Tag Archives: Health

That thundering herd


A herd of leaders charging an outcome

What is this loud thundering I hear across  England as people begin to adopt the new thinking on the English NHS from the coalition government?  Not a year ago many of those same people were saying quite different things. What has changed?

Golly, but now they are all trumpeting the appropriateness of outcome measurement in the NHS, something that should have been the case decades ago, but got hi-jacked by bureaucracy.  As I have said elsewhere, the patient is the most disruptive force in healthcare, and as the ‘auditor of one’ can drive quality and service integration in ways that top-down monster plans never could.

I’ve worked on developing outcome measures, and perhaps the one thing that is important to realise they are best developed as emergent measures from within the delivery of care as much as designed by a room full of experts and some evidence base.  My preference is to develop a system using something simple like a balanced scorecard, (with perhaps 4 to 6 critical measures under each of these four headings, so around 16-24 measures), something like this:

  1. Measures about how well the healthcare commissiong process interprets healthcare requirements, and how well a provider responds to manifest demand for its services. [Measures here focus on the ability to interpret the dynamic nature of the healthcare environment.]
  2. Measures about how efficient a healthcare provider is in organising care, including interconnectedness with other providers (handling referrals across institutional boundaries). Also measures of how effective commissioning processes are. [Measures here focus on efficiency, doing things well.]
  3. Measures about how effective a healthcare provider is in delivering outcomes, including with other providers (integration of capabilities linked to specific desired results). Also, measures of how effective commissioners are in what they do. [Measure here focus on effectiveness, doing the right thing, mindful that the right thing has always been about outcomes, not outputs.]
  4. Measures of how well the various health system actors such as commissioning bodies, consortia, providers, professionals, patient groups, etc. learn how to improve what they do, including driving forward change, introducing innovation, learning from mistakes, and developing solutions. [Measures here focus on ability to evolve, innovate, learn, change.]

None of these require central thinking and with properly strategically managed organisations would have been the norm, but for the various distractions over the years). They can be developed into an hierarchical performance model to tie together what individuals do, what processes are used, and how organisations institutionalise practices to achieve outcomes. (There is a cognitive model at work here by the way.)  This puts the measurement focus onto individual organisations, and not onto arbitrary aggregates (such as regions); the focus also requires much stronger strategic abilities within the leadership of system actors, and greater operational attentiveness by everyone. Hospitals, GP Consortia will need much improved analytical and operational research capacity within their institutions in order to more accurately interpret their local environment and respond in a timely manner; this important capacity has been held higher up in the NHS (in all its devolved parts) and indeed important operational research capacity and mathematical modelling seems the preserve of the Department of Health, whereas the problems are at the front-line. Shifting resources to where they are needed removes top-down performance management as the focus is now measuring performance in terms of delivery, not activity. Keep in mind, too, that as a complex adaptive system, there are no ‘strings to pull’, and that does change the nature of any information that is reported.

Change always requires that individuals learn to behave differently. Organisations are how we group together the behaviours of people to achieve certain goals. It is importnat to understand that:

  1. Some people have trouble altering their behaviour, especially if it requires initiative and originality which in the past was not rewarded — so they may need either help or perhaps counselled out, particularly if they are in leadership positions (and beware the recycling of failed leaders);
  2. Some goals may not require some organisational arrangements that are currently used, and may need to be changed (think of the potential disruptive potential of e-health); but people have a great deal of difficulty with ‘creative destruction’ of publicly funded institutions, which is why public service institutional renewal can be so difficult.

No one said all this would be easy, but it should be done better.

I just hope that great thundering herd is also thinking as it charges along.

Innovation workshop

A very successful innovation workshop was held to identify opportunities in pharmacy.  Fresh thinking and a structured approach to innovation development for hospital pharmacy produced a number of strategic opportunities as well as at least one quick win (i.e. feasible in the short term).

Areas where innovation opportunities were identified included:

  • reducing or eliminating duplicate ordering of medicines from the wards, which produces considerable medicines waste when patients are discharged
  • improving the ability of patients to manage their own medicines regime, with support programmes, and with the end goal to reduce medicines waste from patients not completing the course of medication, one outcome of which can be recurrence or hospital readmission
  • improving the market entry process for new medicines.

Who owns a health profession?

Florence Nightingale, pioneer of modern nursin...
What would Florence do?

Who owns a profession and who should take responsibility for its development?

In the UK, the Prime Minister’s Commission on the Future of Nursing and Midwifery has been working away for awhile to determine the future of these two professions, so lets reflect on this question and look at what this Commission appears to be thinking.

