Healthy Healthcare: A systems perspective to integrate healthcare organisations, worker wellbeing, and patient care

Introduction

Providing economically sustainable and high-quality healthcare services through the maintenance of a healthy and resilient workforce is a key priority for countries everywhere^[1],[2],[3]. This is challenging as the COVID-19 pandemic has revealed new, and laid bare existing, vulnerabilities of healthcare systems^[4] making it even more evident that workforce shortage will be the biggest challenge facing the healthcare system in Europe and globally. This is alongside the need to stabilize or decrease healthcare financing, and for more economically sustainable and resource efficient high quality of care.

Despite contextual differences between different types of healthcare organisations, the causes of challenges in healthcare systems are fairly well understood as the combination of factors including lower employment rates^[1],[5], the steady increase in patient influx, and the complexity of healthcare demands that goes beyond traditional medical problems^[2],[6].

As the challenges of healthcare are contextual, complex, and interconnected between workforce health, provision of safe and high-quality healthcare - so is approaches to create sustainable solutions.

​​​​​​​Healthy Healthcare

Healthy Healthcare (HHC) is a systemic perspective and approach to generate knowledge, develop strategies, policies and evidence-based decisions for a balanced management of a healthy and resilient healthcare organisation^[7].

The central tenet of HHC is the integrative focus on the complex and interdependent relationship between the three main pillars in healthcare:

1. Worker health and wellbeing referring to a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity^[8]  that exists on a continuum encompassing negative and positive constructs^[9],[10].
2. Organisational practice includes objective (e.g., work scheduling, HR and safety routines, workplace design, communication channels, staffing) and subjective working conditions (e.g., psychological safety, workload, organizational support) at the individual, group, leader, organisation, and overarching context levels (the IGLOO model)^[11],[12].
3. Quality of care, refers to “the degree to which healthcare service provided to individuals and patient populations improved desired health outcomes and are consistent with current professional knowledge”^[13]. This is a complex multi-layered pillar founded more in practices than theoretical content targeting factors of Quality of Care that can be broad or narrow depending on the perspective of the stakeholder (e.g., the patient, healthcare professionals or leaders)^[7],[14].

HHC aims to generate evidence-based practices and sustainable solutions for healthcare organisations that simultaneously ensures workforce resilience and wellbeing, high quality of care/patient health and (cost-control in) organisation of services. Emphasizing that any intervention, development or change in healthcare should not just benefit patients, or workers, or healthcare organisation. If benefits for all three can be demonstrated, solutions and practices are more likely to be successful in both the short and long-term. Regardless of whether the pre-specified decision, solution or change rationale is clinical trial, patient reactions, implementing new tools or solutions for organisation of services, or target working conditions that affect physical or mental health among workers.

Applying the HHC perspective in policies, practices or processes will contribute to create an organisation in balance founded in evidence-based knowledge of cost containment, worker wellbeing, and quality of care regardless of the specific aim of any change or intervention. This will enable policy makers and employers to evaluate and continuously monitor the balanced effects of their practices on healthcare services. 

The barriers of Healthy Healthcare research and practice to date

Worker well-being, quality of care and organisation of services does not exist in voids. They are affected by the complexity and interplay of factors between and within each Healthy Healthcare pillar^[7] and at all levels of the organisation^[11],[12]. Accordingly, systems perspective in healthcare is not new^[15],[16] and empirical evidence of this has since been growing on the links between working environments to the quality of care provided^{[17],[18],[19],[20],[21]}. Despite this, there is still little attempt to systematically apply a systems perspective in research and interventions that includes all thee pillars of HHC. This can be due to the lack of consideration that:

• Most healthcare interventions and research targeting employee wellbeing and psychosocial working conditions are conducted in isolation and fail to have any impact at all because the projects were not aligned with the needs or expectations of stakeholders, quality of care and cost-containment in healthcare. By typically focusing on the (psychosocial) work-related predictors and outcomes of healthcare workers they do not reach its full potential or be perceived as relevant for other disciplines and stakeholders, or its impact for healthcare system among stakeholders^[22].
• The development and changes in healthcare are most often anchored in decisions and solutions as a rationale for change to improve organisation of services or quality of services or patient reactions and not staff wellbeing. This includes new treatments, procedures, journal systems, health technology, reorganisation of units and clinics or infrastructure. While many improvements lead to more effective and efficient forms of care, treatment, and development of policies, they can result in additional and increasing costs, and may sometimes work to the detriment of staff wellbeing, patient care, and the organisation of services and policy development because the human factor is not sufficiently accounted for. When introducing a new device, or conducting a clinical study, practitioners or technologists often focus on the benefits of that specific solution in terms of one or two main outcome/pillars. Organisation design, medical errors, the spread of contagious diseases from healthcare workers to patients, or a failure to administer digital platforms can strongly affect healthcare by negative economic consequences or a deterioration in service provision^{[17][23],[24],[25]}. Many of these issues derive from known human reactions to systemic influencers within organisations.
• Healthcare organisations are fine knitted organisations where small or large adjustments into practices in one area can be beneficial for the whole system. Accordingly, they can have unintended and potentially severe negative impacts on the organisation, quality of care or workers beyond the main outcome.
• Neglecting a multilevel and more inclusive perspective that recognises the entire system and mutual dependency of factors at the individual, group, leader, organisation, and overarching context that influences the working environment, worker health, and patient care^[26],[27]. Reviews have demonstrated that larger and more sustained impacts is typically seen when interventions target the wider working environment instead of focusing on the individual healthcare worker where interventions can have beneficial outcomes on their health and wellbeing^[12],[28].
• Trying to cover these far too complex challenges by one discipline alone. Scholars in the social sciences and humanities such as medicine, health, policy, economics, and technology often undertake research independently without coordinating or integrating their findings. These risks fragmented and even obsolete knowledge that inhibits organisations and healthcare workers' readiness for change. This in turn often lead to problems when attempting to incorporate vital research findings into healthcare practice. As stakeholders and scholars do not have suitable tools to conduct research or to monitor performance. Interdisciplinarity and cooperation between research fields and disciplines is imperative to ensure integrated knowledge on the relationship between worker wellbeing, organisation of services, and quality of care^[7].

