I have read two stories this week.

The first was written in an interesting, contemporary literary style – you know the sort – short sparse sentences almost factual, leaving lots of ‘space’ for your own imaginative inference, not making explicit links between facts and events but leaving you to do that for yourself.  It was a love story, rather charming and quite short, describing a familiar narrative of boy meets girl, invites her to the cinema and they fall in love (probably).  It could be described as Chandleresque in style – though it isn’t that good – in fact it could have been written by an 11+ student.  It wasn’t though – it was in fact written by a computer using a form of artificial intelligence called natural language generation with genuinely no human input.  You can read how it was done here.

The second story I read is a description of a falling out of love – of the medical profession with the IT industry and the electronic patient record.  This one is very well written by Robert Wachter and is a warts and all recounting of the story of the somewhat faltering start of the digital revolution in healthcare.  It is called ‘The Digital Doctor’ and I would highly reccomend you read it if you have any interest in the future of medicine.  It is not the manifesto of a starry eyed digital optimist, nor is it the rantings of a frustrated digital skeptic – he manages to artfully balance both world views with a studied and comprehensive analysis of the state of modern health IT systems.  His realism though extends to understanding and articulating the trajectory of the health IT narrative and where it is taking us – which is a radically different way of delivering medical care.  I won’t use this blog to precis his book – its probably better if you go and read it yourself.

From Data to Information to Understanding

The falling out that Dr Wachter describes really is quite dramatic – this is the United States the most advanced healthcare system in the world – yet there are hospitals in the US that advertise their lack of an EPR as a selling point to attract high quality doctors to work for them.  Where has it gone wrong?  Why is the instant availabilty not only of comprehensive and detailed information about our patients but also a myriad of decision support systems designed to make our jobs easier and safer to carry out – not setting us alight with enthusiasm?  In fact it is overwhelming us and oppressing us  – turning history taking into a data collection chore and treatment decisions into a series of nag screens.

The problem is there is just too much information.  The healthcare industry is a prolific producer of information – an average patient over the age of 65 with one or more long term conditions will see their GP (or one of her partners) 3 – 4 times a year, have a similar number of outpatient visits with at least 2 different specialists and attend A&E at least once.  That doesn’t include the lab tests, x-rays, visits to the pharmacy, nursing and therapy episodes.  Each contact with the system will generate notes, letters, results, reports, images, charts and forms – it all goes in to the record – which, if it is a well organised integrated electronic record, will be available in its entirety at the point of care.

Point of care being the point – most health care episodes are conducted over a very short time span.  A patient visiting his GP will, if he’s lucky, get 10 minutes with her – it doesn’t make for a very satisfactory consultation if 4 or 5 of those minutes are spent with the doctor staring at a screen – navigating through pages of data attempting to stich together a meaningful interpretation of the myriad past and recent events in the patient’s medical history.

How it used to be (in the good old days)

So what is it that the above mentioned hospitals in the US are harking back to in order to attract their doctors?  What is the appeal of how it used to be done when a consultation consisted of a doctor, a patient and a few scrappy bits of paper in a cardboard folder?  Well for a start at least the patient got the full 10 minutes of the doctors attention.  The doctor however was relying on what information though?  What the patient tells them, what the last doctor to see them chose to write in the notes, and the other events that might have made it into their particular version of this patient’s health record.  This gives rise to what I call a ‘goldfish’ consultation (limited view of the whole picture, very short memory, starting from scratch each time).  We get away with it most of the time – mainly because most consultations concern realtively short term issues – but too often we don’t get away with it and patients experience a merry go round of disconnected episodes of reactive care.

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When I used to still practice intensive care medicine one of the things that occupied quite a lot of my time as ‘consultant on duty for ICU’ was the ward referral.  As gatekeeper of the precious resource that is an intensive care bed my role would be to go and assess a patient for their suitability for ICU care as well as advise on appropriate measures that could be used to avert the need for ICU.  My first port of call would be the patients notes – where I would go through the entire patients hospital stay – for some, particularly medical patients, this might be many days or even weeks of inpatient care.  What I would invariably find is that the patient had been under the care of several different teams, the notes would consist of a series of ‘contacts’ (ward rounds, referrals, escalations) few of which realted to each other (lots of goldfish medicine even over the course of a single admission).  I soon ceased to be surprised by the fact that I, at the point of escalation to critical care, was the first person to actually review the entire narrative of the patient’s stay in hospital.  Once that narrative was put together very often the trajectory of a patient’s illness became self evident – and the question of whether they would benefit from a period of brutal, invasive, intensive medicine usually answered itself.

Patient Stories

The defence against goldfish medicine in the ‘old days’ was physician continuity – back then you could  expect to be treated most of your life by the same GP, or when you came into hospital by one consultant and his ‘firm’ (the small team of doctors that worked just for him – for in the good old days it was almost invariably a him) for the whole admission.  They would carry your story – every now and then summarising it in a clerking or a well crafted letter.  But physician continuity has gone – and it isn’t likely ever to come back.

