Transactions and Silos

Economists abhor transaction costs associated with carrying or producing a unit of something valuable that involves more than one firm. There are the costs of the contract negotiation, work rules, monitoring of the contract, transporting material, ensuring system integration, and making sure that the process of production runs smoothly. Much of the productivity gains of the past two decades have come from using information technology to remove layers of unneeded management, making information more transparent and speeding transactions along the process of making a product or service valuable. A major challenge facing health care is that it is beset with enormous transaction costs that lead to higher costs and also to poor performance in quality and patient safety.

Much of the investment in electronic patient records is aimed at lowering these costs. The technology will have an impact, but it will fall short of its real potential without redesigning the process that usually accompanies information infrastructure investment in other industries. To do this the system of care will have to take on the guild interest of the health professions and the silos of practice, which have been built up over the past five decades. There are a lot of silos in health care and changing them is essential in altering both the performance of health care and the ways in which patients experience the system as consumers.

As nursing grew into its modern professional form over the past five decades, the allied health professions emerged to operate the new technologies and offer discrete therapies that are at the core of in-patient experience. Operating many of these new machines and providing these therapies were once a part of what nurses expected to do within their practice model. But as the technologies became more complex, increased in number and changed at a faster rate, it was an easy step for nurses to abandon the management of these modalities, particularly as new technologists trained to operate the machinery began to be available. Such separation of competence is to be expected in any system of specialized knowledge, but perhaps it is important to closely examine these silos to see if they still serve the interests and needs of the patient and system. With over 200 allied health professions, each with its own educational program, licensing process, scope of practice and often labor representation, it is easy to see how the transactions with nurses to produce a unit of patient care service could get expensive and error-prone.

One method to decrease costs and errors would be to train across professions. Allied health should take the lead to group professions that typically work together by function or setting, creating clusters such as therapeutic, administrative, or counseling. An all out effort should be made to create a common educational experience for these clusters that focuses on what they share and moves specialty training to become as intensive and short a period as possible. This would allow a therapeutic allied health professional who is trained as a radiological technologist to add on the skills of respiration therapy as needed. This would work with deeper collaboration by professions, educational programs, and regulatory agencies.

The idea of cross training is of course not new, but is needed now for a number of emerging reasons. First, progress on improving the quality and maintaining the cost of care will be hampered without such measures. Perhaps more pressing, the looming shortage of allied health workers will mean that we need more value out of everyone produced and licensed for practice. The educational resources to train these allied health professionals will be more efficiently spent if they are shared across the traditional disciplines and not locked up in particular programs.

To move this agenda forward, nursing will need to return to a more inclusive model of patient care services, one that is developed with the allied health professions integrated in the way described above. This will require the profession to become a little less introspective and to look outward to the needs of the care system and assess what types of leadership and management it needs to achieve its goals, not just what nursing needs to advance itself as a profession. Much of this lies at the center of nursing core competence. It just needs to be focused on the reintegration of a rich team, cross-profession model.

Clearly there are lessons in this process between nursing and allied health that once learned can be broadened to include pharmacy, medicine, and other related disciples, as well as carried to other settings beyond just the inpatient experience.