The principles of the Healthy Healthcare perspective for development of evidence-based practice

Healthcare employees quickly realise that the organisation they joined is not the same as the one they presently work in. Healthcare organisations are often characterised by 24/7 services and in constant development due to sudden changes that tests our healthcare system, where COVID-19 has been the latest and, in many ways, the biggest one yet^{[2],[4],[29],[30]}. In addition to continuous changes by ongoing developments in standards for healthcare practices, medical research and technology, professional training and credentials, healthcare financing, the administration of healthcare, treatment procedures, knowledge production, ethics and more. Patient treatments, clinical and health services research, and education activities to patients, employees, students, caregivers, and citizens are delivered by coordinated actions to ensure patient health by all concerned. This is accomplished by a shared responsibility among healthcare professionals, informal careers, healthcare organisations, governments, individuals, communities, voluntary organisations, caregivers, and the patient/person themselves.

This changing environment creates an enormous potential to include a HHC framework into existing and planned processes, projects, and interventions to ensure balanced management of healthcare organisations. It does not matter whether changes are initiated from identified potentials or challenges within one or more of the HHC pillars. The framework for individual HHC interventions acknowledges that workers at the spear end of healthcare and stakeholders often identify great potentials and risks from everyday work that can be developed into new innovations and solutions. The main change rationale in healthcare derives from revealed challenges, identified potentials, innovations in clinical treatments/trials and new tools and solutions to improve organisational services. Including the human factor by identifying workplace risks and resources that affects workers in these projects and processes is the most potent for creating HHC and monitoring their impact on wellbeing and resilience among the workforces.

Converting HHC’s theoretical perspective into HHC methodology in individual projects ensures the consideration of all three pillars in participatory interventions that fit the individual contexts and build on the complex organisation of services, opportunities, and constraints in hospital care. Participatory design in the HHC project aligns with the EU Framework and recommendations^[31] emphasise the use of employee, employer, and other relevant stakeholders in interventions^[32].

It is important that consideration for Healthy Healthcare practices or interventions acknowledge:

• That testing and evaluating solutions must be concordant with the most often heavily pressured and complex environments with shift work. The organisation’s ability to allocate resources in terms of time and personnel to engage in, carry out, evaluate, and implement in evidence-based interventions can be limited.
• To make evident the often-invisible antecedents in the organisational culture that affect workforce health and resilience, organisational practices, and perception of quality of care. Healthcare is characterised by a diverse workforce with different backgrounds and professional roles that work together in teams within a unit, or at different levels in the organisation that are co-dependent on each other. Organisational cultures between units, departments, clinics, and healthcare organisation can vary to a great extent and do not necessarily align with formal programs and procedures. The culture influences the perception of good practice and values, norms and unwritten rules that are reflected in daily work activity, behaviour, perspectives, attitudes, and work environment, that in turn affects all three HHC pillars.
• That one size does not fit all: Contexts and factors at the Individual, Group, Leader, Organisation or Overarching societal level^[12] are associated with varied contextual demands and resources that affect the pillars of HHC. The HHC are based on systematic and efficient identification of local needs intervened with factors at each IGLOO level to build on existing or new systematic knowledge on best practices. This leads to different intervention needs and recognition that interventions does not go according to plan. Ensuring documentation of amendments and adjustments along the way to learn and create systematic knowledge of crucial details often neglected in scientific publishing and decisions to implement a solution.
• To ensure successful long term and ensure a healthy balanced organisation by emphasising systematic evaluation of evidence based HHC interventions using all three HHC pillars for continuous organisational learning and decision to adjust, implement or at worst terminate an intervention.
• The importance of identifying the specific measures that, if improved, will move the organisation closer to capitalising on the payoff opportunity ensuring balanced management of cost-containment, high quality of care and worker wellbeing^[18] into the HHC project. Improving these metrics or indicators is critical for any healthcare organisation. These indicators are typically present and identifiable in the healthcare system, but at varying levels in the organisation^[33],[34]. They can be i) Strategic and linked to the corporate level, such as financial and patient-oriented care, ii) Operational related to the clinic or hospital level, such as organisational outputs, quality of care, job, and patient satisfaction or iii) Tactical measures targeting a scope and are used at the operational or department level of a healthcare organisation, such as productivity, efficiency, cost control, quality of care, time, attitudes, and individual and team performance. Applying economic data in economic analyses to evaluate cost-effectiveness in individual project targeting a specific factor and outcome will most likely create success in evaluating the proposed solutions and improved decision on whether it is beneficial, must be adjusted or terminated.