The EPR promised to solve the continuity problem by ensuring that even if you had never met the patient in front of you before (nor were likely ever to meet them again) you at least had instant access to everything that had ever happend to them – including the results of every test they had ever had.  But it doesn’t work – data has no meaning until it is turned into a story – and the more data you have the harder it is and longer it takes to turn it into a story.

And stories matter in medicine – they matter to patients and their relatives who use them to understand the random injustice of disease, it tells them where they have come from and where they are going to.  They matter to doctors as well – medical narratives are complex things, they are played out in individual patients over different timescales – from a life span to just a few minutes, each narrative having implications for the other.  Whilst we don’t neccessarily think of it as such – it is precisly the complex interplay between chronic and acute disease, social and psychological context, genetics and pathology that we narrate when summarising a case history.  When it is done well it can be a joy to read – and of course it creates the opportunity for sudden moment when you get the diagnostic insight that changes the course of a paient’s treatment.

Natural Language Generation

Turning the undifferentiated information that is a patients medical record – whether paper or digital – into a meaningful story has always been a doctor’s task.  What has changed is the amount of information available for the source material, and the way it is presented.  A good story always benefits from good editing – leaving out the superfluous, the immaterial or irrelevant detail is an expert task and one that requires experience and intelligence.  You see it when comparing the admission record taken by a foundation year doctor compared to an experienced registrar or consultant – the former will be a verbatim record of an exchange between doctor and patient, the latter a concise inquisition that hones in on the diagnosis through a series of precise, intelligent questions.

So is the AI technology that is able to spontaneously generate a love story sufficiently mature to be turned to the task of intelligently summarising the electronic patient record into a meaningful narrative? Its certainly been used to that effect in a number of other information tasks – weather forecasts and financial reports are now routinely published that were drafted using NLG technology.  The answer of course is maybe – there have been some brave attempts – but I don’t think we are there yet.  What I do know is that the progress of AI technology is moving apace and it won’t be very long before the NLG applied to a comprehensive EPR will be doing a better job than your average foundation year doctor at telling the patient’s story – maybe then we will fall back in love with EPR? Maybe…

Over recent months there has been an emerging consensus – articulated in reports from the Royal College of Physicians (The Future Hospitals Commission) and David Greenaway’s report for the GMC (The Shape of Training) – that it is time to put into acute reverse the socio-professional trend of the last 30 years of ever increasing medical super-specialisation. In their own ways these reports identify that the needs of a health system in which 70% of the activity is ongoing health maintenance of increasingly aged patients with 3 or more coexisting long term conditions, is not an army of doctors each of which can treat only one thing.

They also identify that the key specialties for managing this population – Emergency Medicine, Acute Medicine, Elderly Care Medicine and General Practice – are all ‘shortage’ specialties, i.e. there are more jobs available than people willing or able to do them by a considerable margin (8% – 22% vacancy factor [source:BMJ Careers May 2013] and that’s before you take into account the demographic time bomb of the mass retirement of a generation of GPs that started their careers during the last big expansion of the specialty in the 70s and 80s). If you move down the training hierarchy the fill rates are even more dismal – with 50% of higher specialist training posts in emergency medicine not being filled.

The ‘solution’ to the problem that is being proposed appears to be to increase exposure to these specialities earlier on in young doctors careers – make them do these types of jobs for longer – and at the same time make access to more specialised training (like cardio-thoracic surgery or neurology) much much more difficult by decimating the number of training places for them, in the hope that more of them will stick with the front line specialties rather than flood into the popular ‘super’ specialties (as they currently do – and always have). This apparent solution however seems to be completely ignoring the fact that a young doctor when faced with the choice of not getting access to the training in the specialty they want would rather up sticks and settle in Australia than to stay in the UK in a specialty that doesn’t interest them. Which is exactly what they are doing – in droves [Source: The Times, Saturday March 7th 2015].

So why is it that young doctors are eschewing the ‘Semi-differentiated’ specialities (my term – referring to the specialities listed above and to which I would add my own specialty of critical care – albeit not a shortage specialty)? What is it about the intellectual, practical and emotional challenge of providing care to patients with multi-system disease, in a psycho-social context that requires the corralling and coordinating of multi-professional multi-agency teams that puts them off? What is it about integrated care that is just so difficult?

Both the reports cited above home in on training as the issue – we are just not training our doctors right – and they propose some really quite radical changes to post-graduate medical training to address this. Whilst this is necessary, I do not think it is nearly radical enough – to really address the issue we need to go back to medical school and examine – who we are selecting; what we are teaching them; the skills we are equipping them with; and the attitudes they are possessed of when leaving medical school.

