When rules are barriers

I saw a photograph of a hospital outpatients department from 1904.  It looked remarkably similar to my hospital today; lots of sad, bored-looking people waiting patiently to be seen.

When you think about it, very little has change in the basic process of medicine.  The patient identifies that something’s wrong with them and they try to find another person, who might know what it is and be able to help.  You could illustrate it like this:

Patient has a problem

Doctor has a solution

The bit in-between

The starting point is the same as it always been:

• You notice something’s gone wrong (react to a problem)
• You search for some help from an ‘expert’ (this could be informal or formal)
• The ‘bit in-between’ can take a circuitous path, a long time and may never work out

In theory, this process should be amenable to great improvement using information and communication technology.  It’s really just about bringing a problem and a solution together, which IT is great at doing.  So, why don’t we do it?

In short, I think it’s ‘culture’: the way we do things around here.  When you’ve got something wrong with you, you’re vulnerable and tend to default to what you know.  The doctor has a vested interest in your need (he/she has great status and earning power by meeting your need).  So, both parties are in a comfortable relationship.  In transactional analysis terms, it’s like a ‘parent-child’ relationship.  Both parties know what’s expected of their role and there’s no pressure to change.

But, it’s the ‘bit in-between’ that’s the problem.  It’s full of frustration, wasted time and poor outcomes.  The NHS seems to institutionalise these poor processes.  It is incredibly resistant to change, as any effort to change is immediately seen as an attack.

However, ‘culture’ does change, be it ever so slowly, as the way that people interact day-to-day changes.  IT changes the way we interact, think of social media, texting, messaging, etc.  These external social changes will permeate healthcare and slowly shift the status quo.  Doctors, who rely on possessing ‘elite’ information will be particularly vulnerable as patients will be able to garner the same information for free.  GPs will be especially at risk as they represent an intermediary, or ‘middleman’ between patient and expert.  Disintermediation has a proven track-record of making processes more efficient (think of buying insurance, for instance). 

A practical illustration is rectal bleeding.  Algorithms exist for improving decision-making concerning those patients with bleeding from their anus.  A few simple questions sign-posts the patient to the appropriate specialist without the need for a generalist intermediary.  This saves time, money and suffering.

At present, such a system would be ‘illegal’ in the NHS, since there is a rule as old as the hills, which states that no patient can access a specialist without going via a GP.  Such anachronistic rules act as barriers to innovation and until they are changed, they will effectively inhibit process improvement.

The ‘rules’ are created by politicians and advisers at a ‘high’ level, and operationalised by NHS managers at a ‘low’ level.  By the time they reach the ‘frontline’ they can bear little relation to the original intention, having been altered by misinterpretation, misunderstanding, and sometimes deliberate sabotage.

So, the NHS is in need of deregulation, that is, removing unnecessary rules that simply preserve the current, mediocre system.

Zero harm

Zero harm

It’s fashionable in healthcare management circles to talk about ‘zero harm’.  The phrase implies a zero tolerance of anything that might possibly harm a patient, a kind of guarantee that no patient is harmed in this hospital. At its centre is perhaps the idea that if scrupulous care is taken in everything, including the small things, then the big things will take care of themselves.  If we eliminate the possibility for error then no harm can ensue. It’s a bold claim; can it be achieved? 

In some ways, it’s akin to the old medical aphorism, attributed to Hippocrates, ‘Primum non nocere’, ‘First of all, do no harm’.  There are nice differences however.  First, do no harm, means:

• Do nothing unless it helps
• Don’t make the patient worse

The principle is non-malfeasance, not intending to harm.  At medical school, students are taught ‘never say never’, if a patient asks, ‘is this dangerous?’.  There is nothing in medicine that is risk-free.

I like another aphorism from a 16^th Century French surgeon, Ambroise Paré, who said:

‘Cure sometimes, relieve often, comfort always’.

In other words, as a doctor, you should always be able to do something that makes the patient feel better, even if it’s just holding their hand.

So, I think what people who espouse ‘zero harm’ really mean is ‘zero preventable harm’.

Culture

There are well-described cultures and sub-cultures in healthcare organisations.  The ‘way we do things around here’, always trumps top-down instruction.  As Peter Drucker famously said, ‘culture eats strategy for breakfast’! 

Humans make mistakes.  There are two basic types; slips and lapses.  That is, things I didn’t mean to do, but did, and things I meant to do, but didn’t.  As the Anglican Confession makes clear, all human error is summed up by ‘sins of commission and omission’.

