Checklists in Healthcare - not easy

Checklists in healthcare is not the same as in other industries and is not easy

Checklists are the hot and happening thing in healthcare today, it is to improve the safety and quality of care delivery.

The WHO safe surgery checklist was evolved after good research showed its benefits across the world in reducing deaths and complications. It is a simple one page document. Prof Atul Gawande who pioneered this effort has described the background using construction, airline and other industries as examples.

The checklists as used in industry and by some eminent healthcare providers places seem to be different from the kind of checklists that we do, including the WHO surgical checklist.

In industry checklists are used to define what precisely the work is, in what order the work has to be done – the people who do the work look at it, do the work as it says (execute the work) and tick the box (checklist) to indicate that the work has been done according to the work specification. Often that is the main documentation to record the completion of the work. Here is an example of a construction checklist http://www.sustrans.org.uk/assets/files/guidelines/appendix.pdf I have no special knowledge or affinity to this particular checklist, it simply comes high up on a google search. I encourage you to look at the detail with which the work is specified. I am reliably informed that many construction checklists are even more detailed and project specific. Prof Gawande's book points that in construction work, checklists are done for every component with about 16 different specialities being involved.

In aviation the checklist is aircraft specific. Here is a checklist for a Piper PA28 which is a very small basic plane which is often used to train pilots and it runs to 11 sheets. It is both precise and detailed – it tells you what degree and what RPM to set and so on. The checklist is read out loud and followed every time. It is never 'tick'/'check' marked, never signed and never filed anywhere.

The ‘check’ in industry e.g. construction – is to indicate the tick, cross, ‘check mark’ other marking in the document – a one step process that documents that the defined work is done. In aviation it is a document that is followed but not filed.

The ‘check’ as used by us in healthcare in general and UK in particular – seems to indicate that we need to check (as in inspect/confirm/verify the correctness/hold back/restrain/stop); by the way this is the dictionary definition. This is a two step process – do the work document it and then confirm in a different document that the work is done. The WHO checklist is an additional document – i.e. the antibiotic is ordered and given elsewhere in the process, documented elsewhere and these are confirmed in the checklist; the checklist becomes a supplementary document. This also gains medicolegal importance and adds the bulk of the medical notes. The WHO checklist is allowed to be changed but is often not and where they change it, is still organisation specific and not specialty specific (and never ever patient specific).



When the industry and aviation use detailed and project/plane specific checklists why did healthcare choose to use a single page, generic, general checklist? Clinical medicine and healthcare delivery is obviously more complex than industry or aviation, yet the checklist is a simple single page. The beauty of the WHO checklist lies in its simplicity. It has proven itself under research conditions across the world. However, it is valid to ask whether it is proving itself in real time practice in the NHS. The evidence is not clear yet if there has been a year on year decrease in the incidence of various problems the WHO checklist is supposed to address. The consensus is that the checklist helps.



My personal view is that a one size fits all checklist that the WHO Surgical Checklist is will see its own limitation in time; after all there was a checklist even prior to the WHO one. Procedure specific checklists are the needed urgently - a good example is the matching Michigan checklist for the insertion of central lines. For surgical patients, each patient/procedure should have a customised detailed and specific checklist with an obligation for the surgeon, anaesthetist and their teams to modify the checklist prior to surgery to a patient specific checklist. This empowers the local team members and the process becomes directly relevant to the specific procedure that a specific patient is having on a given day. That is when the power of the checklist seen by Atul Gawande in aviation, construction and finance can truly be realised in healthcare.

©M HEMADRI 

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My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 

A day in court

Attended Leeds Crown Court recently. First time in court as a professional taking the stand to provide witness evidence for defence (no not as expert witness).

Standing in the cold, very windy, wet pavement fully drenched in a queue to go through security to enter the court building was irritating and unpleasant start. Contrast that with the NHS, we do not keep our customers/patients/visitors on the pavement wet and soaking before they get into the hospital.

I believe there was a change of judges and our judge was given the case only at 4.30 pm on the previous day. Well, well, not so different from the NHS.

Then there was the matter of the court room itself. The judge informed us that the room was that of a criminal court whereas our case was a civil case. With some humour he added that we would find all the chairs were bolted to the floor as some people in criminal courts tended to use the chairs for purposes other than sitting. There was another attempt at humour about bowels which in my personal view did not really click as the case involved a patient who had severe complications on that subject. This would have been seen as poor taste in the NHS and it would be well possible that GMC or other authorities might take a dim view of this, if doctors were to joke about this.