I have had cause to visit a number of university open days – not their medical schools but their engineering departments (I’ll leave you to guess why that might be). Engineering is a profession that requires the acquisition of at least as much if not significantly more technical skills and knowledge as medical training – the courses are just as intense and nowadays just as long (typically 4 – 5 years with a year in industry). Competition to get in is just as stiff and the bright young things wanting to do it are as possessed of the same desire ‘to make a difference’ as that which motivates those who enter a medical career. What has struck me though is that every engineering course I have looked at not only emphasises the knowledge and technical skills required (The maths!) but also have very large parts of their curriculum given over to the acquisition of non-technical skills – leadership, team work, collaboration, project management, business skills – all of which are required to be a successful engineer.

They are required to be a successful doctor as well – but we don’t teach them. You are selected for medical school on academic performance at the age of 18 – pass through 15 years of undergraduate and post graduate training and emerge as a highly knowledgable, very skilled technocrat – a heroic doctor – any non-technical skills acquired along the way more by accident than design. It is not just the non-technical skills they teach engineers that doctors need either. Becoming a doctor in an integrated care system requires many of the technical skills associated with engineering as well. Understanding complex adaptive systems, industrial process design, informatics and information technology (amongst many) are all skills we require of doctors if we are to ‘industrialise’ modern medicine.

We need to train a generation of doctors that are able to command and corral the multiple professions, agencies and technologies required to support the complex interaction of social, psychological and physical pathologies that represent the disease burden of our patients. We need a generation of specialists too – but specialisms built on a foundation of whole systems care. We need a generation of doctors that recognise that its not good enough just to be brilliant at one thing.

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As a medical director of a large acute hospital trust, how people die in our care occupies quite a lot of my waking thoughts (and quite a few of my sleeping ones too…). I thought I knew quite a lot about this subject – coming into the role from a background of critical care (where death is common). I have found though that my experience, whilst a useful primer in the topic, has demanded significant additional learning on my part – this post is my attempt to share some of that learning.

People Die in Hospital – That’s what they do

There is a curious symmetry in the social changes that have occurred at both the beginning and the end of life. The realisation over the last half century or so that many of what were believed to be inevitable tragedies at the beginning and end of life were in fact amenable to technological intervention and thus avoidable – and the change in the medical profession from overseer and commentator of natural tragedy to intervener and preventer of such – has driven these life events from a home based setting managed by community based services into a hospital setting managed by doctors, nurses and midwives.

This is largely a good thing – more mothers and babies survive the traumatic vagaries of child birth than ever before and people live longer healthier lives than ever before.

There is one rather stark asymmetry though – whilst death and tragedy in child birth is now a very rare event indeed – death at the end of life is still ultimately inevitable. As a society, even though we know we have to die eventually, we still haven’t worked out how we should die. This means that the majority of people end up dying in hospital (over 50% of people – thanks to Shaun Lintern and Craig Stenhouse for correcting this for me!) with doctors and nurses trying to stop them from doing so even when death is inevitable.

This is not a good thing because dying with someone trying to stop you with all the technological weapons of modern medicine (however well meaning) is not a good way to die.

The alternatives – provided by the heroes of the hospice movement – remains a cinderella service, patchily provided, reliant on charity and sparsley funded by public money.

Avoiding the Unexpected

So, people die in hospital – in our two hospitals that is about 1600 people a year (about 1 in every 75 admissions or put another way 4 or 5 admissions every day don’t make it home alive).

When these deaths are studied they can broadly be categorised into three groups according to whether they are expected or unexpected deaths and avoidable or unavoidable deaths.

Category 1Unavoidable expected deaths. This is overwhelmingly the largest category of deaths in hospital. People reaching the end of their natural lives, where their frail bodily systems have reached a point where they provide no defence against otherwise modest insults such as a fall, a urinary tract infection or the flu. Dying in hospital, as I alluded to above, has become the natural order of things in modern Britain (and many other developed health care systems in the world). Also included in this category are the deaths that we would recognise as ‘palliative care’ where even 21st century medicine genuinely has no response – terminal cancer or devastating neurological disease.

Category 2Unavoidable unexpected deaths. These are the genuine tragedies that punctuate life in a hospital. The relatively rare, but affecting cases that litter the landscape of a professional career. These are the maternal deaths from catastrophic amniotic fluid embolus, the brain haemorrhage from an unsuspected cerebral vascular anomaly, the tragically successful suicide or the disastrous major trauma from a road traffic accident (sadly I could go on). These deaths are often met with heroic efforts on the part of hospital staff to prevent them and are followed by dismay and soul searching when unsuccessful. When deconstructed at a later date there is often some learning (we can always do better) but just as often there is little to be learnt – bad things just happen.

Category 3Avoidable unexpected deaths. These are the ones where we got it wrong. Where lapses, incompetence, inexperience, neglect and system failure succeed in lining up in a single case to either actually cause death or prevent avoidable death. These are the cases that stay with you (believe me). This is the missed diagnosis because of a failure to follow up a test result, the failure to act on the deteriorating patient, the unacceptable delay in life saving intervention or the failure to take responsibility for a situation. They are thankfully rare (and overwhelmingly the smallest category of death) – not because the lapses and system failures are rare – they are not – but because (other than in exceptional circumstances) it takes several in a row to have such a devastating outcome, the good old Swiss cheese effect.

