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NHS Leaders in the United States
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By Mark Jennings, Priority Programme Head, NHS Institute for Innovation and Improvement; Kathy Mason, National Implementation Director - PACS, Department of Health; and Susan Went, Director, Joint Modernisation Programme, Kingston and Richmond Health Economy.
In May 2006, a group of senior NHS Managers, with support from Oakleigh Consulting, visited the Institute for Healthcare Improvement (IHI) based in Cambridge Massachusetts USA.
The IHI is a not-for-profit organisation leading the improvement of healthcare throughout the world by supporting the development and trialling of new ideas. The IHI was one of the major influences in the setting up of the NHS Modernisation Agency and more recently the NHS Institute for Innovation and Improvement in the UK (www.institute.nhs.uk).
The visiting senior NHS managers were from the Advanced Management Development Group (AMDG), a learning set they established following their participation in the prestigious King's Fund Top Manager Programme in 1999.
The group had six key objectives for their visit:
1. Learning from the IHI experience of introducing quality into health care;
2. To expand knowledge and understanding of improvement science and methodologies by visiting one of the leading authorities;
3. Looking at ways at raising the bar - how to improve clinical programs;
4. To gain experience of health service development in the US;
5. To share our collective and significant knowledge of the NHS and have the opportunity to discuss key issues with US colleagues; and
6. To undertake a collective learning experience with other members of the AMDG.
Leadership and Creating Joy in Work
The opening session had two elements, 'Inside IHI' and 'Leadership' both presented by Maureen Bisognano, IHI Chief Operating Officer. Maureen described their leadership framework which focuses on setting direction in terms of mission, vision and strategy. The framework incorporates 'PULL' elements (making the future attractive) and 'PUSH' elements (making the status quo uncomfortable).
She stressed that making it happen requires the building of will, the generation of ideas and clear executions of change underpinned by a foundation of organisational capacity and competence. Members of the AMDG were particularly enthused by her emphasis on joy. Core IHI values include, 'celebration and thankfulness' and one of the five strategy areas is to 'Raise Joy in Work'. This is seen as key to underpinning the partnership of energy with leadership.
A point of interest and comparison was made here between the IHI and the NHS Institute. The IHI believes that it is important to foster a culture of selling its work and products, keeping a clear customer focus and avoiding over reliance on grant funding. Not only does this keep the organisation sharper edged, it ensures that the organisation and its work is properly valued and taken seriously.
Adopt-Adapt-Abandon
Maureen then moved on to explain their approach to quality improvement. The IHI use quality and improvement to deliver cost reductions rather than hope they will be a by product. Their mantra is Adopt-Adapt-Abandon, emphasising the unending requirement to innovate and improve rather than not achieving a set of goals and then becoming stuck. She drew our attention to the work of Noriaki Kano, who suggests that there are three approaches:
1. Eliminate quality problems as experienced by the customer (patient) [High historic healthcare focus]
2. Reduce cost significantly whilst maintaining and improving quality [low historical healthcare focus]
3. Expand customer (patient) expectations by providing care that customers perceive as unusually high in value. [very high historic healthcare focus]
Maureen highlighted the need to focus on Kano's second point '. For the IHI this means converting 'light green dollars to dark green dollars' (potential to real savings) whilst cutting 'muda' (waste) through defect reduction to remove unnecessary work and rework.
The two parallel tasks that she highlighted, 'redesign the system' and 'tend to the finances', have great relevance in today's NHS. She described how once you are aware of 'muda' you can't stop seeing it! Several of the Group saw lots of it at the airport on the way home.
Over the subsequent three days the Group were almost overwhelmed with the energy, enthusiasm and sheer volume of material that the IHI presented. This whilst not only 'business as usual', but also ongoing internal continuous improvement in the form of a 'Lean Week', was underway. Lean being the concept of driving out waste so that all work serves and adds value to customer needs.
