The KIWI hospital – by Henrique Martins
Hospitals are, for most human beings, the more visible, historical and futuristic, dramatic and hopeful, side of healthcare. From large, multi-building facilities with academic as well as advanced research components, to small district or local homecare for proximity healthcare. Home, hotel and hospital, all share a common root: to bring close to heart something restful, peaceful, reenergizing, restoring and healthy. Yet, most hospitals today face criticisms for being too complex to navigate, too risky for elderly and frail people due to nosocomial infections and still intolerably high rates of medical error, too inhuman, cool and frightening, too technical and too difficult to reach due to limitations to access through a maze of walls both financial and walls created by the complexity of existing patient referencing networks from community doctors/practices.
Many good examples of large and small institutions around the world are making significant steps to eliminate these causes of criticism. There are many examples, ranging from Patch Adams’ type of work to the rigorous “Clinical Governance” initiatives in the UK; from highly digital Kaiser Permanente examples or AI (Artificial Intelligence) projects for future hospitals funded by the European Commission, to the Toyota Production System inspired Ng Teng Fong General Hospital in Singapore. These efforts focus on different areas of development of future hospitals, making it difficult to know exactly what future hospitals should look like. I do not mean their physical appearance, size, or even medical specialities, but more profoundly their organizational culture and the purpose behind each of their strategies to deal with Human Resources, Information Systems, Facilities and equipment, Nursing and Doctoring processes. If one could put this “essential spirit” into one word, the difference between ancient monastery hospices and current hospitals would be: Science. Similarly, between today’s hospital institutions, albeit their heterogeneity, and the future hospitals, this “essential spirit” I suggest is very likely to be that they possess Hybrid Intelligence and Wisdom.
It is undisputable that hospitals are, or should resemble, Nonaka’s “knowledge organizations” as they are human-resource intensive spaces where most of what happens depends on highly skilled doctors, nurses, pharmacists and all other professionals. However, few are structured according to clinical pathways, ie, the “ways of the patient” where he or she, should go in order to get the best care. Hospitals offer and deliver knowledge intensive services such as an eye cataract surgery or a brain electro-implant therapy. They must be quality focused, error aware and avoiding, so as to improve, gain and regain citizens trust. While this was true 20 years ago, it has still to be achieved in most organizations. However, new times bring new challenges: Scientific explosion and personalized medicine define a new meaning for “knowing patients” and “knowing what to do to them/with them”; Intelligence is no longer a human exclusive, as Humans have set on a serious journey to create Artificial Intelligence Systems/Agents. Wisdom, a long-time human attainment is now critical to balance incredible technological possibilities that bend the limits of ethics, humanity and dignity. Multiple information systems, and the need for connected and interconnected organizations and interdependent care process, remind “the hospital” that it is often not more than a multitude of “smaller, often divided” mini-hospitals or departments, in an ecosystem of regional, national and now, more than ever, global public health interdependency. In order to ensure the best response to the aspirations and raising challenges KIWI hospitals of the future are those that combine four elements in an equilibrium. They need to be Knowledgeable, Intelligent, Wise and Interoperable. These four elements must be present in all processes. Just superficially in this brief paper they refer to:
Knowledgeable – Hospitals will need to increasingly operate and require the highest degrees of science and technology (from the simplest ones to complex genomics, and other “omics”, research outcomes) combined with practical expertise which is still required. The usage of Clinical Decision Support tools as well as extensive clinical pathways structuring of services will be paramount. These elements make up their knowledgeability.
Intelligent – Usage of Artificial Intelligence (AI) in basic medicine procedures (DaVinci Robot; Imaging or Genetics, for example), but also in so called Intelligent Hospital Management.
Wise – Only people can be wise. Wisdom is still a human prerogative yet trust and ethics are needed at the “deeper and transversal levels” of the organization. Trust and Digital Ethics reinforcing structures and processes will need to become their core competencies, as technical and scientific potential to do harm or “bad” is immensely increasing.
Interoperable – A term often associated with information technology (IT). While IT interoperability, standards use, and Big Data spaces for exploiting the value of secondary and tertiary data use remain necessary and difficult. Interprofessional teams and inter-organizational Virtual Competence Centers are key features of KIWI hospitals in their struggle to inter-operate healthcare inside and inside-out.
Finally what do KIWI hospitals mean for those that are born, suffer and die in them, those that work, manage and study and lastly for all of us, passing by knowing one day we too may need their excellence to survive or improve our lives.
The KIWI concept can be immediately applied to health professionals. They too, need to be focused on Knowledge, as knowledge workers who they are as medicine and health practice is highly knowledge and science dependent. By knowledge I do not exclude non-conventional medicine, to accept traditional medicines and other forms of healing. Artificial and enhanced intelligence as well as human-robot hybrid professionals will make-up new hospital workforce, while wisdom, the rarest of all commodities will need to be sought collectively. Finally, healthcare professionals need to be interoperable, like different electric sockets and voltages work though rules and adapters, they too, the different professions will need to find interpersonal and interprofessional human bridges as most current issues of low performance and errors have been tracked down to communication and multi-professionalism problems.
Patients and citizens are to expect better care, but perhaps even more important, they are expected to learn about their health and their rights to self-determination, from the way their data is used, to their treatments, tissues and cells usage and reusage, to their exposure to Artificial Intelligence based decision making or robotic therapeutics. It will be no longer enough to “solve” the healthcare problem, as citizens want to “know” it, exert some agency about it and expect wise decisions, which, in the area of health cannot exist without their inclusion.
Managers will need to be more capable of funding the right investments to get to KIWI hospitals. Not just beds and drugs, wages and surgical material. Intangible assets like culture development, reflection processes, excellence and performance appraisal systems, just to name a few, will be essential to attain the level of KIWI maturity they, themselves, agree would be ideal for hospitals in the future. New ways of teaching medicine and other health professions, broader health research agendas involving social and enterprise sciences, and implementing the concept of “hospital-as-a-university” in all hospitals would reshape much of current ethos and practices of the large health academy centers. New healthcare and education services are to result from functioning mature KIWI hospitals. All involved are called for this transformation. A simple, yet ambitious, framework is needed to communicate this vision.
Finally, the organization most academics agree to be the most complex in the world will remain relevant, vibrant, open and transformational. Perhaps more importantly, if this process is done hand-in-hand with citizens and patients alike, hospitals will lose their “white, cool, and somehow mystic” image, to be spaces and places of happiness even in the most difficult of human situations.
Medic and Univerisity professor
Alcainça, 28th September 2020
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