Table 1

Realising the strategy

Pathologies of industrial careAlternative: careful and kind care
What might this currently look like?What might the alternatives look like?
Hurry
  • Where the organisation evaluates efficiency as achieving more ‘patient care’ in less time.

  • When brief and rushed encounters and poorly supported conversations lead to lack of meaningful participation by the patient and the clinician.

  • When there is a focus on duration (rather than depth) of time with the patient leading to rigid and unforgiving scheduling and an ethos of ‘time is money’.

  • Where the organisation demands completion of extensive documentation for auditing and accountability, structuring and eventually displacing care itself.

Elegance
  • Creating an ethos of ‘no haste and no waste’.

  • Designing care to better support unhurried conversations—not necessarily through longer visits of time slots as a slower conversation may waste the time of both parties, could introduce opportunity costs and reduces access to care for others—but by enabling interactions through improving the tempo, for example, promoting smarter scheduling such as predictive analytics, AI and self-scheduling

  • Removing interruptions, reducing friction and eliminating distractions at the point of care to make it easier to care well, ensure maximal opportunity for participation and presence during the clinical encounter.

Blur
  • Where care responds to symptoms or an abnormal test results in isolation and with limited regard for the person that has them or their situation.

  • Adhering to guidelines that produce standard practices for ‘patients like this’ rather than respond to ‘this patient’. The focus is on what should be done rather than accounting for preferences, values and goals.

  • Data and decisions driven mainly by episodic, administrative and aggregate data, or based on extreme or rare events (readmission, death). The ‘mundane and common’ (inconveniences, suffering) remain unmeasured and unattended.

High definition
  • Ensuring that each patient is treated with humanity, as our kin, as people. In doing so, specifically seeking to understand both the biology and biography in a patient’s situation.

  • Cocreating plans of care that are both evidence based and responsive to the needs of individual patients and their situations, optimal care of this person. Avoiding over reliance of guidelines that curtail responding to individual circumstances.

  • Responding with care that reflects each patient’s goals and priorities and asking patients and caregivers What matters to you?’

  • Gathering and curating insights and from care reflections and stories that foster learning, compassion and caring relationships gathered in an ongoing way.

  • Encouraging staff and patients to seek to understand ‘Were we careful and kind to each other?’ and holding each other accountable for the answer to ‘Was our care careful and kind today?’

Cruelty
  • The organisation tells people ‘what’ to do through an extensive set of policies, protocols, and rules that fail to consider particular circumstance but instead seek conformity.

  • The organisation accepts attrition and turnover of staff that suffer burnout, as a way of life. Where attempts are made to address this, they tend to be generic interventions to treat ‘all staff’ similarly, promote resilience at the level of individuals and focus on responding to issues rather than tackling the causation.

  • When staff are fearful, discouraged, disempowered or disinterested in responding to a specific care situation that may deviate from general practices or policies leading to ‘it’s not my job, or I’m just doing my job.

Responsiveness
  • Staff are valued for their integrity and given authority and discretion within simple boundaries to respond to the needs of each patient and have a clear understanding of ‘why’ that is explicitly articulated behind each boundary.

  • Identifying, questioning and eliminating policies and practices that get in the way of care, are inhumane or unresponsive to particular situations, or that are cruel to patients and cruel for care givers to enact for example, banning all visitors to accompany patients during the COVID-19 pandemic or restrictive visiting policies pre-pandemic.

  • Reviewing recruitment, selection, induction processes and procedures to ensure staff are valued for their diverse expertise and experience.

  • The organisation takes responsibility for staff well-being, addressing the ways in which it organises work, and focusing on causation and preventing burnout, caring for staff as individuals seeking to understand differing needs, promoting communities of mutual care, enabling staff to care—‘care in care out’.

Burden
  • The organisation pursues efficiency through transferring waste to the patient—testing the ‘patience of patients’, for example, lean batching all patient appointments at 8:00 to make them wait for the doctor.

  • Burdensome administrative tasks and medical errands are transferred onto patients and caregivers: they must repeatedly communicate their concerns, facilitate communication and coordination across clinicians and organisations, negotiate disagreements between clinicians, correct errors in documentation, close administrative loops, and follow-up on tests and consultations themselves.

  • Patients with multiple conditions and their caregivers shoulder the cumulative complexity, harms, and costs of self-care and healthcare use that result from the uncoordinated implementation of all applicable single-disease guidelines—all recommended but lead to uncoordinated visits, tests, activities and treatments.

Minimally disruptive care
  • Taking lean to patients and caregivers. Continually identify and reduce non ‘value-added’ activities which overwork and overwhelm patients and caregivers.

  • Assessing the work of the patient and consider minimising the burden of treatment as a key target for improvement and innovation.

  • Avoiding the use of administrative barriers as a means of managing the demand for services.

  • Simplifying system navigation; and when not possible, navigators made available to assist patients.

  • Care is carefully cocreated by participation of patients and clinicians and is crafted to advance patient goals while minimising the burden of treatment.