Barristers, though masters in their work, seemed to show significant stress, one with furrowed brows and the other with clenched fingers to the point of blanching. It is not easy for the barristers as they stop between sentences to allow the judge to type his notes. I was particularly impressed with the claimant's barrister's knowledge of the relevant anatomy, pathology and their applications to the surgical technique. They still wear the funny wigs.

I noticed about 6 or 7 large lever arch files with identical individual copies for the judge, barristers, witness and solicitors. At least 4 large document transport boxes for the defence. Two large size luggage cases, many stroller type luggage cases, many 'pilot' boxes. If you hated the NHS paperwork you may want to change your mind and be thankful that you are not a lawyer.

It is very difficult especially for lay witnesses when the 'do you recall' question is put to them only then to be countered by 'it is not suggested in the notes' response. An expert witness was shaking his head in the yes/no directions as the witnesses were speaking – wonder if that would influence the witness responses.

If you thought NHS was hierarchy bound, think again. The court had highly defined places on who will sit where in strict order of rank with the bowing and formality. Apparently barristers who did not take toilet breaks at the right time have even gone into urinary retention. A colleague made an observation that the judges and barristers did not share the same cafeteria as the witnesses and visitors whereas in the NHS doctors shared the same cafeteria as visitors. I suppose the medical professional equivalent of the much valued water cooler conversations cannot happen due to concerns of potential confidentiality breaches; a lost opportunity.

The judge and lawyers were very polite, considerate and respectful to the doctors in room. The judge noticed that senior doctors were sitting on very uncomfortable observer benches and moved them to jury box chairs (there was obviously no jury in this case) which were far more comfortable.

In my personal view the overall customer experience is better in the NHS when compared to my one day at court but obviously you would expect me to say that. In terms of what goes on insider the court room, one clinical colleague called it daunting, another called it long drawn out and boring. Personally I found the triangulation between the witness's aim (to speak the truth, nothing but the truth and the whole truth), the lawyers aim (to get to that part of the truth which will support their client's case) and the judges aim (to constantly probe which way the balance tilted) confusing and demanding; this became particularly acute while in the witness stand.

What stuck to my mind was the judge saying in mild frustration something like 'in cases involving patient care the doctors can't agree on anything and then the lawyers can't agree on anything' and carrying on with a wry smile. Shows the importance of agreeing as the starting point of good clinical care, which incidentally is the best means of avoiding the courts in the first place.

©M HEMADRI 

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PS: The inability of doctors to agree is part of Clinical Wrongology. An attempt is made to resolve it by asking my 4 fundamental questions

'Nakamura invented the light bulb'

Would Nakamura invented the light bulb if he was working in the NHS?

Nakamura invented the light bulb, that is what we might probably say one day, that Nakamura invented the light bulb or to put it correctly that Nakamura re-invented the light bulb. Shuji Nakamura's inspiring story has been told before but here is an ultra-short version of it

Nakamura gets a masters from a relatively small university in a small city in Japan, goes off to work in a small company in a lab competes against the big companies, discovers many right things and makes products that would not sell.

Times get difficult, his department shrinks. He goes to his boss and wants to make a product that the big boys have tried to make and failed; with his record, he gets turned down. He goes to his boss's boss and gets some support to make it, despite his record of making nothing that sold, his company chairman gives him money, $2mil actually and he reinvents the light bulb. Well, he actually gets the blue component of the LED to work and the rest is history.

What is interesting is that Nakamura was a non-PhD working in the industry as a lab scientist who then gets a doctorate from his local university and within 5 years is head hunted by University of California and becomes a professor.

Nakamuras in NHS?

Let us imagine a scenario of a doctor who becomes a consultant in a DGH in the NHS and wants to do something that the big boys tried and failed.Then the DGH consultant fails as well, fails repeatedly - what are the chances that he will not be performance managed out of his/her activity and driven to the end of his wits.

What are the chances that the medical director or CD will be over-ruled by the CEO or Chairman and a doctor provided funding to carry on despite a record of 'failure'? What are the chances that even after this doctor discovered something interesting a big place will head hunt and make him/her an 'academic'? In fact he/she should be grateful if the GMC and the rest of the regulation did not land on him/her and crushed him/her out of existence.

