It might be tempting to take the shortcut and implement digital solutions without reviewing organisational structures, ways of work or patient flows. But, if you really want to see results of improved efficiency and a less stressful working environment you need to have the courage to change the way you work, says Petter Tourda, M.D. and manager at Cederkliniken Piteå at Swedish primary care provider Praktikertjänst. Cederkliniken, situated in the northern town of Piteå has gone through several major changes over the past five years and has managed to turn the business around, reducing stress and sick leave among employees. Here he tells us how.
Do you want to start by telling us about your practice and your responsibilities?
Four general practitioners started the health center Cederkliniken in Piteå in 2010. At that time, we were 13 employees. I started as an ST doctor, and back then, four other business managers ran the health center.
It is tough to start a health center. Patients who are dissatisfied with their care elsewhere tend to apply to the newly opened health center. The care choice system’s financial logic is that the 90 percent who are healthy pay for care for the 10 percent who are most ill. In the beginning, we mainly had patients with more significant care needs listed with us, so then the financials didn’t add up. This led to high stress and sick leave among our employees and we had difficulty making the business work.
I joined as Deputy Operations Manager in 2015. When we received extra funding from the Norrbotten region, several employees and I attended a 1.5-year change management course in health care. Then we started three parallel change projects, we revised our processes around sick leave, launched an entirely new way of caring for patients with mental illness, and created a digital drop-in clinic.
It was a challenging journey, and our employees have subsequently expressed that even if change is good, it may not be optimal to run three major change projects at once. At the same time, there were no alternatives for us. We would not have survived today if we had not implemented these rather radical changes. The changes paid off. In a short time, we managed to reduce sick leave among our personal staff by half and doubled therapists’ availability. The drop-in reception quickly led to a reduction in the phone calls and is still much appreciated both among our patients and the staff.
In 2019 the clinic was moved to a premise twice as big, and we got some time to reflect on what to do next, where digitalisation became a natural step to improve the health center.
Since the staff had previous experience of changing their work ways, the digitalisation initiative was met with enthusiasm from almost all of the staff.
What would you say are your short- and long-term challenges?
The current challenge is to get the budget to add up. Covid-19 has meant that we have lost 30-40 percent of our visitor revenue and are therefore forced to lay off several employees. Thankfully, due to the efficient digital tools we now have, we still manage to maintain capacity, although we have reduced staff. However, it is problematic for us that we only get paid for synchronous meetings, i.e. video. We currently do not receive compensation for chat consultations, even though we deliver the exact same type of care through them.
How do you work to guide patients to the digital platform, and what reactions have you received from staff and patients?
All callers who have a bank ID are referred to the digital platform. For example, for some of the elderly patients who do not have a bank ID, there is, of course, also the possibility of calling the clinic. Overall, the reactions have been positive because patients receive help much faster and more efficiently. The employees are also very positive. The physiotherapists, for example, no longer need to have any telephone contact. Instead, the patients book the appointments themselves.
How has digitalisation affected your way of working?
We have changed our way of working in three different ways. First, the nurse can get advice directly from the doctor via the chat and not have to wait for the round. This enables a much more efficient way of working, and, above all, the patient does not have to wait.
The second is digital. I start the morning with digital consultations, and if I have a patient who needs a physical examination, I book them directly via chat. Sometimes the patient has to leave samples first. Before the physical examination, I have already sent them knowledge material about the presumptive diagnosis so that the patient, in turn, has the opportunity to prepare their questions. I usually send out information about the probable diagnosis via the system before we meet – the patient often has very few questions about his illness once we meet. Then we return to the digital chat to give feedback on test results or treatment follow-up. The fact that we have ongoing contact for perhaps two weeks means that the patient’s experience more care, even though the time I as a doctor need to spend on the patient matter is less than before. The patient also gets more knowledge about their disease, which I believe makes the patient calmer.
Finally, I feel that we, as doctors, get a better review and control. Instead of a patient being booked in with three different doctors depending on where there is an opening, we can distribute the case to the doctor who previously had contact with the patient directly in the system. It creates continuity and a sense of security for patients. Another advantage is the patients who contact us because they have substance abuse problems and are looking for drugs. It is much easier for me as a doctor to say no in the chat than for the nurse to discuss it on the phone.
What do you think is important when you, as a care provider, start working digitally?
That you dare to make this disruptive change and go “all in”. If you only replace the phone with video, you will not see any significant changes. One must dare to make this radical change, which also means changing working methods to see any real results.