Center for Activity Theory and Developmental Work Research

Negotiated Practice in Health Care Project

Developing a negotiated practice between primary health care and specialized hospital care in Helsinki.

Patients suffering from chronic or multiple illnesses appear to have problems and disruptions in their care. Many of the problems have to do with the lack of coordination and communication among the different care providers. For patients this means an excessive number of visits, unclear loci of responsibility, and the care providers' failure to properly inform their colleagues.

In the ongoing project of improving cooperation between primary and secondary medical care in internal medicine, the City of Helsinki and the District of Helsinki and Uusimaa County Patient Care have taken initiatives to support the introduction of a new tool called the "care agreement," and the method of "care negotiation" to tackle these problems.

The tools were developed in a "Boundary Crossing Laboratory" organized by developmental work researchers (see Engeström & al, 1999) in a project for improving the care of chronically ill children in the Helsinki region. The Boundary Crossing Laboratory is an application of the broader Change Laboratory method.

The care agreement and the method of care negotiation are designed to meet the needs of planning, observing and coordinating the care processes. The care agreement is also a tool for communication and dialogue, and it clarifies the division of labor and responsibility between various parties in the network. The tools have been introduced to a patient group in internal medicine, in the unit of internal medicine in specialized medical care and in two pilot health centers in Helsinki. The population in the pilot area amounts to about 200,000 inhabitants.

The ongoing project of implementing the care agreement and the care negotiation into the internal medicine patient care involves five patient groups (diabetics, rheumatics, cardiac, lung and kidney patients). Two patients from each group are selected to participate in the research project by the professionals either in the primary or secondary care. The selection criteria are that (1) the patient lives in the area where the pilot health centers are located, (2) the patient suffers from diabetes, rheuma, coronary, lung or kidney disease, (3) the patient has also other diseases, (4) the patient's care requires intensive cooperation between professionals, and (5) the patient himself is willing to participate in the project.

Because the interest of the project is to develop the medical care of patients, the final selection favors such patients who have experienced problems and disruptions in their care.

The project is carried out in two phases. During the first year, the disruptions and problems in the medical care of the selected patients are identified through their videotaped and tape-recorded interviews and those of the main parties in their medical care. Also the doctor's appointments of these patients are videotaped, if possible, and the patient's care histories are traced from documents. Next the case data gathered are applied in arranged meetings called "Implementation Laboratories" where the patient and the practitioners involved in his or her care are invited to discuss the problems and their solutions. After the meeting, the solutions created are put into practice in the patient's care during the period of one year.

The Implementation Laboratory, like the Boundary Crossing Laboratory, represents a way to learn at the work site. As applications of the Change Laboratory method they draw from the ideas of expansive learning (Engeström 1987; Engeström & al. 1996; Virkkunen & al. 1999). The emphasis is that there are no ready-made solutions available for the encountered problems; these have to be collectively worked out. This means that learning, regeneration and development are joined together in a collective activity.

The basic idea applied in the Boundary Crossing and Implementation Laboratories follows the method of dual stimulation deriving from Vygotsky (Engeström & al. 1996, pp. 13-14). It is put into practice by the presentation of data, collected by the researchers concerning problems and disturbances in work practices called the "mirror". In this case the data presented as a mirror acts as a catalyst for the improvement of the medical, practices between separate providers. The problems identified, the ideas for their solutions and the models for this are recorded on three separate sets of white boards by a secretary who is elected from the participants.

The second phase of the project deals with the actual implementation of the care agreement and the method of care negotiation by experimenting and improving the tools.

References

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