Getting real

Now a lot of you are going to say that reinventing a light bulb while surely profound is unlikely to involve any damage to real human beings. You might say that any lurking Nakamuras in the NHS if supported could end up hurting patients. Good logical argument. Is that what is really hurting patients? Probably not. It is not any innovation by enthusiastic people that harms patients, it is the bureaucratic nay sayers who use the language of clinical governance and risk yet know very little about process capabilities, refuse to learn shared baselines, practice unimaginatively poor leadership who perpetuate harm in healthcare. They refuse to fix the system instead try to 'fix' the people in the system. Of course the medical profession does not do itself any favours by its ego, jealousy and macho attitude which will aim to shoot down anything that arises outside its hierarchical constraints by treating them as bad apples and recommending the use of evidence the origins of which  can probably attributed to the Abilene paradox.

In healthcare especially in the NHS it is pretty much impossible these days to take an extra breath without CD, CG, R&D, GCP, LREC, NREC, NICE, and every other alphabet in the soup wanting to spoil it for you, while claiming to support you. It is when people who are typically NHS managers and every other hierarchical bureaucrat stops behaving like researchers and most doctors who are not researchers begin to look at operational evidence as a valid method of creating a new practices, innovation and improvement that healthcare will be truly successful.

Allowing and managing 'Nakamuras' in healthcare is not easy but will be rewarding; eliminating the healthcare 'Nakamuras' will allow the managers to sleep peacefully but might push true healthcare innovation into a coma.

If you know of any 'Nakamuras' in the NHS please let me know by leaving a comment below.

©M HEMADRI 

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Links & reference
The dream of the blue laser diode
http://engphys.mcmaster.ca/undergraduate/outlines/4e03/Nichia%20%27s%20Shuji%20Nakamura%20Dream%20of%20the%20Blue%20Laser%20Diode.htm
Time magazine short feature on Nakamura
http://www.time.com/time/magazine/article/0,9171,1604891,00.html

Preventative Health Checks: Just because you could, doesn’t mean you should

“Just because you could, doesn’t mean you should” was a “mantra” given to me by one of my family medicine teachers and I have come to appreciate its wisdom over years. Over the last decade as a practicing clinician, I have come to realize the limitations of modern medicine, started seeing patients as people with different goals and values and have been trying to equip myself with knowledge of patient centered healthcare.


Preventive Health checks in India have gained popularity in last decade or two. As a practicing physician in urban India, I come across patients who have been getting the “health checks” year after year. A huge number of patients are “self-referred” and get annual check-ups in hospitals and diagnostic centers. A good number of these check-ups are also offered through the employers and I have seen patients in their early 20s getting routine health checks as well.


I looked up the health checks offered and they come in various forms. I asked some of my patients to look at these packages and tell me which one they thought was the best package for them. Some picked the most expensive package; some went by the keywords like “full body check-up” or “advanced” check-up. Very rarely do I come across patients who understand exactly the tests they have been getting and the appropriateness of these tests. While there are some hospitals/centers that have put some thought in designing the “health package”, a majority of them take the “shot-gun” approach of offering multiple tests that all the patients undertaking these packages may not necessarily need. Some examples are routine ECGs/ECHO in young adults, pap smears in women older than 65 years, routine abdominal ultrasounds in young adults etc. Some even go to the extent of causing potential harm, for example, cancer biomarkers for several types of cancer- many of them have been studied to cause more harm than good. Also, In patients at little to low risk for heart disease, an electrocardiogram or stress testing can actually lead to harm. However, they seemed to be a common component of majority of health checks.


A recent analysis from Cochrane review concluded, “General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased.” Due to missing or unreliable data, the authors could not estimate costs, harms, or the use of follow-up medications and testing as the result of screening. Although all the studies used for this review are from western context, I think this study brings out a whole new perspective on how we should look at the preventive health care sector in India.


