PERH (The North Estonia Medical Centre) is one of the top healthcare providers and larger hospitals in Estonia.

The project was set in motion as an international collaboration involving the Estonian Connected Health Cluster, Government Office of Estonia, North Estonia Medical Centre, Estonian Academy of Arts, University of Lapland, Lapland Central Hospital, University of Gothenburg, Academy of Design and Crafts, Sahlgrenska School of Innovation and Entrepreneurship, and Sahlgrenska University Hospital.

Project length
4 months

Collaborators
Maria Del Mar Salazar Soto
Triin Jürgens

Mentors
Ionel Lehari
Ruth-Helene Melioranski

Healthcare in transition

Healthcare systems in Estonia are in transition — currently towards a quantitive systematic approach. As new discoveries and technological advances raise the quality and opportunities in healthcare, more and more people become eligible for treatments where previously medicine was unequipped to provide relief. This has called for raise in efficiency which in turn has distanced the system from a personal approach towards the patients. Holding no negative or positive connotation on its own, it merely calls for a shift in approach — an opportunity to be seized.

The relationships between the different parts of the hospital system are complex. In our process we set to understand the interconnectivity and dependency of all parts. Instead of looking from a viewpoint of a particular actor, we made use of various viewpoints in order to make observations that hold stronger ground. In the context of PERH, a co-designing approach allows for combining multiple perspectives and in that for a richer, more holistic picture of the existing complexities.

päevakirurgia visiit1.jpg — Finding the focus

During the initial information gathering we were introduced to PERH and given a tour of the clinics. In our team of three students, we decided to focus on the day surgery clinic.
PERH Day surgery clinic is fascinating as it operates differently from other clinics of the same hospital. In a way it can be viewed as **a facility for surgeries** — patients come in for surgical procedures that are performed by corresponding surgeons of the hospitals. The main requirement for surgery to be eligible for the clinic is that the patient can leave the hospital on the evening of the surgery.
After a thorough tour of the clinic, we had a good overview to form our general understanding of the clinic and make first assessments on what to focus on in the interview process.

Stakeholder interviews

In order to understand the different experiences and expectations of all actors involved we organised and conducted 17 interviews with patients, surgeons, nurses, the head of surgery, the head nurse, the secretary of the clinic, the head of customer service and others.

Since hospital staff are very busy, we had to be flexible with planning our interviews, having even interviewed a surgeon while he was operating on a patient. Gathering information in such high intensity situations gave us insight we wouldn’t have gained otherwise.

Featured

The hospital classifies people by their illness, patients don't relate

There is no such thing as an average patient, yet people are treated as one. The single categorisation the hospital system uses is by their illness and treatment.

Although the system categorises patients by their diagnosis, no patient defines themselves by their ailment.

Currently, all patients of the same “type” receive the same unified information which doesn’t take into account their differences in age, experience, understanding, and know-how of their diagnosis or the fact whether they are recurring or first-time patients.

The unified treatment of patients does not have the desired effect on delivering the crucial information to the patients that the system expects the patients to know.

Visibility of only the next step

Patient is currently only able to be aware of one episode at a time in their treatment journey. This is supported by the system of the healthcare, where all treatment episodes are viewed as singular events instead of a connected path to treatment.

Approx. 90% of the treatment journeys related to the Day Surgery follow a predicted path, but as the system only makes arrangements for the next episode once current one is finished, bottlenecks in patient treatment plans are highly likely to occur.

Patients rely on the specialist

In order to make the day surgery system more efficient and the waiting list shorter, the Day Surgery approaches the patients as patients of the hospital. Although interview findings suggest that many people don’t have a problem with the fact that they are operated on by a doctor they haven’t met before, it is evident that losing the connection with a specific doctor loses the perception of being under the care of an expert with a holistic view of patient’s treatment. Patients rely on the doctor’s guidance, as they perceive the specialist holding agency and a holistic understanding of the treatment steps that patients themselves don’t have.

The system views the patient’s GP holding the guiding role, but in reality, the GPs are overloaded with work and majority of people either don’t trust their GP-s enough or their relationship with their GP is not a close one.

Efficiency

The Day Surgery strives for efficacy in their work to lower the risk of complications and to shorten the waiting time for surgeries.