I suppose in theory there is a fourth category of avoidable expected death – that feels like a contradiction to me and I can’t conceive what it might be.

The ‘management’ task here is to attempt to assign every death to one of the three categories. That is not a trivial task – and it is not one for which you can take a statistical short cut, however compelling a notion that might be. Not least because in every category there will be deaths where on review there is identified a lapse of care – yet how many lapses does it take to move a death from either of the first two categories to the third?

Lies, Damn Lies and Mortality Statistics

Regular readers of my blog will know that I have been here before in my earlier post: Thinking about Mortality – Fast and Slow. I am not going to rehearse the arguments of the weaknesses of case mix adjusted, risk modified mortality statistics. Suffice to say that the reported ‘dramatic improvement’ in HSMR of the 11 Keogh Review hospitals will have had as much to do with scrutiny of their coding practices as the quality of care they provide.

Professor Nick Black through the PRISM (and soon to be published PRISM 2) study has shown little correlation between quality of care and HSMR (or SHMI or RAMI or any other way of measuring institutional mortality rates). I am trying not to be cynical about these – because they are in fact very useful tools, and cannot be ignored. However one has to be very careful in interpreting them because they tell you as much about what type of hospital you are and what type of patients you treat as they do about the quality of care you provide.

I can tell you without looking that:

Small provincial district general hospitals with proportionately large elderly care, stroke and fractured neck of femur services will have high mortality ratios (however well risk adjusted).

Large urban inner city general hospitals with relatively young transient populations will have low mortality ratios.

Tertiary Centres that carry out high risk care on relatively young patients (like liver transplants or major cancer surgery) will have high mortality ratios.

A Recipe for Managing Mortality

So where does this leave us? We can’t trust the stats and identifying the deaths where we got it wrong, sufficiently to have at least been a causative factor in the death, requires painstaking review of very large numbers of deaths and the judgement of Solomon.

Here are my tips:

1) Don’t ignore the stats – have a committee that looks at your death rates in all specialties and diagnostic groups – identifies the variances, the outliers and the alerts and investigates them even if CQC or Dr Foster don’t notice. You will learn a huge amount about how care is delivered in your hospital and how patients are moved about within it. You will also learn quite a lot about coding.

2) Have a system in place that reviews every death in the hospital. Some have chosen the Medical Examiner solution to this – paying a recently retired doctor to review the notes of every death and extract learning and identify those where more scrutiny is required. We have gone down a variant of the trigger tool methodology – every case is assessed against a set of criteria by a consultant not involved in the care of that patient, if enough triggers are present in one case it gets a table top review.

3) Have a method of sharing the learning – particularly with the consultants doing the screening (in our case that’s all of them), it is laborious work and it has to feel worthwhile. We are not so good at this yet – we have a news letter that goes out, we could and should do more.

4) Don’t trust Dr Foster – they are a commercial organisation that profits from scare stories. Don’t ignore them either.

5) You will find that 70% of patients that fall into category 3 are due to sepsis – invest in physiological track and trigger, sepsis screening tools and implement the sepsis 6 bundle and critical care outreach. Your avoidable mortality will fall.

6) You will also find that acute hospitals provide dreadful care to the majority of patients for whom death is unavoidable and expected (Category 1). The fortunate minority that find themselves under the care of palliative care doctors will get excellent care, the majority that don’t, won’t. Invest in end of life services – this has to be the greatest single priority for the NHS. We are about to publish our ‘Last Year of Life Audit’ – an investigation into the care provided in that critical period of a persons life. It will show that we admit to hospital on average three times in the last six months and start ‘supportive care’ on average 24 hours prior to death.

7) Finally – keep the politicians out, they don’t get it and never will and will do a great deal of harm meddling with stuff they don’t understand. You wouldn’t let them meddle with airport safety would you? why would you let them meddle with hospital mortality…?

We had an ill child in our A&E for over 20 hours yesterday. Read that again – yes its true – 20 hours in an inner-city A&E – on a Friday. Actually she isn’t a child – according to half the professionals that saw her, but was according to the other half. Conveniently for each of them they were able to define her in a way (wrong side of of her seventeenth birthday) that meant neither had to take responsibility for her. A definitive safe place of care was eventually found at an adolescent mental health facility over 100 miles away. Throughout this whole episode she was suffering an acute psychiatric illness.

