of the system.

Clearly in Australia hospital builders and designers aren’t ever going to be recommending a look at this sort of system integration, but increasingly the policy people in both federal and state governments are facing off to the obvious advantages of such set-ups.

As for those nurse and midwife leaders in those new Victorian hospitals that put a nurse call button in the bathroom where the light switch should have been, there are some simple things that can be done now which will help our builds and upgrades. Such as getting more digitally savvy frontline clinical staff into the earliest parts of the specification process.

And training and employing a lot more CNMIOs in Australia to work in the new hospital build groups to bridge the translation gap between systems and workflows.

After that, much of the immediate problem is at the policy level in the state governments.

The traditional engineering and design firms aren’t going to pipe up and say to the state governments they really should be thinking more deeply about digital and allowing a lot more flexibility of budget and thought around the implementation of more expensive platforms, based on the idea that such investment will deliver significant return in efficiency and safety over time.

They aren’t going to point out that “hospital in the home” has huge potential to bring efficiency to the system through keeping a lot more people out of hospital from aged care and the community. And that if you engage in such forward thinking, you’ll need to work out a way to engage much more meaningfully with the primary care community, although you know you aren’t responsible for that community and you don’ t pay them.

It’s now down to the policy people in the health departments of each state government, perhaps with a little urging from the federal Department of Health via how it funds state governments’ health budgets, moving forward.

Wild Health recently hosted a panel discussion about this topic. Register here to watch the recording.