Simple Change, Big Gain

The role of managers in the provision of healthcare.

(This article was published in the British Medical Journal http://careers.bmj.com/careers/advice/view-article.html?id=1998)

Do any of these sound familiar: cancelled appointments, delayed or lost results, no access to patient records or history, “same problem, every day, for years,” and a surgeon told to “go slow” because he is too efficient? [1]

 

Imbalance

Often the quality of service provided by healthcare professionals does not match their dedication and aspirations. This imbalance presents a case for review from inside the healthcare system. No single solution will fix all of the above mentioned situations, but small changes can make daily work more efficient. As you have probably guessed, in this article I will be talking about the role of healthcare managers.
I will make one point first: this article is not about the National Programme for Information Technology (NPfIT) and its benefits. NHS Connecting for Health, a relatively new agency of the Department of Health, has a well written website with all the related information. [2] The set of changes that will be introduced to health care in England and Wales by NPfIT will lay the foundation for a more efficient system. However, these changes will have to start from within the community of health professionals. Healthcare managers can help facilitate these changes because they will have a critical role in bringing these modifications successfully to the fore. Of course, we will need an NHS care records service, choose and book, electronic transmission of prescriptions, a national network, contact, picture archiving and communications systems, and IT supporting general practitioners. But as you can see from the NPfIT portfolio (see box for definitions), these are mere systems that will be put in place, and health professionals will be left to work them out. This article is about going back to the basics of management and its timeless principles, and how healthcare managers can facilitate the work of health professionals.

Impact of simple changes

A recent edition of Harvard Business Review gives examples of how simple and relatively easy changes could have a great impact on the daily work of health professionals. [3] Steven Spear, a senior fellow at the Institute for Healthcare Improvement in Cambridge, Massachusetts, argues that in the United States medicine does not deliver on the science it employs. I think we can add technology to this statement as one of the short changed assets. Healthcare safety expert Lucian Leape compares the risk of entering an American hospital to that of parachuting off a building because of the number of people who die each year in US hospitals from medical errors. [4] This is happening in a country that is committing trillions of dollars to its healthcare budget. The UK government has already secured billions of pounds for NPfIT. So the issue is not solely financial. It is not that health professionals don't care either. People working in health care are typically intelligent and well trained and have chosen their careers expressly to cure and comfort. Spear has followed several projects over the past five years. These projects are about opportunities that need little capital, can be started immediately, and in most cases can be realised in the near term. Before I summarise the main points of his work, you need to understand why there is a gap between the skills and intentions of healthcare professionals and the US healthcare system's performance. Spear argues that the problem arises partly from the system's complexity. This inherent complexity creates many opportunities for confusion, especially in a multi-team care setting. On the other hand, healthcare workers contribute to the problem by adapting a “work around” culture. Rather than improving the process of doing their daily jobs, they just adopt a short term measure. The quick fix then becomes an almost permanent solution as the involved team becomes accustomed to it as their daily routine.
Here is a summary of two of Spear's case studies and projects.

Theme: ambiguity

Preparing a patient for surgery requires a number of steps, one of which is to take blood samples for investigation. Nurses at Western Pennsylvania Hospital were uncertain whether blood had already been taken from admitted patients or not. So, visual indicators were introduced to identify which patients needed the procedure. The second uncertainty was who should do it. The unit designated a staff member to be the sole person responsible. To be more efficient, they agreed to take samples as soon as the patient was registered. Despite all of these changes, a few patients were still turning up at the operating theatre without blood test results. The process was reviewed further, and it turned out that it was unclear where the procedure should take place. The unit converted a small closet into a room to take blood samples. With this final change, the number of patients without blood tests fell to zero and stayed at that level.
Spear noted that much of the credit for the successes at this hospital could be attributed to the problem solving support provided by the unit's clinical coordinator. In a previous incarnation of the clinical coordinator's role, it was simply about we “need this and that” and “there you have it.” Missing laboratory test results, important paperwork, and so on were on the daily to do list. The newly defined role of this particular clinical coordinator was to investigate and work with key people solving reported problems. Solutions were jointly developed, tested, and validated. Ambiguity was tackled by applying simple management skills and employing an experimenting method.

Theme: work operations excellence

Two dozen hospitals in Pittsburgh have reduced the incidence of central line infections by more than 50%. In one hospital, a team of infection control experts documented every line insertion and identified variations and shortcomings. Measures were developed to improve this procedure. Changes were designed to make it clear:
Who was to get what procedure. For example, a new rule was introduced whereby all new admissions with central lines were to have new ones so that the history of the current line could be verified

Who did which aspect of the procedure

What signals could be used to trigger the work: visual aids to prompt removal sooner rather than later, transparent dressings to give a view of the wound site (to see whether it's infected)

Precisely how each step would be carried out: new types of disinfectant, various sized surgical drapes, and a new arrangement of the kit used in this procedure was devised from controlled trials to identify best practices.

Human error

One study showed that for every death due to drug treatment error there were 10 injuries (non-fatal) and 100 instances where harm was averted. [5] Unfortunately, it is only after a patient dies or suffers serious injury that the type of mistakes and the contributing factors are studied. This is where managers and coordinators have their (other) role. Managers can help to implement a common approach to process design and implementation by encouraging “experiments” in a controlled and safe situation (even if that means a mock set up to witness and learn from daily routines with a fresh pair of eyes without the rush of “just do it now”). Healthcare managers can help turn daily work into continuous learning and learning into a collective asset of best practices. In the two examples, simple practical solutions were introduced. Managers can make sure that problems are revealed as they occur and addressed in a structured manner (where the situation permits—in emergency cases lessons learnt can be deferred). When managers work with their colleagues from other departments they can systematically deploy all these enhancements. It is by switching from “why you didn't do your work” to “why you couldn't do your work” that specifics are picked up and addressed in an organised fashion. It's a change in attitude and sometimes a change in behaviour of teamwork. This is what's needed now.

Finally, there was the story of the NHS surgeon who said he would not be forced to have a waiting list. [1] Mr Alastair Paterson, a consultant at the Royal Cornwall Hospital in Truro, said he ran a diary system, which meant seeing and speaking to patients and making a date for their operation. He has never had a waiting list. He said: “I see this as being efficient and also kind to my patients.”
Back to the examples cited in the first paragraph, can you identify a way to address these situations? And, curiously, for the efficient surgeon who was told to take it easy, I think you can see my point of how these changes can be implemented outside the frame of the NHS, can't you?

 

References

1 BBC News. Surgeon told to make people wait. BBC News  2005, 7 2 December.http://news.bbc.co.uk/1/hi/england/cornwall/4506734.stm
3NHS Connecting for Health agency: www.connectingforhealth.nhs.uk
4 Spear SJ. Fixing healthcare from the inside, today. Harvard Business Review  2005, September.
5 Leape L, Adjunct Professor of Health Policy, Department of Health Policy and 6 Management.www.hsph.harvard.edu/faculty/LucianLeape.html
7 Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. ADE Prevention Study Group. JAMA  1995;274: 29-34.