The patient’s needs (besides having the surgery done) have become lost in the context of the larger treatment plan. In order to perform more surgeries, the time each doctor can spend informing the patient has been cut to a minimum.

The efficiency of the Day Surgery is met with bottlenecks in planning and waiting lines in other areas of the treatment journey. Striving to remove complications in surgeries, the likelihood of complications is now transferred to the time gaps between events of the journey. Disconcertingly, those are also the points where the patient feels the least informed in their journey.

Undefined waiting results in patients distancing themselves from treatment

Waiting, as a recurring act in the patient’s treatment plan, becomes a stressful, compulsory stage. As the patients lack holistic understanding of the whole treatment journey waiting for them loses all context of meaning and time. Being placed on the waiting list for a surgery, the patients wait for a call, often for months, to be given a set date for the surgery.

Nurses are the actors who try to bring the personal approach and meaning into the waiting stages during the day of the surgery in the Day Surgery, but they are only dealing with the consequences.

Time gaps can lead to consequential complications

Due to the fact that the waiting line for the surgery and other steps in the journey can be long, patients often forget vital information regarding their surgery and treatment. The waiting time also increases stress as it lacks context for the patients. As many stages of the treatment journey are interdependent, time gaps between these can lead to complications in patient’s health and require repeating expensive procedures (e.g. repeating MRI scans) as in time the condition of the patient can change.

It also causes problems for the Day Surgery as the people either come to the surgery not prepared enough or cancel their surgery time because they have made other plans in between.

Patients have no way of contacting the system

All communication lines with the Day Surgery end after the patient leaves the clinic. Patients don’t generally know who to contact when questions or complications arise. Some patients realise they missed crucial information they received verbally while recovering from anaesthesia. The issue of not having a point of contact in their treatment is expressed in various stages of the patients’ treatment journey.

If serious complications emerge after discharge, the patients have to turn to the ER or restart the journey through their GP, but the statistics of patients who have returned is not collected and not available to the Day Surgery Centre.

Patients are not prepared

In order for the surgery day to be successful, stress-free and the recovery later to go well, a lot depends on how prepared the patient is.

If some of the information the system expects the patient to hold in order to prepare for treatment events has gotten lost in the system or hasn’t been conveyed to the patients, it causes stress for the patients, more work for the actors involved, and can lead to complications in the procedures.

Problems arise with patients who do not comprehend the full effect of their surgery can have on them and the fact that they require someone to accompany them to get home and help them during the recovery process.

Repeating unnecessary procedures

Certain duplicated procedures occur during the patient surgery: e.g. asking the same information during the anaesthesiologist’s appointment and on the surgery day.

On some occasions, when the interval between the specialist appointment and necessary scans exceeds certain amount, the scan needs to be repeated to ensure successful surgery as in time the condition may change.

There are also relics of the system which are not necessary. Changing the regulations is time consuming as it requires permission from the hospital system.

Mapping out the complexity

When the system is as complex as the one in PERH the necessity for maps presents itself. The level of complexity becomes so high that without one, information and connections can start slipping. Mapping all the interviews in a complex mindmap allowed me to compare the viewpoints of different actors and perceive that to all actors the system is very different. There is no single problem patient or a single problem for that matter, there is no well-behaving patient, it is rather a matter of perception and a matter of communication. Comparing side-by-side what actors were saying opened the system in its full complexity. Mapping the journeys allowed to always understand what moments different actors were talking about and to see all the actors in motion in these moments. Mapping out the stakeholders and their levels of influence gave more understanding to their actions.

The maps allowed me to see the holistic picture of how the findings form and how they connect, how parts of the system form a whole. This is especially important as we are dealing with a unit in the system that currently is facing difficulties fitting into the larger ecosystem. The relations between the encompassing unit and the smaller unit contained within form the basis of any future development and design implementation dealing with a more holistic approach.

Findings as the foundation of the design phase

The key insight from our research shows that patients’ treatment plans currently are managed fragmentarily, leading to every event (e.g. GP appointment, specialist appointment, waiting list, surgery, recovery, possible lifestyle alterations) being perceived separately also by the patient. When treatment events are planned separately by the system (usually after the previous episode has ended), it leaves unnecessary gaps in time in between and in consequence it becomes ambiguous where the patient’s responsibilities at each stage lie. As a result, the journey becomes abstract for the patient and thus can have serious setbacks in treatment.