I am a family physician who strongly believes that “prevention is better than cure”. I am a “prevention enthusiast” who believes preventive measures done right can not only add years to your life but also improve the quality of life. As Dr. John Mandrola says, “The four legs of the wellness table are good food, good movement, good sleep and good attitude. Doctors can’t do this for people, neither can screening tests nor pills.” Moreover, in most of the western countries, the preventive health care recommendations are offered and to an extent “tailored” to meet the patient’s risks as opposed to Indian setting where one can walk into any center offering health checks and get a whole host of tests done. So, if there is strong evidence showing general health checks do not decrease the risk of deaths from cardiovascular events or cancer, why are they so popular? Two of major reasons in my opinion are lack of patient engagement and education related to preventive care on part of family physicians and a “belief” held by majority patients that these health checks will make them healthy.


There has been extensive discussion following the Cochrane review and there are few things that one can argue upon as being beneficial. For example, Checkups can be beneficial in getting people to think about their health. Also, if the health check-up is being offered by your family physician, there is value in getting tailored approach to your preventive health check. There is also evidence for some meaningful screening approaches, such as screening obese patients for diabetes risk, patients with a family history of disease etc.


I guess, the bigger question, to ask is not whether preventive health checks are needed but how should they be designed so that they truly impact the lives of majority of people undertaking these health checks.


Dr. Danielle Ofri writes, “a detailed conversation is much more likely to uncover lurking medical issues than the physical exam or blood tests”. Even in the hospital setting, the advantage of detailed history and exam supersedes any combination of labs and imaging. You can see the results here and here. In my experience, however, these are two things most neglected and many a time skipped in most of the health checks being conducted.


Now, Let’s talk about the preventive measures that are backed by strong evidence but don’t make it to the preventive health checks: Counseling against tobacco and alcohol use, mental health screening for problems like depression and anxiety that are increasing in great numbers, obesity, infectious diseases (TB/HIV etc) and certain adult vaccinations etc.


So, Can we design a health check that can steer a patient towards wellness and just not give a “sickness free” check? Can we have a healthcare innovation from India that is disruptive enough to make a business case for “prevention” without relying on battery of diagnostic tests?


© Dr Jaya Bajaj
Guest Blogger


Dr. Jaya Bajaj is American Board of Family Medicine (ABFM) certified Family Physician with strong clinical and research background. She is a strong proponent and practitioner of patient-centric, evidence-based medical practice.

She graduated from ETSU Family Medicine Program, holds MPH in Biostatistics from University of South Carolina, Columbia, SC, and MBBS from Nagpur University. She also has completed Executive General Management Programme at Indian Institute of Management Bangalore.

She is passionate about improving patient care in India and believes technology can play a key role in bridging the knowledge gap. Dr Bajaj is the founder of HealthRadii, a healthcare networking site.

(Dr Bajaj's declaration: I am a family physician and this article only addresses preventive healthcare issues in adults.)

The Pretence of Better Communication

This blog was first published at doc2doc http://doc2doc.bmj.com/blogs/doctorsblog/_pretence-of-better-communication It has been modified, extended and re-posted here.

Discharge Summaries in NHS
10 years ago in the NHS most consultants used to do discharge summary letters for their in-patients. Quite rightly so. The discharge summary was and is the only communication that the hospital provides to primary care on what happened to the patient in the hospital. It is one of the most important pieces communication that the specialist sends to the generalist. It was the knowledge of the expert given as an opinion. It was also an opportunity for the consultant to review and reflect on the care provided, identify errors and recognise the capability/limitations of the team members.

5 years ago the consultants mostly devolved this responsibility to some experienced staff working with them such as Staff Grades or Registrars. The discharge letter became a task that had to be done. Information was passed to the general practitioners.

Now, the discharge letters are electronic and are primarily if not exclusively done by FY1s or FY2s who are the least experienced doctors in the system. Discharge letters are a part of the contractual requirement to be sent within a set time. There is enormous data within those discharge letters which is sent to the GP more or less contemporaneously. The junior doctors do a very good job; of transmitting data; they cannot with their level or training, expertise and experience do anything more.

Anyone who knows a little about this things will recognise that to derive any meaning or learning from what we do on a day to day basis, data has to be processed and assembled to generate information; information has to be analysed and contextualised to create knowledge. In the case of the NHS discharge summaries, knowledge transmission has now deteriorated into data transmission. Transparency and detail which are important have taken the place of trust and succinct senior opinion which are equally important.