Fragile Minds

After toddlerhood – adolescence is the most active phase of brain development. It is a critical period during which personality, skills and traits are developed that set the patterns of mind, thought and behaviour for the remainder of adult life. It is a crucial phase of transition from childhood to adulthood – a period of ‘finding ones place in the world’ apart from the security of parents and family. It is an intensely psychologically vulnerable time – one of which we all have memories of our own we would probably rather forget. It is also the commonest period of life for mental health issues to first develop – by some estimates up to 20% of adolescents and young adults are experiencing some degree of mental illness and over 40% of adult mental illness commences in the adolescent period. The combined assaults of alcohol, drugs, sex hormones and dramatic changes in life circumstances on a fast developing brain have unpredictable consequences – which for a growing minority include breakdown, psychosis and the roots of devastating life long mental illness.

When your world falls apart

Psychosis is the most terrifying symptom of disease. It is the awakening of primal fears – normally locked away by evolution and civilisation. Psychosis is the manifestation of every self doubt and vulnerability we harbour, a total loss of security. The very ground you stand on loses its solidity, the certainties of perceived reality evaporate. Paranoia is intense, everyone is against you, every sound becomes the whispering taunting voices – undermining and aggravating self doubt.

During this potentially lethal psychological experience – our service finds it most appropriate to leave the sufferers sitting in A&E cubicles, overseen by security guards and witnessed by the drunken fray that make up the core clientele of A&E on a friday night. Meanwhile professionals play ‘pass the buck’ – skulking guiltily in the background too nervous to engage with a ‘difficult teenager’ – the behaviour surely being noticed and fuelling the paranoid beliefs of the patient ‘for whom no-one cares’.

Why do we do this? Why do we let down such a vulnerable group in such a catastrophic manner?

Too Special to Touch

Throughout my career I have witnessed, and been exasperated by, the phenomenon of medical super-specialisation. This is the process by which small groups of sub-specialists – usually based in well resourced centrally located university hospitals – develop standards of care for a sub-set of a population with a branch of a disease that produce significantly superior outcomes for those patients. This isn’t a problem in itself – this is how the frontiers of medicine move forwards. The problem arises when this standard of care – attainable in the rarefied environment of the academic centre – becomes the expected standard in all healthcare settings. A process of centralisation of care then ensues – as ‘good enough’ becomes the victim of ‘perfection’ – standard care in general settings is discredited. Generalists are stripped of the right to provide certain aspects of care – patients are diverted to diminishing numbers of ever distant specialist centres – as the skills for providing even ‘good enough’ care at local centres evaporate.

One of the most striking areas of medicine where this has happened is children’s services. Most paediatric services are now provided by centrally located children’s hospitals – these highly specialist tertiary centres do a fantastic job – but to survive they have had to grow their business ‘down the value chain’ to the point where they now also provide the bulk of standard secondary care. This has resulted in the shrinking of paediatric services in district general hospitals to below critical mass levels – many paediatric services have closed – many others are teetering on the edge of viability, even in quite large general hospitals. It is reaching a point where in many hospitals it is just unsafe to be a child – and the doors are simply closing on them.

This march of progress wouldn’t be a problem if wasn’t for the fact that very sick children – whether physical or, as in our story above, mental – still come to A&E expecting life saving treatment. Our doctors, with dis-credited general skills, diminished exposure and experience – are not only discouraged but actively criticised for trying to provide good enough care. So they have stopped – and patients languish in A&E awaiting transfer to over subscribed specialist centres – not receiving immediate care they need that might prevent harder to treat long term conditions. Meanwhile the generalist tiptoes around them – too terrified to touch.

A Relentless Epidemic

Childhood and adolescent mental health is very special indeed. Most ordinary doctors are scared of mental illness – this is hived off very early in training – and even more scared of children. Yet the story of our seventeen year old in crisis is becoming more not less common, what was a handful a year presenting to our A&E has become dozens a month. We don’t know why – but the wide availability of cheap alcohol, potent cannabis, met-amphetamines, and other ‘legal’ highs along with the as yet un-evaluated impact of the psycho-social complexity of a life lived ‘on-line’ must all be playing a part. And this is a drama that is being played out in emergency departments across the NHS – daily.

There is an urgent need to find a solution for delivering safe ‘good enough’ care for these patients – at the point of presentation – until a place of definitive care can be found. The needs are not complex – but they do transcend organisational boundaries – the ability to provide safe dependable holding treatment in an urgent mental health situation – is a good test of health system integration. The care of the intoxicated, potentially physical injured patient that is in the throes of a mental health crisis requires professionals that normally work in isolation (traditionally somewhat distrustful of each other) to come together and meet the physical and psychological needs of these patients.

Above all this needs system leaders to come together, organise their services to deliver and demonstrate that – yes, we do care about this calamity – we care very much.

As a medical director I am routinely required to assess, grade and act on the results of serious adverse events that have occurred in hospital. Often these events have resulted from failures of care through lapses, oversights, errors or neglect. This is often accompanied by a clarion call for some form of disciplinary action and or restitution – usually most insistently from within the organisation rather than by those directly affected, either carers or the patients themselves.