Happily, this is where electronic systems can have real impact, since they change the way people interact with one another day-to-day.  Dysfunctional cultures can be modified by the constraint and discipline that electronic systems impose.  A great example is the simple one of legibility of prescriptions.  Every year, thousands of patients are potentially harmed by adverse drug incidents, some of which are simply due to the fact that the nurse couldn’t read the doctor’s handwriting.  Electronic prescribing eliminates this particular risk from go-live.

Electronic systems that alert the user to potential error (‘do you really want to do that?’), such as drug-drug interactions, or prompt the user to take action (‘the oxygen level is unusually low!’) can really help overcome slips and lapses.

Change

Zero harm is really a cultural change aspiration.  Information can drive the change.  If you want to reduce the amount of alcohol you’re drinking, start by keeping a diary of everything you drink.  By making the issue visible you begin to change.  Model the change you want to see in others.  If ‘zero harm’ is really important, then the senior Executives and medical leaders need to demonstrate it, for example:

• Executive safety ward rounds, asking questions like, ‘What’s not safe around here?’
• Staff focus groups, ‘when did a patient last come to harm here?’
• Stop insisting on activities that we know add little value, such as clinical audit!

Conclusion

The more I think about it, the more I feel that ‘zero harm’ is about quality.  There are dozens of definitions, but, ‘Right first time, every time, all the time’, links the two ideas.  Quality is often cheaper, and quality is safer.  Some healthcare organisations are developing a ‘Preventable Harm Index’, which is simply the sum of all adverse events.  There is no denominator, just an absolute number; the aim is to get to zero.

On Wednesday, 20th July, I spent the day at our Leeds offices taking part in the Executive ‘Roadshows’ with several other Execs, and Sheri Thureen (President UK Healthcare).  There were some formal presentations, followed by a ‘Floor Walk’, where Sheri and I met representatives of all the teams at Leeds.  A couple of things stood out for me: 

• The enthusiasm and passion shown by various teams as they described what they do, day-to-day, in their jobs.  I found it really fascinating to hear about the details of aspects of other people’s jobs and the important part they play in making up the whole
• The sense of being part of something really important to the NHS.  All of us do, or will, come into contact with the NHS – we are, or will be, patients or relatives of patients.  We therefore have a personal stake in improving the NHS so that it becomes one of the best healthcare systems in the world.

 In my view, we are at the beginning of what could be the most important and exciting change in the way the NHS ‘does business’ since its inception over 60 years ago.  The intelligent use of information and communication is starting to revolutionise the NHS, and it’s great to be at the forefront of this – and be reminded of it!

Do you know about Action Learning?

Action Learning is a methodology for solving the intractable problems that keep the CXO’s awake at night!

In brief, it is ‘learning through doing and doing through learning’. The basic premise is that those closest to the problem are best able to solve it. It is summed up by the equation: L = f(P + Q)

where L = learning, P = programmed knowledge, (in other words, what we already know and carry around in our brains) and Q = questioning, (to gain insight into how people think, feel and preceive).

If the rate of learning exceeds the rate of change in the environment then individuals/organisations can thrive. If learning is less than the rate of change, then failiure is likely.

Reg Revans, a physicist, who worked at the Cavendish Laboratories in Cambridge, came up with the idea when wrestling with the structure of the atom in the 40’s!

I came across action learning a few years ago, and now see it as an extremely powerful methodology for organisational improvement. Business-driven action learning is a variant that aims to focus action learning on the busienss objectives of organisations. The Singapore conference I’ve just come from brings together best practice, and many organisastions similar to CSC have found it useful (e.g. Siemens, GE, Intel, etc).

Hectic tour accompanying CSC’s CMO

Monday:  Early start on the ‘red eye’ – the 06:54 from Doncaster to Kings Cross, then short tube ride to the ‘Gherkin’ to meet up with Dr Robert Wah.  Today’s our media day.  First stop, the Guardian for an interview with their Social Policy editor, who was interested to learn about the US healthcare system from Robert.  Next, we did a ‘live’ webcast at the HSJ, where Robert’s IT skills enabled the interview to proceed!  We discussed similarities and differences between the two countries health IT approaches.  Back to the ‘Gherkin’ for an evening dinner with a group of influential, senior doctors from London and the South of England.  Great food and lively debate.  Star guest, (apart, of course, from Robert), was Dr Charles Gutteridge, National Clinical Director for Informatics at the Department of Health.