The most crucial and often the only piece of communication from hospitals to general practices is now generated by a combination of off the shelf software programmes filled in by the junior most medical staff and usually has no oversight from anyone senior. Of course there are reasons for this, the letters can be generated quicker, can reach general practitioners on time and the current economic climate a consultant who is an expensive human resource is better used doing actual clinical work. Fully understandable. But let us not make the mistake of assuming that this is superior communication.

A friend who works on analysing and reporting risks in financial industry wrote in to say 'in my area of work if I do not provide the final oversight on what gets published on the credit opinions..which can sway bond markets...an error means I can be banned from working in financial services...if related to sovereigns...maybe jailed as well'. Now that's how seriously communication should be taken.

The Abuse of Communication Skills

Now that this blog has a growing readership; friends and acquaintances are writing in with examples from their own places of work. There seems an increasing cultural tendency where people think its okay to abuse communication skills. Righting a wrong not by action but by words. Not fair but read on.....................

Car Parking Vs Patients

Clinician running late, found a parking place and noticed that the parking permit was missing. Dilemma. Go to work and ring security to inform - risk of clamping and £60 fine. Go to security first and late to work - patients waiting.

Decision. Go to security first. Cannot afford £60 fine.

Explanation: 'Oh we can apologise to patients, show them empathy, sympathy, tell them our story, sit by their side rather than opposite them, perhaps even hold their hand and build a better relationship. They will forget the waiting. But security will clamp and will fine £60; my work place will not be supportive'

'We can handle complaints'

Bed manager rings on-call doctor: 'Try and send patients home from A&E, there are no beds in the hospital and we don't want patients to breach in A & E'

On-call doc: 'Well, apart from clinical reasons, there is also patient expectation. We could have serious complaints'

Bed manager: 'Oh don't worry about that. Complaints come only later. We can handle that. We are really good at handling complaints. We can provide them a detailed explanation and an apology if necessary'


Those are classic examples of abuse of a good skill. I have a problem with people using great tools and doing wrong things with it.

Let us get real. Let us not delude ourselves in the NHS by harping on about the primacy of communication.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Servant Leaders in Healthcare - Stand up and make it count

Airline operational performance results for major carries in USA have come out and it shows that in general flying experience parameters are all getting better. The WSJ has a nice tabular column which explains it really well.

Southwest Airlines had the largest number of system wide emplanements (I take this to mean the highest number of passengers took Southwest flights) and they have the lowest rate of complaints per 100000 emplanements. Southwest had about 40% less complaints than the next best complained airline and the highest complained about airline had 14 times (1400%) more complaints than Southwest.

United had the highest complaints. The stats show that United had the highest rate of bumping (passengers denied boarding due to overbooking by airlines) and highest rate of lost baggage and understandably they had the highest complaints.

Then an interesting fact leaps out:

Out of 7 major USA airlines, Southwest had the second highest rate of bumping, third highest rate of late flights and was in the middle of the field for lost baggage but had the lowest rate of complaints. As I explained earlier it was not just lowest it was (at least for the month November 2011) had 14 times lower complaints than United.

There is nothing more that annoys passengers than bumping or flight delays or lost luggage. Why did Southwest have such a low rate of complaints? Why did Southwest customers not complain more? Looking at the data, one would expect many more complaints. How can we explain this?

Southwest Airlines practices Servant Leadership, which is pretty unusual at a whole organisation level. Servant Leadership seems to have led to employee empowerment which then leads to building ground level relationships with customers. All those lovely videos on youtube about Southwest are examples. Customers begin to see Southwest employees as 'friends' who are coping with difficulties that are common and typical of airlines; they do not want to add to the burden of their 'friends' by complaining.

Relationships trumps poor stats and bad stories. This is true of healthcare as well. Patients relationship with their doctors and their local hospitals are the ones that keep our NHS hospitals going; if that was not the case we would see a significant movement of patients away from high mortality hospitals every time the mortality results hit the press or a bad news story hit the press. That is not happening at a perceptible level.

However, some hospitals are finding an increase in complaints every time the mortality results are published and on the occasion when bad news stories are published. Complaints are a useful tool for feedback, problem detection and improvement but when an organisation is already on a well recognised path of validated development complaints on routine operational matters can also be a source of distraction, expense and negative publicity. Problems which were not or could not be prevented, as might happen in healthcare often, if identified, as soon as they happened and customer service methods were used to deal with them, could avoid complaints and its ill effects.