Bad things happen in hospital all the time. Healthcare is the only industry where for a significant minority of users the outcome is death or injury, either expected or unexpected. The overwhelming priority in this situation for both the recipients and providers of the care is learning: learning the truth of events, learning if it was avoidable, learning how it might be avoided in the future, and sharing that learning so it might be avoided elsewhere.

Prerequisites for Organisational Learning

We have, as human beings, an innate gift for learning – it is built into our DNA and, whilst most active in our early years of life, never really leaves us. Individual learning is the most powerful lever of change in human societies, because people love to learn and change as a result. Teams and organisations are made up of people and yet team and organisational learning does not happen by chance as it does for individuals – team learning is an unnatural and deliberate act.

There are three prerequisites needed within organisations in order to promote learning from error and system failure. It is strangely rare to find them all reliably present in healthcare organisations.

  • A Learning Environment
  • A Team Based Learning Infrastructure
  • A Compelling Vision Delivered Through Leadership
  • I will expand on these three prerequisites, but first I want to explore why they are found rarely in our hospitals and healthcare organisations.

    Two Key Barriers to Organisational Learning in Hospitals

    Hospitals are busy places, this is a universal truth – not unique to the NHS. The work processes of nurses and doctors in hospitals rarely run smoothly – they are by their nature characterised by frequent interruptions, unexpected deviations and minor crises. In order to get the job done a large part of the work involves having to create on-the-hoof workarounds and solutions to problems – giving rise to the familiar sense of almost continuous ‘fire fighting’.
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    We are actually incredibly successful at doing this, much of our individual innate learning capacity is consumed developing coping strategies for the chaotic environment we find ourselves in. The problem with this ‘first order problem solving’ for ‘low level failure’ is that the learning it generates is of value only to the individual nurse or doctor – they are simply adapting to the flawed environment they find themselves in – just to get the job done. In doing so they are condemning themselves and and their successors to having to learn the same lessons in perpetuity – this grinds you down and drives talent away from ‘the front line’. How do we break the cycle of low level failure that requires constant first order problem solving making every day work flow inefficient and time consuming? The first step is to recognise the problem and then acknowledge that low level failure, whilst common place, is neither inevitable nor acceptable. The next step is to then deliberately and collectively make the time to move first order problem solving into second order problem solving (of which more later).

    The second key barrier to organisational learning in hospitals is a deeper, more cultural one. This is to do with interpersonal attitudes and responses to error. The shameful truth is that the overwhelmingly pervasive culture is a blaming one that inhibits speaking up with questions, concerns and challenges that might otherwise have caught and corrected human error. Moreover there is a culture in medicine that does not encourage admissions of error. Both ourselves and others have high expectations of success in medicine – when we don’t meet those expectations we are as blaming of ourselves as we might expect others to be. What is interesting is that the direction of blame isn’t just top down – in fact top down blame only really materialises when the failures mount up to catastrophic levels. The vast majority of, and undoubtedly more corrosive, blame is that of our colleagues and peers. What is clear is that whilst blame remains the primary response to failure opportunities for learning will be lost and the quality of the lessons learnt will be poor. Overcoming this barrier is a true challenge of leadership at all levels of an organisation as it requires a change in culture – a clear and sustained statement and restatement of values, unwavering adherence to behaviours that follow from those values, even in the face of challenges from within and without the organisation.

    Leading Learning for Patient Safety

    So where should we start with creating a learning culture in our organisations? The answer has to be with leadership, because without leadership on this issue nothing else can follow. The type of leadership and skills required to lead learning, however, are not what are typically viewed as traditional leadership skills. The leadership model for leading learning differs from the traditional leadership model in several important ways:

  • Whilst a ‘burning platform’ undoubtedly exists, the future state can only be guessed at (in an educated way)
  • This makes it hard to articulate
  • The flaws in the current state are hard to spot – there is a deep seated culture of acceptance of low level failure
  • The way forward is not a clear plan with deadlines and critical paths but a process of experimentation, a gradual reduction of uncertainty and regular revision of interim goals and ultimate vision
  • The leadership task is primarily one of engagement and reduction of fear not a promotion of employee effort
  • The task will never be finished
  • If you have read my previous blogs you might guess that I believe these ‘New Model Leaders’ need to come from the rank and file of doctors, nurses and other healthcare professionals that don’t often put themselves forward for such a role.

