Thursday, 30 April 2009

If we’d known the start point, we wouldn’t have ended up here!

If we’d known the start point, we wouldn’t have ended up here!

A tricky situation

A few years ago, my team and I were asked into a major teaching hospital to ‘run service improvement workshops’ in three directorates.

They were at very different stages of development. One directorate ran seminars every year, and enjoyed brainstorming their possibilities, selecting the best options, working up action plans and benefit reporting, and assigning the tasks. Talk in the room was about opportunity and possibility, and how much had been achieved from previous years.

One directorate failed to set a date for the workshops. The senior clinician was acting medical director and never had time to call his top team together, and the top team didn’t want to make a decision without him. Our best efforts to get them to talk about opportunities were met with talk of targets and indicators that they had to meet now.

The third was different. On the surface all seemed normal – fairly high levels of sick leave and busy shifts that nobody wanted to work; give and take and banter.

Preparation is the key

As we interviewed each of the senior team in private, in preparation for the workshop, it became apparent to us that they weren’t on speaking terms with each other beyond the minimum required to keep up the façade. To try to run a service improvement workshop with this lot would be to try to teach a hungry tiger how to perform first aid – the end might be worthy but they just weren’t ready for it.

A disaster waiting to happen – averted by careful planning

In our case, we spotted the situation and were able to change the nature of the workshops so they became much more personal, directly tackling the communication issues and the very real resentment. We got the 6 top team members to discuss (in a protected environment) how working in that situation made them feel, what they thought could be done to put it right, and their own personal responsibility for both the problem and the solution. With the top team united, many of the problems of sickness and understaffed shifts resolved themselves with substantial improvements in patient safety and patient experience.

Cost-Benefit Analysis

The key is to use facilitators who are skilled and experienced enough to identify the situation they face, and to prepare a plan to resolve it.

Can you imagine the ‘successful’ workshop that failed to address the real issue, and that perhaps resulted in humiliation for senior staff with the inevitable litigation and claims for unfair dismissal. I often meet people with the title “service improvement facilitator”, and there’s an enormously wide range of skills and experience. Some have 20 years’ of managing teams and delivering workshops, whereas others are just out of training grades (“no experience needed”).

It will pay for itself many times over to get the right outside organisation to tackle those difficult situations, and give your staff facilitators a chance to learn from example.

Thursday, 9 April 2009

The Hippocratic Oath

THIS PAGE HAS MOVED TOΔιαιτήμασί τε χρήσομαι ἐπ' ὠφελείῃ καμνόντων κατὰ δύναμιν καὶ κρίσιν ἐμὴν, ἐπὶ δηλήσει δὲ καὶ ἀδικίῃ εἴρξειν.
I will prescribe regimens for the good of my patients according to my ability and my judgement and never do harm to anyone.

Further, in GMC's "Good Medical Practice (2006) - Good Doctors" Patients need good doctors. Good doctors make the care of their patients their first concern:

This focus on the individual patient and their immediate need can conflict with community welfare, conserving economic resources, supporting the criminal justice system or simply making money for the physician or his employer.
This means that a doctor is almost obliged by his/her vows as a doctor to ignore Public Health priorities or the strategic objectives of the health economy to serve the immediate needs of the patient in front of them.

What does this mean in practice?

Management of resources, and treating immediate need, are difficult bedfellows.
The bridge between them is Public Health, or a proactive attempt to prevent ill-health through resolving the environment that will ultimately (and probably already causes) cause poor health.
Actions to reduce smoking can be perceived both by physician (improved health) and the economist (reduced future cost, reduced lost production) as beneficial to society.
Finance managers can see the long-term benefits, but sadly this year's budget has to provide both for this year's clinical needs (last year's smokers), and extra resources for the proactive programme that will reduce next year's bill. It's a difficult decision and it emphasises the importance for doctors to recognise the legitimacy of public health targets and the need for planning, and of course for managers to understand the constraints under which doctors work.

Sunday, 5 April 2009

Clinical quality vs profit

They say another key difference between clinicians and managers is that managers are only interested in what will make money, whereas clinicians are only interested in delivering the highest quality.
I don't know if you've studied Lean methodology in any detail? It's a series of techniques for improving the delivery of services and products, and
NHS Institute for Innovation and Improvement has released a number of guides of its Productive series, Productive Ward, etc.
This is about getting people to question the way we do things round here, to see if there's a better way.

Community Engagement

It's about getting staff engaged locally, down to their own individual teams, and some of the techniques including management by walking around and process mapping involve everyone working together - sponsors (typically executive directors), senior doctors, consultants, nurses and AHPs, hospital staff or primary care health care staff (staff nurses, staff medical, etc) - to map out how the patient journey is done now and where are the things we do that don't add any value.
For example, the patient waiting in the waiting room doesn't add any value. The patient going home and coming back for another appointment doesn't add any value. Writing labels on blood samples going for diagnosis adds value, but is there a better way (adds more value or takes less effort). Recording the number of patients waiting only adds value if you do something with the results.

Staff Evaluation

Staff themselves are involved. We work together. We learn from each other, understand why a particular action or a particular step is necessary, and jointly evaluate and agree what isn't necessary. The service is better quality, because there's less waste. The service is lower cost/ uses less resource, because there is less waste.