There is an opportunity to support a more holistic approach towards the whole treatment plan of a patient and in that allow for the patient to be more informed, empowered, prepared, and responsible in their own healthcare. This would allow for the patients to be better equipped to be involved in making the decisions about their treatment options and becoming more engaged in the treatment plan resulting in reduced complications and in improved health.

An intense week of
co-design

In the ideation phase we worked closely together with experts from various related fields. During a week-long intense phase on the hospital premises our team met with actors from the Day Surgery department on various occasions, along with hospital management, the IT department, physiotherapists, ministry experts and service designers with previous experience in similar projects.
Within that week we developed our main concept idea and got direct feedback to it from the hospital actors and experts in order to take the next steps to develop the idea further and finalise our design concept.

Introducing Amicus

Every industry has a human element, but human connection is the heart of medicine.

Trust towards doctors and nurses is often the primary driver of patient behaviour. Patients are more likely to open up and share information, but also follow treatment plans, if they trust their healthcare specialist. Better quality of interaction results in greater patient autonomy and shared decision-making.

Amicus brings forward the nurse as the main point of contact

Nurses are highly educated and equipped medical personnel who, with the help of Amicus, are able to follow the patients’ whole treatment journeys and answer any questions the patients may have about it. This is not a big leap at all from what they are already managing today.

Having a friendly voice and face supporting the patients during their journey adds trust for the patients. Amicus allows patients to be under the care of a dedicated nurse during their treatment journey who would also be the one to call the patient to inform them about their surgery time, welcome them on the day of the surgery and make a call appointment a day or two after the surgery to check on the patient and answer any remaining questions.

Amicus gathers and manages all schedules and resources

This means that surgery lists, appointments, and staff schedules don’t have to be put together manually – this kind of work is time-consuming and prone to human error. Automation of these processes results in higher reliability, availability, and reduced costs.

More importantly, it frees up human resources which means there is more time for person-to-person interaction with patients for the assigned nurses.

With Amicus hospital staff can check their schedules and surgeries and patients can access their treatment journeys. Nurses are able to look at their daily schedules including their assigned patients as well as call appointments and start filling out the documentation for the surgery patients.

In a way, Amicus acts as a bridge between the hospital and patients, allowing them to communicate with one another more freely, reducing the unnecessary and allowing to focus on what really needs to be communicated.

Being able to make choices about one’s health is the key towards more engaged individuals and a more health-conscious society.

Amicus enables patients to actively participate in decision-making. Whenever possible, giving them an opportunity to decide over treatment options or simply give them time and have a moment to think it over before acknowledging an upcoming surgery. Even having a say about a surgery date is a step towards more active involvement.

An important feature of Amicus is a clear understanding and visibility of the treatment journey.

Patients can access information about their treatment throughout their treatment journey and zoom into each step. The system reminds patients about upcoming events through notifications and helps to keep track of each stage of the treatment journey.

Technical advancements can and should foster progress but technology alone means little without the human connection between patients, doctors and nurses. But when designed well, what technology can do is enable a stronger bond through increased personalised communication and understanding, and help to create a more patient-centred experience.

Amicus strengthens human connection and trust in healthcare by combining personal interaction with system automation.

Amicus supports a holistic treatment journey and hospital schedule management powered by an intelligent algorithm. With Amicus patients have an assigned nurse as a single contact person, can follow and access information on the go and be actively involved in every step of their treatment journey.

Amicus provides doctors, nurses, and administrators with valuable data but also allows patients to feel cared for, even at a distance, so that patients become involved in their own health.

After the project concluded…

Amicus was developed as a design concept and handed over to the Day Surgery department of PERH. Although the project itself concluded and the budget to fully develop the concept has not been allocated, the hospital has taken steps to implement ideas Amicus brought to attention. Currently, the Day Surgery department and the IT department are working on solutions how to notify patients more conveniently about upcoming appointments. A physiotherapist has been brought in to consult the patients about their recovery at home and the necessary precautions in their treatment before surgery time.

It was a successful collaboration project and in many ways we owe it to the incredibly supportive, cooperative, and accommodative staff of the Day Surgery of the North Estonia Medical Centre.