Clinical Management in Hard Times

Clinical management (CM) can be defined as an improvement strategy that systematizes and organizes health care processes adequately and efficiently. It should be supported by the best scientific evidence available and the participation of professionals for patient-related decision-making. In short, it transfers decision-making capacity and responsibility for clinical management to healthcare professionals in order to improve the cost-effectiveness of quality services.

CM has it origin in the concept of clinical government, which was initially introduced in 1998 by the Department of Health of the United Kingdom, where this concept is associated with responsibility, quality, guidelines and standards in clinical practice. In Spain, CM is closely linked with the financial problems of our healthcare system; briefly, it makes physicians responsible for the efficient use of resources used as well as the care that they provide. The creation of CM institutes/areas and units has been taking place in the Spanish Sistema Nacional de Salud (National Healthcare System–SNS) since 1997. In general, these management experiences have been positively assessed by the responsible clinicians,^1–10 who agree that the management autonomy of CM units and institutes is very limited. While improvements in efficiency and quality do exist, they do not reach the potential for improved efficacy and quality that can be found in the healthcare units of the SNS. In the Primary Care setting, the model with the greatest amount of experience is that of associative entities, which are an organizational model that has been relevant in the reforms of the Primary Care system in Catalonia; it also enjoys consensus among medical professionals and has obtained good results in terms of efficiency and quality.^11–14 Other more recent cases have taken place in Asturias (2009), Andalusia (2007), and Galicia, with the upcoming publication of a Decree and pilot program experiences in hospitals in A Coruña, País Vasco, Catalonia, and Castilla-León, with a project underway for the implementation of these units.

In the current context of financial and budget crises, it is our obligation to reach excellent levels of efficiency, efficacy, effectiveness and quality when treating our patients, which can only be achieved with the participation of healthcare professionals. True healthcare management must be centered around the healthcare process itself; it makes no difference if we are able to reduce the costs of varicose vein surgery if we are operating on patients that do not need it. As stated by Muir Gray, we should be doing the right things the right way. Our clinical decisions will be quality decisions if they generate economic efficiency and not mere cost control.

CM units are healthcare units that are managed autonomously. Their configuration and dimensions vary, while similar departments and specialties are grouped together under a single management unit. They are structured according to homogenous healthcare criteria and oriented toward specific type of processes with the aim to efficiently provide excellent clinical services.

The professionals who voluntarily participate in the development of the unit need to have information, knowledge and opinions about the management plan for the unit. This plan should be reasonable, with attainable objectives and clear, stable indicators (waiting lists, delays in outpatient appointments, clinical results, consumption of resources, patient satisfaction, etc.), which should be evaluated every 3 or 6 months in a transparent manner to provide agile, effective solutions for specific problems.

The individuals who make up these units are its greatest asset, and in these groups it is essential to include nursing staff as well as physicians. If 20% of the individuals are highly involved in the unit, then it will surely succeed. The proposal to create CM units should arise from the medical professionals themselves and not be imposed by the Administration. In addition, the leaders of the CM units should be well selected, and it is not necessary for department heads to feel responsible for their management. Leadership is fundamental, and the leaders of this Project should be trained and supported and not left to their own devices when the short-term healthcare and financial objectives are not met.

The Administration should support projects planned by these units, not only in the context of healthcare production and cost savings, but also education, innovation, influence and training in the population. Patient safety and satisfaction should be the guiding principles of the annual management plan to be followed by the CM unit in collaboration with the Administration.

We should not forget that one of the fundamental conditions for creating the unit is professional recognition and economics, with a variable production percentage depending on the results. This has direct repercussions on the individual professionals and also the CM unit in terms of training, material resources, ability to hire staff, etc.

After the creation of the CM units, most of them have been at a standstill. They are currently becoming reactivated, partly due to the economic crisis, because it is believed that they may contribute to sustain the healthcare system. The reasons for creating or reactivating CM units should be centered on improving patient care: reduction of unjustified variability, adequate wait list management, efficient resource management, etc. To do so, the participation and involvement of all professionals are necessary.

Scientific societies should not stand by the wayside in this new initiative. The Asociación Española de Cirujanos (Spanish Association of Surgeons) has participated in training surgeons in management concepts, managerial tools and indicators, as well as the publication of guidelines and training courses for members of our association. It has collaborated with the Administration to define requirements and standards to improve healthcare safety and efficiency, while defining indicators for quality, results in terms of health, and indicators for the evaluation of results in management contracts.

Modern CM should be focused on healthcare processes while combining clinical knowledge, evidence-based medicine, management, quality and new communication technologies. Thus, they cannot be implemented by administrators or clinicians on their own; it is essential to work as a team. It has been sufficiently demonstrated that CM management allows for greater involvement of medical professionals in the intended healthcare results based on scientific evidence.

If this new CM strategy is to be a success, it is the responsibility of all of us: medical professionals, scientific societies, managers and a strongly committed Administration.