Continuity of hospital care: beyond the question of personal contactBMJ 2002; 324 doi: http://dx.doi.org/10.1136/bmj.324.7328.36 (Published 05 January 2002) Cite this as: BMJ 2002;324:36
- a HELTEF Foundation for Health Services Research, Central Hospital of Akershus, N-1474 Nordbyhagen, Norway
- b Department of General Practice and Community Medicine, University of Oslo, N-0316 Oslo, Norway
- Correspondence to: U Krogstad
- Accepted 5 July 2001
Patients' experiences have placed continuity of hospital care on the agenda in Norway1 as in other countries. 2 3 Although continuity of care has a long history in the literature of primary care,4–9 the concept is not often related to hospital care. Most of such publications deal with long term hospitalisation,10 psychiatry,11 and nursing12 and focus on personal continuity—where one clinician is responsible for each patient. The reality of acute treatment and care in the hospital environment is ignored, and there is confusion over the concept of continuity of hospital care. 13 14
Box 1 : Personal continuity may cause system discontinuity18
“Every time I or another patient asked for help the answer was always the same, ‘somebody else is responsible for you.’ I'm sure that if staff had given the service asked for instead of looking for the ‘right person,’ both the patients and the hospital would have saved time and frustration.”
“I'm satisfied with doctors and nurses, but you have to be really alert to make sure the information you give is passed through to the responsible persons. You never know if you are talking to the person in charge of you or just another messenger.”RETURN TO TEXT
Continuity of care is important for patients' satisfaction in primary and hospital care. 1 15 To compensate for the fragmented nature of specialised hospital care, many hospitals try to imitate primary care by designating one carer to a particular patient. This kind of personal continuity is important, but it does not ensure that patients receive the best treatment during their hospital stay. It is important to recognise that continuity of care when the carer is an institution differs in important aspects from continuity when the carer is a person.
We discuss continuity in relation to the fact that hospital care is an organised, multidisciplinary, and interpersonal service. We consider the implications of continuity of care for patients and for the professional organisation.
Continuity of hospital care requires more than personal continuity
Modern hospitals are complicated organisations and continuity is, or is not, embedded in their organisational structure
Hospital care involves teamwork, and the concept of continuity must be related to these teams and their substructures and superstructures
Strategic priority should be given to staff stability and internal education to build teams with collective competence and a shared ethos of responsibility to secure consistent care, information, flexibility of work, and responsibility
Front stage continuity, at the patient interface, must reflect behind the scenes continuity at the system level
What kind of continuity is needed in hospital care?
Modern hospitals are expected to act correctly and safely within a minimum amount of time. Their complexity and the fact that they run 24 hours a day suggest that there will be gaps between different departments, professions, shifts of work, and individuals.16 Mintzberg describes the paradox of modern organisations as being the need to balance the division of tasks with the coordination of these tasks17—this is particularly true in modern hospitals. Some hospitals now bridge the structural gaps by arranging personal links between staff and individual patients; this establishes personal continuity for some hours in every day of the patient's stay, but it inevitably leads to other gaps, as shown by comments from a Norwegian survey of patients' experiences between 1995 and 1997 (box 1).18
Although personal continuity and individual responsibility are vital in hospitals, no single person or discipline can see the patient through a hospital stay. If hospital work could always be performed according to schedules and routines, it might be possible to arrange all important treatment and procedures for the hours that the responsible staff person is on duty. Emergencies do not follow formal rules or hours and incidents may occur at any time—the hospital must act even if the primary responsible person is not on call and staff members who happen to be on duty when action is called for must take responsibility. A reliance on personal continuity may be hazardous, because it threatens the collective organisational responsibility for the patient and legitimises the idea that there are patients for whom a member of staff is not responsible.
Another example of responsibilities in hospitals being divided is the tendency of every profession or group to develop its own objectives, procedures, and routines. Nurses and doctors work side by side, focusing on the same patient, but with parallel agendas and separate aims, methods, and documentation systems. Both professions emphasise continuity by having one person designated as responsible, but the patient is part of two separate schemes. In this way, the focus on the patient and the continuity of their care become an individual or professional issue, not a collective, organisational issue.
Mintzberg and others point to culture as an important carrier of shared values, knowledge, and practice and highlight the close links between culture and structures. 17 19 When professional systems are separated, the gaps between professional cultures grow, and the continuity and consistency of patient care decrease.
The importance of continuity for the patient
The hospital patient may experience continuity in two ways, illustrated by the classic pair of concepts developed by the sociologist Erving Goffman.20 The first concept is “front stage” continuity, in which the patient sees the same doctor or nurse day after day; this kind of personal continuity is highly appreciated by patients. In a large survey of patients in Norwegian hospitals, continuity and organisation of hospital care were identified as the factors needing most improvement.1 The second kind of continuity important to the patient is “backstage” continuity, which is part of the organisational system. Patients may experience this when all staff members seem to know the plans for their stay, they are not asked to repeat information to different staff members, observations made by someone the previous day are followed up, and information received from different staff members is consistent. This form of continuity is more often recognised by its absence (box 2).