In an organisation that is clinically performing well, to ensure that the doctor-patient relationship and the hospital-patient relationship which clearly exists is translated into a low number of complaints would need empowered employees enabled by an organisation wide servant leadership approach.

Where are the servant leaders in healthcare? Which organisations follow servant leadership approach? I can recognise very few leaders but no organisation practising servant leadership.

The thoughts on servant leadership are quite old, ''Mark 9:35 Sitting down, Jesus called the Twelve and said, "If anyone wants to be first, he must be the very last, and the servant of all''; there are other religious and philosophical variations which are older and younger to that quote. However the management description of it was by Robert Greenleaf who wrote:

"The servant leader is servant first. It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead."
"The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priorities are being served. The best test, and difficult to administer is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servant? And what is the effect on the least privileged in society; will they benefit, or at least not be further deprived?"
Robert Greenleaf: The Servant as Leader 1970. (http://www.greenleaf.org.uk/about.php)


One would have thought that the medical profession with its high altruistic calling of serving the ill would abound with servant leaders; it seems that may not be the case. The time has come for any true servant leaders in the NHS to stand up and be counted as this seems a good model for leadership development for our caring and noble profession.

©M HEMADRI 

Follow me on twitter @HemadriTweets

References

http://online.wsj.com/article/SB10001424127887324081704578231553159491828.html
http://www.dot.gov/sites/dot.dev/files/docs/2013JanuaryATCR.pdf

This blog was originally written for and posted at Faculty of Medical Leadership and Management  https://www.fmlm.ac.uk/blog/makani-hemadri/servant-leaders-nhs-%E2%80%93-stand-and-be-counted
Re-posted here 

End of management (long version)

A shorter crisp version (about 600 words) is published in the FMLM (blog http://www.fmlm.ac.uk/blog/makani-hemadri/end-management)  for which this topic was originally written. This is the rambling 1500 word extended narcissistic version. You are welcome to it ...  

It is important to read Alan Murray’s ‘The End of Management’ Corporate bureaucracy is becoming obsolete. Why managers should act like venture capitalists; in the WSJ. Here is the link: http://online.wsj.com/article/SB10001424052748704476104575439723695579664.html

Once you have read this blog post gets its context and then you can read this either as a commentary of the WSJ article as relevant to NHS or on its own. This blog is deliberately off-key, the topic is such, bear with me. Compared to many healthcare systems we do quite well in the NHS. Could we do better? Of course yes but how we do that will define our future.

We are the management and we will tell you how to end management!?!?!

At a broader level, in the NHS there are no examples that I can think of where corporate structure or management has been ‘ended’. The previous government did good work with top down waiting times and so on; the present government is attempting top down radical change in organisational structures. The government is trying to get us do differently. When individuals try to do something creative, the organisations and the NHS as a whole tries to look at 'where and how it fits in with the overall plan'. But in the public sector there is the government not just wanting us to do different but also telling us how precisely to do it; with organisations 'encouraging innovation and creativity' only if it fits in with pre-defined policies. But that is what modern business is trying not to do; modern thinking in management is not telling people what to do but to let people to do things first and the management to amplify the good ideas.

Thinking of me vs thinking of you

At the narrower level, trainees (I am talking about all trainees in the clinical areas- not just doctors) are taught to think of how they are learning and improving themselves; never to explicitly think about their contribution to the organisation. In fact, often people think that their contribution to healthcare as such starts only when they stop becoming trainees. By that time the mind set becomes so fixed in thinking inwardly about the self and not outwardly about others that it becomes very difficult for the rest of their lives. Careerism becomes the mantra for many people in healthcare; we always thought this was the case in the private sector - true but that trend is changing in some areas. 

Best with limits

This leads to people taking very defensive attitudes. Most people in healthcare management are either numerically shy or numerically illiterate. They are unwilling to make a personal numerical prediction on their or their department/division/directorate’s improvement based on a measurable internal parameter due to the fear that they may be unable to stand by it. In any case most of the numbers are geared towards predefined reporting parameters. People who work in the NHS also seem to think that they are somehow very altruistic and have a high sense of entitlement. That attitude is even more profound in the clinicians with clinicians tending to believe that they express their altruism by their very individualistic approaches to healthcare. It is also possible that there are certain kind of people who are drawn to public services (possibly risk averse, change shy, rule-bound, authority loving, service minded and so on) and it would be difficult to use the same methods as for instance in Google to achieve a new management approach.