Staying at the Cutting Edge
One of the key programmes at the IHI is the IMPACT research, which was presented to us by Carol Beasley, Vice President. This is the IHI's improvement network for US healthcare systems and hospitals. Its main activities are focused on bringing together organisations working on similar problems in similar systems. Key topics covered within the IMPACT networks include:
- flow;
- leadership;
- safety and reliability;
- ambulatory care;
- transforming care at the bedside; and
- patient self management.
These first two topics prompted discussion about organisations that have a reason to improve compared to those that develop improvement behaviours. How do some organisations develop a culture which makes and keeps them at the cutting edge? Is it just leadership, does benchmarking help or is it public accountability? Are there some parallels to be drawn with UK Foundation Hospitals?
Patient Safety
Carol Haraden, IHI Vice President, then presented to the Group details of the Patient Safety Initiative (PSI) that she is leading. The initiative, sponsored by the Healthcare Foundation, takes learning from the US and transfers it to selected UK hospitals. The participating Hospitals are Luton and Dunstable for England, Conwy in Wales, Tayside in Scotland and Down Lisburn in Northern Ireland.
The PSI incorporates repeated application of the Plan-Do-Study-Act cycle in the context of a team working collectively to achieve measurable improvement. The approach uses care bundles as a focus for improvement strategies, for example reducing ventilator associated pneumonia rates. The use of the Statistical Process Control (SPC) method to monitor outcome time series is essential.
Phase 2 is now being developed creating 'couplets' between Teaching Hospitals and District General Hospitals or two DGH's. There was some lively discussion about the possibility of linking secondary and primary care providers in the couplets.
Carol was particularly keen to explore with the Group how to bring together UK Strategic Health Authorities, the National Patient Safety Authority and the NHS to work on the PSI. Having one of the 10 new SHA Chief Executives as a member of the Group meant we were able to provide her with a good briefing and contacts list.
100k Lives Campaign
One of the more 'out of the box' initiatives that the Group met with was the 100,000 Lives Campaign, presented by the campaign manager, Joe McCannon. This is the application of a political campaign approach to a healthcare quality improvement initiative.
The campaign launched in December 2004 aimed to save 100,000 lives in 18 months across US Hospitals with a strap line of "some is not a number, soon is not a time". The campaign highlights and makes public the fact that hospitals actually kill people, something there is little or no drama in the press about in the US.
Action under the campaign is focused on a number of main interventions or 'bundles':
- - rapid response teams;
- - acute myocardial infarction management;
- - reducing adverse drug effects;
- - central live 'infection'; and
- - VAP and surgical site infections.
The premise is that by improving the quality and safety of these specific interventions will save 100,000 lives over the course of the 18 months in the 75% of US hospitals that signed up. In June 2006 the IHI announced the campaign had exceeded its goal with an estimated 122,300 lives saved.
The Group found the approach very interesting and energising and had some thought provoking discussion about how it might be applied in the UK. Public Health improvement was felt to be one potential area where the approach might be effective.
There was also some healthy debate about measuring the outputs from such a campaign. Joe McCannon agreed that this had required some careful thought and they have used an 'all or none' quality measurement, as described in 'All-or-none measurement raises the bar', Nolan and Berwick, 2006, JAMA.
When Things Go Wrong...
One of the most inspirational presentations was given by Jim Conway, entitled simply, Patient Safety. He gave what was clearly a personally moving account of his experiences improving patient safety at Dana Farber Cancer Institute following the death of a Boston Globe reporter Betty Lehanan.
This event was a landmark for the hospital and signalled a change in the management of patient safety. Ms Lehanan had died following a 4 times overdose of a chemotherapy drug for breast cancer. The Hospital immediately disclosed its error, believing this would avoid erosion of trust with patients, public and staff.
This was at odds with how hospitals and health insurers normally acted and has subsequently underpinned the development of a protocol on disclosure, 'When Things Go Wrong', ensuring that there is learning and improvement in patient safety systems from such mistakes.
New Roles for Doctors
Richard Boehmer, visiting from Harvard University, led a thought provoking lunchtime session on the New Roles of Doctors. He set out the premise that while doctors have practiced in the same fashion throughout history they now need to move from 'hands-on' craft workers to 'system architects'.