    Second Order Problem Solving and A Team Based Learning Infrastructure

    Second order problem solving is about creating long term fixes for recurrent problems, it is about analysing root causes and putting in place solutions with ‘traction’, it is often about changing behaviours in ourselves that have consequences for others. There are several reasons why we don’t stop and take the time and effort required to convert first order to second order problem solving. First of all – it does take both time and effort – neither of which we have much left of after a day / week / month / years of fire fighting. Secondly the problems we need to solve are quite often not even perceived as problems, we have been compensating for so long it has just become part of the job – this is where our new model leader has to be insightful. Thirdly second order problem solving requires some quite specific skills such as root cause analysis, process mapping, and change modelling that are not commonly found in healthcare teams. Fourthly – we are quite proud of our first order problem solving, being a coper and thriver in a stressful front line job is associated with significant kudos, particularly in the hospital environment. Finally it does require us to meet as teams for a significant time on a regular basis – which we are astonishingly bad at doing – and when we do for those team meetings to be led in a way that promotes speaking up, learning from others, admissions of failure and a willingness to innovate (and therefore risk failure). This final requirement leads on to the the final pre-requisite for organisational learning – an environment of psychological safety – A Learning Environment

    Blame Free Culture Vs Accountability – A Balance that Creates ‘Psychological Safety’

    Our new model leaders have their work cut out – not only do they have to create time (in an already overloaded time table) to bring together teams (who are singularly reluctant to gather) to discuss both low level and high level failure (failures that may not even be recognised as such) and defend these notions against pressures to use the time ‘more productively’; but also resist the temptation and pressures from above, inside and out to apportion blame for every failure that comes to light. The prize is great if they achieve it – a learning environment in an organisation that continually improves both itself and the people that move through it, one that delivers both on the economic and quality front. A true value adding organisation.

    But – it can’t all be so idyllic surely? People do also make mistakes borne out of stupidity, brazen over confidence, ignorance, stubbornness, laziness, jealousy and – yes – even malice. There is a level of human behaviour for which we all need to be held account. There is also a performance imperative, we all have to be helped to raise our game. Where is the place for accountability in a blame free culture? The diagram below will perhaps help you decide…

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    This is the essential difference between ‘blame free’ and ‘psychologically safe’ for the latter comes not just from creating an environment where people feel able to speak up and admit failure but also feel assured that when boundaries are truly crossed that individuals will be held to account. This is the real test of leadership – knowing and communicating expectations and boundaries as well.

    Blameworthy Acts – the Boundaries of a Blame Free Culture

    Where do you draw the boundaries? There are no text books, there are no rules – there is intuition and there are inspirational leaders we can follow. Here is my starter for ten of blameworthy acts:

  • Reckless behaviour
  • Disruptive behaviour
  • Working significantly outside your capability
  • Disrespectful behaviour
  • Knowingly violating standards
  • Failure to learn over time
  • Failure to work as a team
  • Covering up
  • No doubt there are more. Clear boundaries around a learning zone create an environment in which organisations can thrive and patients can feel and be safe.

    I have to acknowledge the source of the ideas for this article. Amy C Edmonson – a truly inspirational teacher at HBS who not only articulates this message with conviction but backs it up with the irrefutable results of research both in healthcare and other settings.

    In my last post I described my journey to taking the decision to become a medical director. I know that many of my colleagues, whilst being extremely generous in their congratulations and sincere in their wishes of good luck and fortune – may well be thinking along the lines “why would you do that?”. I know that is what I thought for quite some time, and a bit of me still does…

    The Cost

    The loss of clinical practice is the first barrier – it has direct cost to the individual doctor. Earning opportunities for supplementing ones basic NHS salary as a practicing clinician are legion, waiting list initiatives and private practice if pursued with dedication and vigour can easily surpass even a medical directors salary. As one becomes more and more embroiled in the maelstrom of medical leadership the loss of time (and vigour!) gradually closes off these opportunities – the arcane pay structures of the NHS are peculiarly bad at rewarding those that do choose to take that path; and when they do it results in a wholesale pillaging of ones pension by the tax man (that alone is enough to put many off).

    Most doctors though are not wholly motivated by money (fortunately) – but there is a deeper and more personal cost to moving away from clinical practice and that is the less tangible but very real issue of status. The status of medical practitioner is hard earned but once achieved is gratifyingly well rewarded. Doctors are accorded a great deal of authority and privilege both within and outside the work place – with that comes much expectation and responsibility. One’s status as a trained practitioner in your chosen specialty, the time and effort put in to achieving it and the rewards it brings through the gratitude and respect of patients, colleagues and society results in it becoming an embedded part of one’s identity – giving it up is giving up a part of yourself and replacing it with….management (why would you do that?).

    Now I’m not saying that becoming a medical director will result in a wholesale loss of status nor for that matter will I be impoverished by the move. Nevertheless I am giving up part of my identity (in my case I am giving up intensive care medicine), I am stopping doing something that on a good day is actually good fun, I am leaving behind colleagues and friends (who no doubt think me very disloyal) and replacing it all with a new and different status – one with uncertain benefits and certain risks.

    Certain Risks

    There is no doubt the climate is harsher the higher you climb the leadership pyramid (for the record I’m not a fan of hierarchical metaphors for leadership structures with all the value laden implications of rank – common usage though makes them hard to avoid…). Scrutiny is more direct, more personal and less forgiving. Failure is overt, public and consequential to one’s job. The safety net of return to clinical practice gets thinner and the holes bigger the more time you spend away from it. Exit strategies are unclear, career paths poorly defined, training and support hard to find (expensive when you find them). These are realities faced by almost anyone in positions of responsibility both in public and private sector organisations. The wind only feels chillier to a doctor because of the remarkably secure, well rewarded and unassailable position that being a consultant is.