At both the above levels, healthcare and NHS is thought to be too important and too costly to be creative or innovative; the phrase used is 'risk'. Healthcare especially in Europe and even more so in UK has innumerable external controllers and bodies telling people what to do and how to do it that it simply chokes off creativity even before it begins. In other industries there is an obligation to do some degree of statutory reporting with no real controls on how they do their business.

So, it seems like what the above WSJ article is saying is not possible in UK healthcare at all. There seems no space that is available or can be created for those concepts to happen without falling foul of something or someone. But there lies the opportunity as well to ‘end management’ and create self-sustaining systems.

Blue skies

Hence, I can now boldly enter the imaginary world to explore how the 'wisdom of the crowds' can be harnessed. I think the way to do it is to disengage from current conventions and demonstrate its success. That does not mean rebelling, non-cooperating, behaving illegally, not concentrating, becoming disenchanted or any such thing. It is using our own methods to satisfy our requirements and our clients’ requirement rather than using a method or doing a thing to satisfy an external definition. 

For instance when the roads around Birmingham were choking instead of building a new road, they opened the hard shoulder to traffic which in other roads is actually illegal; peak time traffic situation has improved since in that area. Compare that with an example of the situation in some hospitals where they buy yet another business intelligence interface/data-mining tool to provide information at service line specialty level when the managers and clinicians often feel that human connectivity was the issue that needed resolving to enable their older software to be used effectively. Often the tool is not really the problem, our thinking is.

Let us assume for example that one of our services is not accredited by some specialty society because we did not meet one or more of their requirements in the way they wanted. Normally the tendency would be either to stop that service or to work very hard to meet that accreditation standard. However, if our results in that particular specialty or aspect is better than anywhere else, would we as an organisation, anyone in the specialty society or the general society as a whole be unhappy? Certainly not. In this scenario the badge of not being accredited becomes a badge of honour. The problem is we do not think like that in the NHS. We probably should.

Like the Birmingham roads, what 'illegal' things could we do to make ourselves better?

Obviously we should disengage and develop only if it is beneficial to our hospital and patients and we are able to track it and prove it contemporaneously.

Is this an example of wisdom of the crowds in the real world of healthcare?

     Finally let me try a hypothetical yet hopefully practical proposition to disengage and demonstrate. There is a focus on Unplanned emergency re-admissions and we may not get paid for such re-admissions. I am aware of some of the things that we have started doing to tackle this issue. Let me put to you a potentially disruptive solution in the 'end of management' mode 

     

      a) not offering routine follow-ups for any patient who is discharged from the ward (medical, surgical, post-operative) 

and instead

b) Guaranteeing a clinic slot within a defined time (48 hours to one week as agreed) should the patient choose to contact us.

My hypothesis is, this approach will reduce unplanned emergency readmissions as the issue is often/mostly to with patient concerns on access (rather than real life-threatening matters); the 'routine' follow up itself is mostly to satisfy clinicians habit rather than a scientific finding that all complications in all patients happens precisely 3 months after seeing the doctor and hence patients need a 3 months appointment. This will also clear up the 'congestion' we have in our clinics. 

Okay, where is the 'wisdom of the crowd' here? The crowd in our example is the patient; and the wisdom is the patients’ knowledge about their own health on what is wrong with them and they should be able to access us when they find something wrong with them. This is of course one step further than the current thinking on 'crowd' which is usually the employees in a large organisation. We even need to change the definition of crowd to suit our requirement. 

Rambling ambiguity and the threads of new systems

We can predict that the conventional management methods will not work in the 21st century. End of management as we know it is not chaos as many would like us to believe. New models are not apparent or clear yet. Perhaps there may not be one new model; possibly there may not be a well defined model at all. There are emerging themes; democratisation of data, data mining, crowd sourcing, coping with anti-knowledge, cloud care and dumb-terminals, many more............ It is not these themes that are important; it is how we implement these themes that are relevant. We can be told how to do it thus not ‘ending management’ or we can show how we do it.

Thank you for getting to this sentence of the blog. If you thought this was rambling ambiguity, I am grateful for your attention and will do better next time. If there are some threads that we can build on then I have achieved my aim.

©M HEMADRI 

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