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Changing Healthcare Processes
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The National Programme for IT promises to revolutionise the delivery of health care by exchanging paper-based handling of information for interconnected electronic systems.
The NHS Care Record Service, amongst many other systems, will have a huge impact on patient care. But how will the NHS adapt to new ways of working that are largely unfamiliar and treated with varying degrees of scepticism (healthy or otherwise!), but are critical to the success of the Programme?
Realising the full benefits of the systems that the Programme aims to deliver is a major challenge. Potentially, patient outcomes, service capacity, costs and the working lives of NHS staff can all improve. However, the introduction of new IT systems, no matter how good they are technically, will not make much difference on its own, and could lead to a worsening of services as people become increasingly frustrated as they struggle to make sense of what they should be doing.
Simply trying to go on working in the same manner as before won't be possible, and adapting to change in a myriad of ad hoc ways is likely to bring only resentment: the results will fall far short of expectations.
Working practices have to evolve, but the common perception of "change management" as a bit of appropriate training in how to use new systems is not enough. Fundamentally, it is only when ways of working - clinical and business processes - really change and use the new information management tools effectively that benefits will start to appear. But how do we work out what to do, whether any good has come of the changes, and prevent everything slipping back into how it was before? How do we release all this pent-up benefit?
Process modelling tools
The accompanying 5-in-5 article Modelling vs. Mapping: Approaches to Business Process Analysis describes how an approach to process modelling can lead to an in-depth understanding of what is really happening, and identify where things are not going well. Whether the model is a detailed or large-scale undertaking (ideally supported by Enterprise Modeller) or a much more focussed and cut-down view, it forms an indispensable basis for systematically changing the way that activities are carried out. If we are trying to make an existing process more streamlined or taking advantage of new opportunities (such as those provided by new IT systems) we need to understand the landscape.
Building on the modelling - some wider techniques
Based on the understanding provided by such a model, we can look to adapt some of the approaches that have been used with increasing impact and success in a wide range of industries and service sectors. Many of these themselves derive from industrial manufacturing, but it is clear that the ideas are widely applicable - so long as it is not forgotten that we are not dealing with a production line for cars or assembling computers to order!
The first principle, perhaps somewhat counter-intuitive, is that high-quality work saves resources (principally time and money). This seems at odds with the adage that "you get what you pay for". Yet by systematically removing wasted effort and improving the quality and variability of output (hence decreasing waste or need for corrections) it take less effort and time to produce a better result - and those involved gain morale and confidence at the same time. There are few things more frustrating than having to do the same job twice!
A range of well-known methods are available. Some are already used in health care but perhaps not as widely as they deserve to be. They focus either on efficiency, effectiveness, or a mixture of the two.
Most share the use of metrics to guide design and sustain improvements - but these are informative process metrics rather than the summative "judgements of performance" that we are perhaps more used to seeing. Choosing the right metric is crucial to the success of the project, but may not be easy. "Key Performance Indicators" are used, but in a different sense to the performance charts beloved by governments - here they inform and guide the changes that are being made.
Another common characteristic is that many - if not most - effective change projects are small, short and focussed. In contrast to large IT programmes, they are often implemented with a minimum of additional resource. Furthermore, for successful results, the implementation and delivery of benefit is "owned" by the "process owner".
Lean Thinking and Poka-yoke
What sort of things do we have at our disposal? Two of the best known approaches are Lean Thinking and Poka-yoke, both originating with Toyota. Lean Thinking seeks to systematically eliminate all activities that don't contribute value - often, things that make no difference to the final outcome. Typically, reactions such as "why were we doing that?" or just plain relief spill out. Lateral thinking is often needed to get the best results, however.
Poka-yoke is about mistake-proofing by design. Making gas connectors on an anaesthetic machine different sizes so they cannot be mixed up is a good example. In information handling, ensuring data integrity, privacy and availability are obvious candidates: design the process so that there is no way an error can occur. As with Lean Thinking, simple, elegant ideas are usually the most effective.
Six sigma, Constraint Management and the Benefits Dependency Framework
Less well known in health care are Six sigma, Constraint Management and the Benefits Dependency Framework. Six sigma and Constraint Management aim to identify and eliminate causes of variation and bottlenecks respectively. Both rely on good models and decent data (though data collection and quality must not be allowed to become ends in themselves). Six sigma applies statistical process analysis and controls to reduce avoidable variations and errors. Constraint Management uses flowcharts, work-in-process models, dynamic simulation and similar techniques to find and ameliorate delays - often by running things in parallel or changing the order in which things are done.
The Benefits Dependency Framework addresses the problem of identifying what has to be changed to deliver and sustain improvements. It is a multi-step process, which, though simple in principle, effectively works back from the goals that are being sought to the systems that support the processes involved. Related to means-ends analysis, it emphasises measurable results.
Conclusion
So we have an armoury of well-understood and effective methods at our disposal. But health care is not like other services I hear you say, and very different from car manufacture, and these are big, unwieldy tools that need lots of good data...
True, but with skilful, appropriate application of "lightweight" versions of these tools much can be achieved. Understanding health care, the way it works and the motivations and concerns of those involved is crucial, as is knowing how to enable those responsible for health care delivery to change their processes, and then sustain improvements once the consultants have left.
If you have any questions about the subjects covered in this white paper or you would like to find out more about how Oakleigh Consulting could help your organisation, please contact us on 0161 835 4100 or email us.
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