A Message from the Guest Editor

Anyone involved in health leadership has recognized suboptimal results from poorly integrated “silos” of care. Specialization has allowed a focus on discrete parts of healthcare in a way that has led to a magnificent advance in knowledge and capability, while allowing each specialist sector to become an island, or silo on its own, defined by what it does and excluding what it does not do, often in relative disinterest, or even ignorance of parts of the system on either side of it. The phases of transition between silos are notorious for bottlenecks in patient flow, and unfortunate patient safety events. If we were to design a system from the start, integration of each of the parts of the system would be a fundamental goal. The effect of one failing organ on another in the same patient would be appreciated by experts in the care of each organ; parts of the system whose function depends on services elsewhere in the system would function in tandem with the other part to make sure both are able to function optimally. Everyone would share the same purpose: better health for everyone that we serve.

This edition of Healthcare Management Forum (HMF) focuses on “navigating transitions in healthcare.” We wanted to explore what we can do to create a system where we can simultaneously take advantage of the unique and specific skills of providers in every part of the system, while ensuring care that smoothly navigates transitions between them.

In a similar vein to previous editions of HMF, we recognize that a deep understanding of how and why our system has evolved like it has is the most important element of deciding what to do about it. The first two articles in this edition complement each other, introducing the scholarship of silos and specialized care, and help us to understand the origins, impacts, and potential mitigating processes.

Our first article by D. Petrie describes the unintended consequences of both over specialization and generalization/optionality, emphasizing that, in the spirit of polarity management theory, achieving effective system integration is not as much “silo-busting” as finding the “sweet spots” that minimize the risks of each while taking advantage of the benefits.

The next article by Innes goes on to argue that, for systems to effectively evolve, pressures to change have to be felt by players in the best position to make those changes. Without clear accountability frameworks that define who is accountable to solve specific blocks in system flow, no one solves them. He offers accountability strategies, that include each zone being aware of and accountable for patients queueing for their service, with bottlenecks in transition being addressed by the zone responsible for the blockage, and not the one where the patients are forced to wait. These frameworks and strategies, with examples of how to achieve them, will help leaders focus on the causes of system dysfunction, rather than the far “louder” symptoms that result.

Khan and co-authors provide an example of one of the strategies suggested by Innes; that of identifying patients at greatest risk at the transition point between the emergency department and inpatient unit, using existing resources to implement an admission transfer unit, to provide a safer and more efficient pathway through a previously identified bottleneck in the process of care.

Another example of a successful initiative that identified underserved patients, repurposed existing resources and protects patients from bottlenecks in the system, is given by Carter and co-authors who question why many terminally ill patients who had expressed a wish to die at home ended up being taken to hospital when their palliative treatment process broke down. They describe a process employing pre-hospital paramedic providers, traditionally tasked with transporting patients to hospital, to provide palliative care in people’s homes. Not only does this process make the system more able to meet patient wishes, but it frees up stretched emergency and inpatient resources.

Siloed systems tend to push patients into specialized units, where the effects of the primary reason for admission on other parts of the patient may be neglected, leading to delayed intervention, longer stays in hospital, and poorer patient outcomes. Burn and co-authors describe a “front door frailty” initiative in the United Kingdom whereby frailty, and thus lower physiological reserve in multiple organ systems, is identified at the time of arrival in the system. This allows early multidisciplinary team approaches to supporting the entire patient, and not just the most evident problem, improving outcomes and reducing length of stay.

Empowering patients helps them manage their health and navigate transitions in the system. Nasser and co-authors describe the results of an assessment of patient attitudes to virtual triage in a Canadian emergency department.

For patients transitioning from the emergency department to home, Curran and co-author discuss the challenges of and opportunities for providing effective discharge communication for patients, including innovative co-designed interventions and leveraging technology.

Emerging technologies and breakthroughs offer huge promise to healthcare administration, but we need to be wary that they do not create silos of their own. S. Petrie and colleagues explore the impact of digital solutions to healthcare challenges and give examples of unintended consequences that can accompany poor implementation of digital health interventions. Both the article by D. Petrie and S. Petrie warn us of potential dangers of allowing free market approach to fill gaps in publicly funded healthcare. The former refers to a situation coined “the tapeworm economy” where private companies siphon profits from the system without them being reinvested to the interest of the broader community. The latter points to a situation where for-profit digital health enterprises, promising an alternative to the flagging public health system, can contribute to inequities in access to care and fragmentation of services. S. Petrie and co-authors propose a framework for judicious digital health implementation into a learning healthcare system, ensuring ongoing systematic evaluation. They further suggest three questions that decision makers should answer at the onset of any digital health intervention.

Few contemporary discussions on integration of healthcare would be complete without mention of the potential for Artificial Intelligence (AI), informed by large datasets, advancing computing technologies and sophisticated machine learning algorithms. Hassan and co-authors argue that the complexity of AI is such that traditional healthcare technology implementation and governance frameworks are inadequate to the task, urging consideration of a comprehensive and catalyzing approach to AI governance, centred around trust. They propose an AI governance framework that can be adapted to the cultural and structural context of each healthcare system, with principles to guide its development.

Further on the subject of AI, Daya describes the Canadian Institute for Health Information’s strategy development process and areas of focus with reference to the use of AI to advance the use of health data and analytics to guide healthcare improvement in Canada.

The choice of where to die and the ability to do so is further discussed by Funk and co-authors, who compare preferences for setting of death prior to and after the onset of the COVID-19 pandemic. They found that preference for dying in a long-term care facility declined significantly after the pandemic.

As health leaders, we need to look inward to see that we represent a “silo” in our own space. James and co-authors remind us of the underrepresentation of women in health leadership roles. They discuss barriers and facilitators to women in health leadership and call for future research on the role of the concept of care in supporting gender equity in healthcare leadership.

And finally, the ethics column at the end of this edition by Bakewell furthers discussion on the scholarship of poorly integrated healthcare programs, challenging us to recognize that healthcare silos are not simply “accidental features of a piecemeal healthcare system” that need to be fixed by “better collaboration and communication”; their deeper roots lie in social identity and the fiduciary duty of care of healthcare providers. Good and well-intentioned providers in resource-challenged systems tend to feel a moral imperative to focus on patients already in their care, unwittingly restricting care from people queueing for their services. He argues that, as health leaders, we have a “professional identity and duty of care already broad enough to encompass the entire patient population served by our health system, which can be leveraged to break down barriers to transitions of care.”

I feel honoured to have been invited as a Guest Editor for this edition of Forum, and I hope you enjoy reading it as much as I have.