The most obvious observation is that it appears to be thinking of nursing and midwifery within an NHS context. Many nurses work outside of the state-sponsored NHS, such in prisons, nursing homes, private and independent settings and workplaces. The Commission’s focus, therefore, on defining the future role of the profession suffers from a dilemma and in resolving this dilemma in a particular way, may further limit these professions to what the NHS defines as its role. This is particularly worrisome given the dire need for fresh and innovative thinking particularly from such a broad and diverse profession as nurses and midwifes which may indeed need to challenge current political and policy thinking.

I wonder whether, too, it is indeed appropriate for the ‘state’ to sponsor this type of work in the first place. The selection of those on the Commission is probably subject to various criteria — one can only hope that these folk are able to address the work of these professions in non-NHS settings in the first place, and secondly can address the dire need for fresh thinking about future demands and innovative approaches to service delivery, however and wherever.

The other concern is the tendency of these sorts of activities to become a restatement of warm words of praise, and in the end fail to move beyond that to address the underlying interconnectedness of clinical work, the interprofessional relationships and clinical responsibility and indeed to more disruptive and potentially more professionally satisfying professional development itself. Regretfully, the so-called “summary vision” is a weak and predictable statement.

There is nothing inherently wrong with addressing the needs of the NHS, but to address it to the exclusion of the legitimacy of the wider and likely future roles is a mistake.  Indeed, the NHS is a stakeholder in the development of these professions, but should not be given too much authority or control over how the professions develop. When the state steps in, as it has in this case, it should do so with the assurance of fairness to the widest possible range of interests, and not just those that fits its current, and probably ideological, preferences.

In the end, the professions own themselves (in an important relationship with their regulator) and should act to ensure that they confront these issues responsibly. Is it a sign of weakness perhaps that this Commission was even needed? Perhaps therein lies a clue to the future of these professions: take responsibility for your profession, as if you don’t others will.

Smart Hospitals

The elephant in the room in healthcare is the hospital, about which I have suggested that we will build the last one in 2025.  What will “smart hospitals” look like, and why should we care?

Hospital Universitario Marqués de Valdecilla, ...
Hospital Complex, Spain

Why should we care?

Hospitals are expensive and complex labour intensive organisations originating in industrial era thinking.  Little has been done to modernise the institution itself, although much has been done of course to improve what hospitals do. We also know that hospitals account for a considerable carbon burden and consume a huge amount of energy since they operate 24 hours a day. We know that as labour intensive institutions they suffer from the challenges all such organisations face as they try to improve operating practices and reduce running costs. Healthcare delivery is characterised by regulated cartels, which serve both to protect the public, and protect professional practice from incursion by other health professionals.  A bit like an early 20th century factory with craft guilds.

We should care because these institutions need to become smarter in the use of modern technologies and practices, but this process is slow and cumbersome, and while they evolve, the taxpayer is faced with paying the costs of institutions which in many cases should be replaced. This is not to say that those who lead hospitals are not focused on these issues, but only to say that their job is not easy and with the many vested interests around, challenged.

What would be refreshing would be leadership for clinical workflow change to come from the professions themselves, due recognition of their need to evolve and reform rather than simply protect the status quo.  We need these groups to drive change in healthcare, rather than waiting for politicians or Ministries of Health to set the agenda. Of course, informed and empowered patients will eventually not put up with much of the nonsense that confronts them when they seek healthcare, but that is another story.

What will they look like?

We are left with wondering how to improve how they do what they do.  Enter ‘smarts’. This brings together a constellation of forces currently abroad in the world, ranging from automated building management systems, smart grids, energy recovery systems, to wireless technologies in hospitals to remove the wires.

Coupling smart systems together creates networks that can link patients in their home to monitoring facilities and first-responder capabilities. With the added advantage of wireless, we have untethered remote monitoring.  In the end, we have real-time healthcare.

Smart hospitals will not need to define themselves in terms of their geography or location, that is in terms of buildings. They will define themselves in terms of two factors:

  1. their capabilities and
  2. how they deliver these capabilities.

Indeed, the organising logic of the modern hospital will be replaced with one akin to a dating agency — it will link people with needs to capabilities to meet those needs — built on a sea of clinical, and patient information, and connectivity to various organisations that can deliver the services (healthcare) that is needed.  This breaks the current approach to vertical integration (based on the industrial conglomerate model) and replaces it with the virtual hospital, a network of focused and tasked organisations.

I had scoped such an approach to a redesign effort for a teaching hospital, which would have replaced a campus model (mainly an old building and some attached add-ons) with a distributed and electronically-linked (ehealth stuff here)  network of perhaps 24 centres scattered across a city of a million or so.  But industrial era logic prevailed and they went with the single building.

I guess we won’t get smart hospitals until we have smart planning.