Box 2 : System discontinuity experienced as poor organisation18
“They keep asking the same questions—already answered and documented by my general practitioner”
“My file was not present and new doctors were not informed of my situation”
“You always get different orders from new doctors”
“My file, which contained a cardiac test from 1990, was missing, so, when I had a cardiac arrest during my operation, everyone was quite surprised”
“I was admitted and discharged three times before they eventually told me that the hospital could not perform the surgery I needed”
“Too many doctors! A second opinion is OK, but the sixth and seventh are quite frustrating”
Continuity behind the scenes is based on shared information and responsibility, and it is structurally supported by implementation of routines such as shift reports, written guidelines, and regular meetings. Work for hospital staff is full of routines and procedures that patients never see but are totally dependent on for the quality and safety of their treatment. As a result of such routines, an implicit development of knowledge and culture takes place. Staff are being trained to assess instinctively whether a particular patient presents a common picture of symptoms or deviates from the typical course of illness. Experienced hospital specialists often refer to these skills as “tacit knowledge” or “intuition.” Intuition is not different from knowledge, but it is the capacity to assimilate different types of knowledge in a given situation: the formal theory of knowing why, the technical and methodological skills of knowing how, and the contextual assessment of knowing when, and when not, to act. Social sciences describe this as “reflective practice,”21 and nursing sciences as the development “from novice to expert.”22 This kind of expertise develops through system continuity and, although mostly invisible to patients, it may be vital for their care.
The importance of continuity for professionals
Professionals in hospitals navigate between a network of strictly licensed procedures and necessary improvisation. Between wards, departments, and professions, there are grey zones of responsibility that become visible when events do not follow regular routines. For example, at night or during emergencies, nurses often perform procedures that are beyond their regular responsibilities. Situations like these frequently cause frustration and calls for more staff and a clearer division of work. But rather than calling for new frontiers, grey zones could be considered as arenas for team building and education, which increase knowledge, trust, and cooperation.
Hospital medicine has been compared to aviation in that teamwork is important in reducing errors and improving quality.23 This comparison indicates that hospitals are not very advanced when it comes to training different professions, departments, and individuals to identify themselves as part of one organisation with a common purpose. The challenge is to cultivate a common ethos representing continuous and collective learning, instead of defending each professional area as a unique and isolated island of knowledge. Sturmberg states that “continuing care doesn't have to be provided by one person necessarily. It can be provided by different providers, the co-ordination is the important thing. And that requires within the practice a good working relationship with your colleagues, a common approach.”24 Coordination, cooperation, and a common approach are all part of everyday hospital practice, but we know that they vary between hospitals and between units. Aiken and colleagues showed that relations exist between interprofessional cooperation, low turnover of nurses, and improved outcomes for patients.25–27
Another important back stage consequence of continuity among health workers is the ability to manoeuvre through complex organisational systems and put such systems into action. Without knowing people and equipment, where to go, whom to ask, when to expect answers from laboratories, or how to improvise, even expert observers may be unable to implement what they know to be the right course of action.
It is one thing to know these facts, but another to try to implement them in daily hospital life. Firstly, we presuppose that there are management strategies aimed at interprofessional team building and continuity of staff in order to establish a culture of shared knowledge and responsibility.28 That culture must then be transferred to new employees implicitly and explicitly through their interaction with other work colleagues.
How do we know?
Our reflections are based on theory combined with experience of hospital work, and scientific studies are needed. Hospitals, departments, and wards all vary with respect to system continuity—in some places everything runs smoothly; in others, information is delayed, misunderstandings flourish, and cooperation is difficult.
The next step should be to check to what extent factors such as staff continuity, system continuity, and personal continuity are important for the quality of hospital care. In Norway, as in most other countries, clinical outcomes and patient satisfaction differ from hospital to hospital and from ward to ward.1 Wards and departments with different scores on the aspects of system continuity could be compared with regard to patients' experiences. A combination of large scale quantitative studies to trace general traits and qualitative analysis to understand local performances might bring new insight into what form of continuity is important for proficiency, efficiency, and quality of hospital care. De Maesner et al suggested that because organisational continuity has proved successful in primary care, it might be time to investigate whether, and how, similar gains could be achieved in secondary care organisations such as hospitals.29
Contributors: UK provided the original idea and theories for the paper and wrote the initial draft. DH and PH contributed substantially to revisions of the paper and all three were responsible for the final version of the manuscript. UK will act as guarantor for the paper.
Funding The Norwegian Council of Research financed UK during her work with this paper, DH is a senior research fellow at the Foundation for Health Services Research, and PH is Professor at the Medical Faculty of Oslo.
Competing interests None declared.