Healthcare change: the ingredients needed.

Healthcare change: the ingredients needed.

Our earlier exploration of healthcare has highlighted that many healthcare systems are under pressure and need to change.

We have also identified that healthcare is a example of a complex system, where change is difficult to achieve. In our exploration of complex systems we have identified that the Cynefin framework can be useful in framing discussions about complex systems such as healthcare.

Having identified people, process, information, technology, standards and value as key elements amidst the complexity of successful change, we now explore if these patterns apply to healthcare?

Let us begin our exploration of these patterns in healthcare by taking a clinical issue for starters.. e.g. the improvements of trauma care that emerged from the introduction of ATLS internationally.

ATLS: People, Process, Information, Technology, Standards, Value

Prior to the introduction of the Advanced Trauma Life Support (ATLS) programme there was no international standard approach to the management of trauma care and so outcomes varied considerably and were often suboptimal. The success of ATLS can be explained by examining the key elements in successful change…

When Nebraska Orthopaedic Surgeon James Styner and his family suffered in an air crash, the poor care they received immediately after led Styner to conclude there was a significant problem with trauma care and to then lead the changes needed.
The ATLS programme is now professionally led by the American College of Surgeons. This ATLS training programme that began in Nebraska, has since cascaded the cultural change and training required across the medical profession internationally.
ATLS requires a team approach to trauma care where team members take individual responsibility for key processes (see ABC below)

ATLS enforces key common process (and good practice) patterns that are key to success in trauma. Those processes are labelled ABC, i.e. Airway, Breathing, Circulation and should be undertaken in that order, i.e. you should address problems in order of A then B then C, regardless of how complex the case. Once complete you should reassess in a cyclical fashion.
This simple set of rules amidst the complexity helps unite the whole trauma team effort.

The language of ABC offers the trauma team a shared and well defined language which helps greatly. The trauma team leader can simply tell a member to look after “A” and that is widely understood. Trauma care documentation is standardised with a trauma chart.

Each of the key processes has a related set of technologies that are key to success. e.g.
A: Airway adjuncts and Oxygen supply.
B: Breath sounds- requires stethoscope for listening.
C; Circulation; IV Access for taking blood samples and administering IV fluid replacement.
Again all of these are universally understood.

The ATLS approach is in essence a set of professionally led standards that help address a challenge that previously suffered from unnecessary variation.

The value sought in ATLS is a mix of time/ safety/quality.
The “Golden Hour” of trauma care simply means that time is a proxy for good care.  Standardised processes ensure a safe approach and greater consistency in the quality of care, regardless of the setting.

Our structured exploration of the common people, process, information, technology, standards, value  issues in trauma care should help explain the importance of these key elements in change.

We will now move onto another exploration.. this time from the UK.

This second example of healthcare change revolves around the 4-hour Emergency Care in the NHS in the UK.

Ahead of the recent reforms in Emergency Medicine in the UK, the care of patients in the emergency departments in the UK was less than ideal, with many patients waiting long times to be seen by medical staff/ on trolleys to be admitted to the inpatient ward. While these conditions still prevail in many healthcare systems around the world, the NHS has been pioneering changes in the Emergency Care over several years and with dramatic results.

The changes in Emergency Department care were led from the top of the Department of Health in England, with the appointment of a Czar for Emergency Care to oversee the changes. They were also supported by the College of Emergency Medicine in England which helped to tackle the cultural change which was required.
While the changes were led by Emergency Care staff in the hospitals, the Chief Executive of hospitals were also held to account to deliver the standard which helped work the standard through the rest of the hospital organisation.

While ED processes had been very variable prior to the introduction of the standard, the introduction of the 4 hour standard drove major changes in ED processes. Note that detailed processes were not imposed from the Department of Health down, rather Emergency Departments were encouraged to locally innovate to meet the standard. While local innovation was encouraged emergent and good practice between departments was encouraged through a process of sharing of practice of Inflow, ED flow and Outflow by the NHS Modernisation Agency/Institute for Innovation based on the Lean Thinking methodology.
As the standard was implemented incrementally over several years, departments were actively encouraged to iteratively innovate their processes to achieve the standard.

Within this complex change the power of a single information measure has been very clear.
The 4 hour maximum time between patient arrival at the department to discharge from the department in 98% of cases made for a huge focus on that single measure to drive the change.
Some critics expressed issues of gaming of the measure, although there is now widespread acceptance that it has been very good for patients and Emergency Departments alike.

Closely related to the information requirement, many departments moved away from white boards to track patient progress towards electronic systems to monitor and then analyse their 4 hour standard, which also facilitated the incremental change.

This 4 hour Emergency Care standard is very good example of a single national standard  that successfully allowed for local innovation in tackling a complex change.

From a patients point of view, by reducing the time that patients spent waiting for care in the emergency department, it is widely agreed that this change has added value.  Indeed as  time to care is generally a useful proxy of quality in Emergency Medicine this suggests that quality and safety improvements have also accompanied the change. Critics have pointed to safety concerns (i.e. patient care being rushed) and some overall increase in costs as there is some evidence that the number of admissions to hospital has increased as a by-product of the change.
As the standard is currently being revised, a more balanced scorecard of ED value is currently being prepared to inform that revision.

These two illustrative examples of healthcare change should help confirm that the key elements of change (people, process, information, technology, standards, value), explored earlier, apply as well within a healthcare setting as anywhere else.

To reiterate these key points.. healthcare reform requires;

People; Clinical Leadership and Cultural Change

Process: Adoption of process improvement methodologies, while cognisant of  the complex systems nature of healthcare.

Information; Healthcare is information intensive. Information and Knowledge are key to change..

Technology: Staff need technology that supports their key processes. In noting that healthcare processes are information intensive, therefore healthcare has important information technology requirements.

Standards: Standards are very helpful in focussing change efforts. Again standards should be developed with awareness of the complexity of the healthcare system.

Value: Healthcare delivery may be difficult to quantifiable value. Yet benefits in terms of quality & safety improvements, time and/or cost reductions should be pursued with every change..

As our initial exploration of healthcare under pressure highlighted the particularly information intensive nature of modern healthcare, we now focus our exploration on the particular needs in healthcare for process improvement supported by better information technology as essential to achieve significant healthcare reform.


Advanced Trauma Life Support (ATLS)

Bauer J, Hagland M (2008) Paradox and Imperatives in Healthcare: How Efficiency, Effectiveness and E-Transformation can conquer waste and optimize quality”

Graban M (2009) “Lean Hospitals, Improving Quality, Patient Safety and Employee Satisfaction”

Tussing A.D, Wren, Maev-Ann (2006) “How Ireland Cares; the case for Healthcare Reform”

Porter, M, Teisberg, E, (2006) Redefining Healthcare: Creating Value Based Competition on Results

Transforming Emergency Care in England

Walley P, Silvester K, Steyn R. Managing variation in demand: Lessons from the UK National Health Service. Journal of Healthcare Management. Sep 2006;51(5):309-322.


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