Tuesday:  Morning prep at Mouchel’s offices in Westminster for MP’s briefing at Portcullis House (opposite the Commons), where many MP’s have their offices.  This was to help them understand the importance of IT in the NHS and how it will improve patient care in the NHS.  Unfortunately, something even more important than Health IT must have been on their agenda, as only two representatives turned up (one was the wife of an MP and she was impressed!).  We then travelled over to Cambridge where our CSC marketing  ‘minder’, Simon Lewis, gave us an insider’s tour of the town (him being a 1st class honours graduate from Jesus College – bright lad!).  Later, we met clinicians and managers from Cambridge and Peterborough NHS Trust, and that evening hosted another dinner with senior doctors from the area.

Wednesday:  Car journey to Derby for a big, SHA event at the football ground.  Our ‘chauffeur’ left a bit to be desired (only joking Martyn!).  Again, Robert addressed the participants and congratulated them on their successes, e.g. 18 million patients on CSC’s electronic systems.  He provided a compelling vision of the future of Health IT, where better  information systems produce better decisions.  This was followed by a smaller group discussion where participants could freely air their opinions.  We left Derby and travelled on to Solihull (in a hire car that my EA, Tracey Hewitt, had amazingly provided!).  Dinner with senior clinicians from the Midlands.  I left early to get back to Doncaster as I was in theatre the next morning.

Thursday:  A clinical day for me, anaesthetising and teaching for Orthopaedic surgery, whilst Robert visited Liverpool to hear from doctors how happy they were with our new Clinical Portal solution.  Drove up to Leeds in the evening for (another!) dinner with Robert and some doctors from Bradford, where we deploy Lorenzo, ePF and SystmOne.  It’s fair to say that there was a mixed response, which reinforced my belief in the crucial importance of good clinical engagement in IT projects.  Got home late.

Friday:  Another clinical day, this time on Labour Ward.  Pretty busy, but always a delight to welcome brand new people into the world!  Helps maintain a sense of perspective and reminds me why we’re all doing this important work.

Can ‘austerity’ promote creativity and innovation?

You’ve probably heard the old assertion that the health of Britons during Wartime rationing was never better.  There’s probably some truth in it; certainly levels of obesity were lower, and levels of physical activity higher then.  There were innovative recipes and advice on how to feed a family cheaply and with healthful meals.  Perhaps necessity is the mother of invention, after all!

We often pride ourselves in our innovation and creativity, so I was thinking about how that could be applied to current calls for cost control.  I began challenging myself with the following questions:

• If you added up the combined cost of physical meetings, of which salaries are the greater part, and posted that on the door of the meeting room, would it focus minds on achieving outcomes worth at least that amount?
• What percentage of all my meetings are ‘virtual’? 
• Do I worry about not attending a meeting in person; if so, why?
• Can I confidently exploit virtual conferencing and do I encourage my colleagues to do so?
• How much use do I make of low-cost personal and leadership development tools, e.g. when did I last read a book on these topics?  (see book club)
• How much personal and leadership development can I do ‘for free’.  My analogy here is physical training, do I really need a gym membership and personal trainer, when I could just walk and use the stairs more?  How much does it cost to be kind and offer encouragement?

You will be able to think of more yourself, which in turn will help our colleagues believe that we practice what we preach.  Modelling the behaviours we want to see in others is an essential part of good leadership.  Please point out to me (gently!) when you see my inconsistencies!

Day 1 at CSC – Medical Director’s perspective

Kate had given a lot of thought to my first day. She’d appreciated that a two-hour car trip on the M1 could be awkward and getting orientated to new colleagues and surroundings uses up a big chunk of brain processing-power. She’d built in breaks with no meetings and lined up a useful lunch ‘date’. Very considerate. Yet, we got through all the dull but important ‘house-keeping’ items.

As I drove home, I reflected on the overall impression of the day. I felt quite happy and relieved. It’s well known that people rarely remember what you’ve said, but they do remember how you made them feel. I was surprised by the style of the organisation – open-plan offices with frosted-glass offices for ‘special’ people. At least, that was how it appeared to me. It seemed a million miles away from the NHS. There were no desktop PC’s in sight; indeed, there was very little desktop clutter. Not like most hospitals I’ve worked in, where jumble and chaos seems to be the modus operandi! There were no messy pieces of paper stuck on the walls either. The NHS seems to have been decorated with wallpaper made out of ‘important’ notices that nobody takes any notice of! These visible signs are giveaways as to the culture of the organisation. Just like the way people dress and present themselves, so an organisation signals its values by its outward appearance, whether deliberate or not.