The complexity of medicine now means practice needs to be systemised and that some doctors will become designers or 'architects' of the medical production systems while technician doctors deliver care in most cases. The Group felt that this was already present in the NHS in key areas and that it provided great potential for system transformation, but that there was a lot of cultural and change management issues to overcome with the clinicians.
Lower Costs, Higher Quality
One of the areas of key difference that the Group observed between the NHS and the US Health System was that of commissioning and market management. This was brought into focus by the presentation from Steve Jenks of the Centres for Medicare and Medicaid Services (CMS).
CMS manages care for 100 million people with a budget of $500bn (£2,700 million). He presented the findings from a key piece of research that has shown a strong correlation between lower costs and higher quality in the delivery of secondary care.
The study arose from a desire to link incentives for healthcare providers to clinical outcomes. Hospital Quality Incentive Demonstration (HQID) allocated points for clinical quality for six clinical areas and aggregated this into a 'composite process score' (CPS). The study then compared the CPS score to the costs and length of stay for patients within CMS system.
The study found a clear relationship between lower length of stay, lower costs and higher CPS scores across all areas studied. The Group were very interested in the research findings; however, they reflected the focus of much of what we saw at IHI, improving the quality and safety of acute hospital provision.
Ensuing discussion with Steve confirmed the view that commissioning care services in the US is a very different animal to commissioning health services for populations as the NHS does and that leaders on both sides of the 'pond' have much to learn for each other.
Inspiration for the US
In between the wealth of knowledge and learning that was shared with us, we gave two seminars to the IHI Faculty members and Fellows. The first of these described the process and outcomes of the Emergency Care Programme to achieve the 4 hour waiting target for A&E patients.
This was presented by Jane Cummings who had led the Choose and Book initiative for the Department of Health prior to taking up her current role as National Director for Choice.. She was supported with local insights into the programme as it had rolled out from Mark Jennings, Priority Programme Head, NHS Institute for Innovation and Improvement, England and Susan Went, Director, Joint Modernisation Programme at Kingston and Richmond Health Economy.
The second seminar was led by Mike Farrar, now Chief Executive of the new North West SHA, entitled The Transformation of the NHS. It focused on the overarching aims of the current reforms and the importance of commissioning and effective leadership in achieving them. He was supported by Kathy Mason, National Implementation Director for PACS, who reflected on the impact of the reforms on the National Programme for IT and by Steve Spoerry, Director of Strategic Planning for the Tees Health Economy, who gave a 'worm's eye view' of reforming the NHS over that past 20 years.
Key Lessons from the Visits
The IHI reflected a far more developed ability within the US healthcare system to capture and effectively use data to produce hard evidence to drive and underpin change. However, this is still confined to the relatively narrow arena of the acute hospital setting. The concept and practices of commissioning holistic health services for a population are not at the forefront of even this leading edge organisation.
In developing commissioning in the reforming NHS there is much to learn here about using evidence to improve quality and safety, and possibly how to define value for money. There is no doubt this whole experience can be applied in the acute and non-acute provider setting in England.
Learning on the commissioning front though is more difficult as there is not a direct comparison. Health care in the US features highly sophisticated acute providers in an insurance driven market while in the UK there is an evolving and largely centrally managed market covering acute and primary care commissioned by emerging organisations.
The understanding of the NHS 'managed market' clearly still needs some development in the US, as part of the initial response to our presentation on the achievement of the Emergency 4 hour waits target was incredulity and healthy scepticism!
In taking forward a mutually beneficial relationship between the IHI and the NHS, in the words of one Group member:
"They have the knowledge of evidence driven improvements and we have the opportunity to learn and apply it."
Central Role for Leadership
Finally, a key factor that was the basis for unequivocal Anglo-American agreement was the crucial and central role of strong and clear leadership in taking forward healthcare improvement anywhere. All agreed that the strongest and most lasting improvements were achieved where leadership was evident, clear and able to build and inspire teams to continually strive for best.
And the nature of such leadership?...well that's another article.
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