Challenges and change in taxing time

The paradigm of care needs to be changed to adopt methodologies appropriate to the needs of the population and to improve patient experience, if we are to maintain and improve quality while taking out cost, write Dr. Peter Lachman, Lead International Faculty RCPI, and Paul Rafferty, Quality Improvement & Organisational Consultant.

Dr. Peter Lachman
Dr. Peter Lachman
The Challenge

Health care systems worldwide face unprecedented challenges that will change the way we deliver care.  The challenges providers of health care face include growing demand, increasing cost, and political management. The healthcare system is under immense pressure with real or perceived lack of staff and beds. Over the past few years cuts in service funding have resulted in the need to find ways to be more efficient and effective in delivering the care that is needed. This has to be against a rising expectation for safer and higher quality care on the part of the funders (government) and patients and their families. The taxing question for all in healthcare is how to maintain and improve quality while taking out cost. The concept advocated by the Institute for Healthcare Improvement is the Triple Aim – balancing quality and good patient satisfaction and outcomes with lower cost.

The answer is complex but it is clear that we cannot continue to operate in the same way if the challenge is to be met. A number of solutions are required and all will involve a close compact between medical and nursing staff and managers. The paradigm of care needs to be changed to adopt methodologies appropriate to the needs of the population and to improve patient experience. Hospitals were designed for infectious diseases and are not appropriate for the complexity of chronic care, which is the result of the increase in life expectancy. The design of services into subspecialty silos is an obstacle to effective patient care. Therefore care needs to be transformed to a new state, using disruptive innovations to decrease cost and make a real difference.  This will require a change of principles of working to allow the development of positive environment of engagement in a learning environment. Constant study of what works and what does not, while honouring the work that the frontline members of staff are undertaking can result in effective change.

Hospitals were designed for infectious diseases and are not appropriate for the complexity of chronic care, which is the result of the increase in life expectancy.

The solution seems simple but is difficult to implement.  Firstly we need to focus on reducing variation by standardising care where possible; both in the way we organise care and in the clinical care we provide. This requires the reduction of professional autonomy and the establishment of integrated teams around the patient, meeting the needs of the patient rather than the system. Secondly we need to sort out flow so that scheduled and emergency patients are not in competition. This will decrease inefficiencies and release resources. It decreases the real demand by reducing length of stay and improving safety. Thirdly, the focus moves to caring for those with chronic care who consume more resource so that we become cost effective and give careful consideration to what is value for the patient and for the healthcare system. In essence this means a critical analysis of how we spend funds before one asks for more funding to spend in the same way.

The change process

The challenges outlined above and the recommended solutions imply a significant level of change. Don Berwick, in his covering “Letter to the people of England”, attached to Mid Staffordshire recommendations implementation report, argued that to meet these challenges we needed to “bet on Learning” and to “Foster the growth and development of all staff and  their ability to improve the processes within which they work”. Many have invested in training staff in methodologies like Quality Improvement, Lean, Six Sigma, etc. But how many have got a return on that investment? How many have achieved the holy grail of sustainable change? In fact one of the surest ways not to deliver sustainable change is to follow the following steps:  Pick an improvement methodology, then a training date, identify the trainees, find a project and then train. This approach could have an opposite effect to the one intended. It can create cynicism rather than real and sustained change. As people come off the training they return to a culture and set of management processes that does not leverage the benefits of the training. They are drawn back into day to day management and fire fighting and don’t have the opportunity to apply the skills learnt. After a while some one begins to ask, “Why, if the training was so great, do we not see change?  And thus the seeds of cynicism are sowed.

The design of services into subspecialty silos is an obstacle to effective patient care.

To mitigate this risk and ensure we get a return on our “bet on learning” we recommend two things in addition to training. Firstly the adoption of a management process that drives continuous improvement. The management process begins with the agreement of a clear set of objectives under five headings; Safety and quality, Access, Flow, Team and Cost. The other requirements of the process are a standardised set of pathways, with clarity of who is accountable for their safe and effective operation and a transparent performance data set. The performance data needs to be presented in a fashion that illustrates variation clearly e.g. using run or control charts and in a manner that engages clinicians rather than disengages them. The key step in the management process is that we run effective data driven meetings where actions to address variation are presented by the accountable pathway owner.  This management process will ensure that improvement projects will be proactively identified rather than project identification been triggered because someone is attending training. The management process will create a sustained pipeline of prioritised improvement projects.

Secondly, a support infrastructure is required for those who are trained.  This will include quality improvement clinical champions with protected time and supportive executive leadership. In addition they need a project support office to track projects aided by improvement coaches and trainers and an integrated change team bringing together audit, safety, quality, data analysis and process improvement.  These two actions in addition to training will ensure that improvement projects become part of business as usual and are not seen as something triggered as a result of attendance at a training course.

In conclusion, the challenge is great, so we need to redesign the way we approach the solution and move to a state of continual improvement, with the infrastructure and investment to deliver the change that will improve quality and decrease cost.

This is a report from the Cork meeting organised jointly by the HMI South and the Royal College of Physicians of Ireland.

Further reading if needed
  1.  www.optimizehealth.org
  2. Going to the Moon in Health Care: Medicine’s Big Hairy Audacious Goal (BHAG)E Emanuel JAMA. 2013;310(18):1925-1926.
  3. Increasing Demands for Quality Measurement
    Panzer et al JAMA. 2013;310(18):1971-1980.
  4. M Porter and T Lee http://hbr.org/2013/10/the-strategy-that-will-fix-health-care/