There was also something strange that took me a little while to work out. The place was full of men! I guessed 80:20 ratio. The NHS is the opposite; it’s female-dominated. I don’t pretend to understand the significance of this, but it struck me as a noticeable difference.

I wondered what one of the men would say if I randomly asked them what the purpose of the ‘NHS Account’ was. How connected do they feel to the patients who are going to benefit from their work? How could we make it ‘real’ for them? Could we get some high-quality images of healthcare in action? How about some quotes from patients, doctors and nurses, etc? Do they visit hospitals to see what goes on?

As I talked things over later with my wife (a nurse by background) at home, I remembered how impressed I’d been by the professionalism and dedication of the people I’d met. I was optimistic about the future and looking forward to going back for Day 2!

‘Leaderless’ or ‘leaderful’?

 Both these expressions have been in vogue at different times to describe great organisations.  Can they both be right at the same time?

If Martians landed in the NHS and said to a doctor at random, “Take me to your leader”, what would he/she do?  Personally, I would probably stammer, “Err, what do you mean?  Do you mean the person I think is the head of my professional body (President of the Royal College), or the Chief Executive of the Trust I work in?  Perhaps you mean my Clinical Director or is it the Medical Director?  On the other hand, maybe it should be the Chief Medical Officer; no wait, what about the NHS’s Medical Director?  That can’t be right, it must be the General Secretary of the BMA, or do I mean the GMC?”  I imagine by now the Martian will be having second thoughts about visiting!

Is my indecision a symptom of an egalitarian, democratic Utopia where no-one needs to be ‘in charge’ since all are working towards a harmonious, unified goal?  Or is it a ‘leaderful’ community, one where everyone takes a leadership responsibility and models great teamwork and mutual encouragement?

I guess no objective observer would ever describe the UK’s NHS as a great example of highly effective leadership.  So perhaps my plethora of ‘leaders’ is more of a ‘leader-heavy’ institution, i.e. one where there are more ‘Chiefs than Indians’!

Taking over the asylum

I watched a TV programme about what would happen to the world if all the humans left.  It seemed that the world would ‘just get on with it’!  I then got thinking about bureaucracy in the NHS and what would happen of all the managers left.  Would anyone notice? 

There’s an urban myth in medicine about a doctors’ strike in Australia (or was it New Zealand?).  There was much hand-wringing by the chattering classes about all the terrible things that would happen to patients.  In fact, the number of people dying during the period of the strike was less than normal!  Doctors are dangerous.  (You’ll be able to think of other reasons yourself).  The counter-intuitive sometimes works out right. 

So, what would happen if all the managers were sacked overnight?  Probably not much.  Patients would still turn up for their operations and doctors would still operate.  There would be some disconcert when no salaries were paid into bank accounts, so perhaps we should keep the salaries and wages department!

 The WHO reckons that one of the reasons the developing world’s health services are so poor is that they have no health managers.  When I visited Malawi recently the head of a hospital was a surgeon with no managerial training who appeared daunted by the responsibility. 

Can the lunatics really run the asylum?  Probably; but would you dare try? 

The Next Level: what insiders know about executive success

  Scott Eblin, Davies-Black Publishing, 2006

There is often a feeling of vulnerability when you find yourself in a position of high authority in an organisation.  Many new executives fail to thrive in their new role and self-doubt is common.  Scott Eblin has analysed this transition and come up with characteristics for success.  His book is built around the notion that new executives must let go of previously successful tactics and pick up new ways of working at the higher level.  Simply doing more of the same is inadequate.  He quotes extensively from recognised high-performing executives.

The ideas and strategies suggested in ‘The Next Level’ are particularly pertinent for doctors in managerial/leadership positions, (or those who aspire to such positions).  For most of their careers, doctors have kept their ‘nose to the grindstone’ of clinical practice, studying for professional exams and perhaps engaging in some research of doubtful use.  They have not had to engage with non-clinical managers much, let alone executives or boards of organisations.  So when they achieve some sort of formal leadership role, say, Clinical Lead or Director, they usually don’t have the necessary skills to succeed.

Scott’s book has straightforward, practical advice drawn from real-life examples of success.  If you apply his advice you will astonish your colleagues and delight your board!