    Uncertain Benefits

    You are paid more – though the pathway through clinical directorship and associate medical directorship on your way there is hardly littered with gold. Most Trusts struggle to release the time let alone the money to encourage doctors down the path – certainly insufficient to compensate for the opportunity costs outlined above. Your salary is a matter of public record and subject to scrutiny in a way no other consultant has to endure. Should this discourage you? – Absolutely not, the money is good enough that for the vast majority of us it is a non-issue, it’s ‘off the table’. The role brings a level of autonomy, self determination, sense of purpose and opportunity for personal development that no other leading to it can – for me this is the motivation.

    So would you do it?

    It doesn’t stack up well – and there are lots of things we could do to make it stack up better. Many outlined in this report. I am certain there are many doctors out there with the leadership skills that are needed that are reluctant to put themselves forward. My advice is take the plunge, change is good.

    On the 1st of August 2012 I will be taking up the post of Medical Director at a large NHS Trust in the Midlands UK.

    This blog is an outline of my journey to this critical juncture of my career and I intend to use it to share my experiences in this role and I hope to help others – either actual or aspiring medical directors – in their journeys too.

    It is my belief that too few doctors put themselves forward for leadership and management positions in healthcare in general and the NHS in particular. Having made the plunge – I understand why and want to use my insight to support others in following me. My motivation is that I genuinely believe that without active engagement of and leadership by doctors the quality and safety of the service we provide is significantly threatened by the current and ongoing funding crisis. Only doctors have the insight and knowledge that equips them with the skills to make the really hard choices involved in balancing cost and benefit. However to put themselves in a position where they can make those choices in a way that makes a significant difference to large numbers of patients at a scale that also makes a significant difference to the cost of delivering healthcare to the economy requires individuals to make real sacrifices.

    My Journey

    I am by training an anaesthetist and intensivist. I became a consultant in 2002 and within 2 years found myself clinical director of critical care services in one the of the largest acute trusts in the NHS – operating out of three acute hospitals. This wasn’t because I was ambitious to do so, or even envisaged myself doing that role when I was appointed, it was simply because no one else wanted or was ready to do it (neither was I). My first year as CD I had no directorate manager, I had no training but I did have a fantastic team of senior nurses and consultant colleagues willing to work together as a team. Over the subsequent 5 years I had 6 different directorate managers working with me, some excellent others less so – and therein lies one reason why we should not leave radical reform of services to non-clinicians; only doctors and nurses are in it for the long haul, managers by their nature move on, and don’t always witness the consequences of their actions.

    I am lucky to have trained and worked in a truly modern specialty – one that recognises the necessity of team working, that sees doctors, nurses and other healthcare professionals as equal partners in that team delivering an outcome for the patient – one that recognises the need to take control of the whole cycle of care including the pathway to the door of the ICU (through MEWS and critical care outreach) – one that recognises the need to codify and simplify the process of care delivery in order to improve reliability (through care bundles – checklists by another name) – one that recognises the need to measure risk adjusted outcome and use it to continuously improve the service (through ICNARC). Ten years or more of this approach has resulted in an un-sung triumph of healthcare – the virtual elimination of central venous catheter related sepsis, the placing of sepsis in general at the top of the emergency medical agenda, year on year reductions in mortality (our SMR has fallen from 1.3 to a low of 0.73 just before ICNARC re-calibrated the risk model). This is not a unique success, it has been replicated in intensive care units across the country and the world.

    I recognised that there are some generalisable principles in the critical care story that if applied across a healthcare economy could bring about radical improvements in the quality of care delivered at the same time as reductions in the cost of care. This belief motivated me to not only learn more about models of healthcare delivery and their practical implementation but also to put myself in a position where I could influence – rather than remain a frustrated observer. It struck me that not only is this an area of fulminant intellectual activity, it is also an area where as an individual one can make more difference to more patients in a shorter space of time than any area of academic medicine (I am after all an archetypal anaesthetist – an impatient physician!).

    These thoughts (not necessarily as well formed at the time) led me to apply for the position of associate medical director at my Trust (in 2009), and also to the hallowed halls of Harvard Business School (in 2010/11) where I was exposed to the global cutting edge of thinking in healthcare delivery. This experience has been transformational for me personally, affirmed my belief that this is the right career path for me, and equipped me with knowledge and insights that I am impatient (again) to see put into practice. Many of the ideas will be themes I will draw out in future posts. The time is right – new ideas are becoming established in the thinking of policy makers – integrated care, outcomes frame works, value based competition, improvement science – and the need has never been more urgent.

    And so here I am in 2012 about to take up MD post at another large trust. In my next post I will talk about why many wouldn’t do what I have done and why I nearly didn’t…