Considerations for Stabilizing the Two Main Pillars of Healthcare: Financing and Nursing

Abstract

Franz Porzsolt

Background: Reducing healthcare expenditure while improving the quality of care could help stabilize the two major challenges facing healthcare systems: rising costs and declining sustainability. Randomized controlled trials (RCTs) have been recommended for evaluating the effects of health services for more than 50 years. When first introduced into health services research, however, this experimental approach was controversial because methods for objectively evalu- ating its limitations were not yet available.

Objectives: Our aim was to describe methods that enable the identification, verification, and correction of suspected errors in healthcare delivery.

Methods: The intellectual legacy of Albert Einstein (born in Ulm in 1879) and the “hochschule für gestaltung (hfg) Ulm” (Ulm School of Design, 1953–1968) provided the conceptual foundation for clarifying not only formal but also functional relationships. We adopted two principles attributed to Albert Einstein: "A problem cannot be solved with the same mindset that created it" and "If I had 60 minutes to solve a problem, I would spend 55 minutes understanding it." Collaboration with Prof. Hans ("Nick") Roericht and his hfg team encouraged us to apply a design principle developed by American architects and designers. This principle serves both as a framework for developing new products and as a tool for assessing the quality of existing products, concepts, and systems.

Results: (1) The experimental findings of RCTs provide proof of principle (PoP) but do not directly measure real-world effectiveness (RWE). Consequently, RCTs systematically overestimate RWE by approximately 30%, contributing to overprovision of healthcare services and increasing financial pressures. (2) The principles derived from the Ulm legacy enabled further development of methods for identifying healthcare errors and supported a redefinition of the tasks and responsibilities of nursing staff in both clinical care and research. (3) Because of the complexity of healthcare delivery, care provision, research, and data collection should be performed by separate teams.

Discussion: Current approaches to healthcare evaluation can be refined and improved. However, this transformation is complicated by inherent conflicts of interest. Healthcare research should focus on measuring the outcomes that are achieved under routine clinical conditions ("care as usual"). The strategy required to demonstrate these real-world outcomes ultimately benefits all patients who depend on healthcare services. Although healthcare professionals may initially perceive these changes as disruptive, broader acceptance is likely once public trust in healthcare policy has been restored. An essential first step toward rebuilding this trust is to actively involve frontline healthcare professionals in redesigning the tasks and responsibilities associated with everyday patient care.

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