Examples of Healthy Healthcare projects and practices

Although interventions in healthcare that target two out of the three pillars exist, there have been limited interventions targeting all HHC three pillars. There have been some efforts of existing unpublished HHC practices, interventions and case studies published in the academic and grey literature by experienced practitioners and scholars to improve working environment of healthcare workers that have been associated with changes in wellbeing and resilience of healthcare workers, as well as quality of care and experience of patients such as:

1. Information Exchange during Surgical Procedures: Effects of the StOP? protocol on the Surgical Team and on Patient Outcomes. University Hospital Bern/University of Bern/University of Neuchâtel, Switzerland^{[35], [36]} Good teamwork in operating rooms is the key component of high surgical performance, team performance, and quality of care by reducing complications, preventing errors and mishaps. Improving the organisation of work by task related communication as predictor of patient outcomes and positive effect on work satisfaction among the surgical team in terms of team situation awareness, ease of speaking up and collaboration quality.

2. Cultural sensitivity to reduce aggression towards Emergency Medical Service (EMS) staff. Ben-Gurion University of the Negev, Israel^[37]
   The EMS context is difficult to manage because the work is urgent, involves high risk, and entails a high cost for failure. The project targeted when and why people are likely to respond with aggression in an EMS context. The project showed that values of collectivism determine what types of situations are perceived as unjust by whom and how perceptions of injustice fuel aggression among patients and their caregivers. When health care staff are educated and provide patients and their caregivers with culturally sensitive explanations of organisational procedures enhances perceived procedural justice and reduces aggression. Demonstrating a resource efficient solution to change organisation of services, increase in patient satisfaction and wellbeing and resilience among EMS staff.

3. Evidence-based hospital design^[38]. Dublin Methodist Hospital in Ohio, US was created to culturally and architecturally fitted into the local staff and patient community. The design and build followed the eight steps of the evidence-base design process, resulting in a design and construction of a new hospital that impact on all three Healthy Healthcare pillars. For organizational practices the close participatory process between the design team and the users developed a common model to ensure that planning aligned with the intended culture of the organization with the design and set-up for the hospital impacting on the subsequent recruitment of staff to work on the new site. For patient and staff wellbeing, rest facilities and staff areas were created and the incorporation of garden spaces and natural light to benefit staff and patients. Central nurse stations were removed to allow for better interaction across different professional staff groups, improve patient visibility, and increase staff-patient contact time.

4. Annualized hours in emergency medicine.
   The rota and shift allocation in the emergency department within the Brighton and Sussex University Hospital in UK^[26] contributed to poor work experience of staff. The consultant group decided to move towards an annualised system, with opportunity to self-rota of shifts a year in advance. This gave doctors more control over their working hours, improved work-life balance, and work satisfaction. It allowed the identification of staffing gaps was filled with new staff, reducing the need for agency staff, longer work hours or to give up other academic and professional duties to cover shifts. Changes in work practices of shift and allocation of work involving human resources and payroll functions led to more openings for part-time and flexible work that improved staff retention. After five years, the emergency department went from 7 to 23.8 full time equivalent consultants and from 7 to 20. Spending on agency staff reduced from £1.3 million to only using agency staff to cover for sickness. The savings was used to recruit for all available staff posts. The benefit of quality of care included a 68% reduction in emergencies on the wards due to better staffing at the weekend.

The Healthy Healthcare community

With the ever-increasing number of health care interventions and treatments being developed, it can be challenging for healthcare professionals, patients, researchers, and policymakers to keep up with the latest evidence-based information on their efficacy and cost-effectiveness.

To ensure transferring knowledge and the long-term and continued uptake and implementation of HHC among healthcare organisations and stakeholders in Europe and globally the project is grounded in the Healthy Healthcare community of universities, scientific disciplines (e.g., social sciences, nursing, medicine, psychology, technology), industry, health organisations, worker unions, policy makers, leaders, national and European agencies, and stakeholders building a pool of evidence-based knowledge from existing HHC practices and new interventions derived from different rationale of change at individual clinics or organisations.

This contributes to bridge gaps sharing and creating knowledge on synergies, practices, and collaboration between hospitals in the project and through channels of outreach to the European community^[30]. Evidence based knowledge from HHC practices in local, regional, or national health care organisations are transferred to HHC policies, practices, and processes in healthcare. Promoting societal and economic transformation to healthcare that ensures resource efficient healthcare services of high quality performed by a healthy, competent, efficient, and resilient workforce.