Payment for hospital discharges is wrong

Addenbrooke’s Hospital in Cambridgshire has introduced cash incentives to reduce bed blocking, says the BBC news website. From the article:

Addenbrooke’s Hospital wards will get £1,000 if they discharge two patients by 10:00 each day for a week and £5,000 if they manage it for a month.

The “Two out by 10″ programme has been introduced by Dr Keith McNeil, who took over as the hospital’s chief executive this year.

This is a classic example of an arbitrary numerical target made worse by offering a monetary reward. The focus of the ward managers and staff every morning will be identifying the two patients they can ship out as fast as possible so they can get the cash. It may very well lead to some people being discharged before they should be which may cause unnecessary admissions or further treatment.

Moreover, staff will go hell for leather for the first two patients to meet the criteria and other patients will fall back into the old system. By focusing on the discharge plans of the first two patients, it may be the case that everyone else’s plans receive less effort, worsening the problem as a whole.

Dr McNeil says,

“The idea is to get everyone involved in improving patient flow in a pre-emptive way, rather than leaving it to the last minute.”

These are the right words but entirely the wrong actions.

If they want to improve discharges to free up beds, they should understand the factors that cause the current performance, understand what is important to patients about discharge and then measure the variation to see what they system is capable of. Then and only then can they start to make improvements to the whole system of care, not just the discharge procedure, so that both care and discharges are improved.

Best,

Rob

Patient need should trump service convenience

A link to a very short article in the Independent today, NHS ‘should operate seven days a week’.

When you stop you stop to think about this, it is amazing that this has taken so long to come to the top of the agenda. Granted, there are medical issues that can wait until Monday and elective surgery times can be chosen by definition. But broadly, people can’t chose what day of the week they have their accident, heart attack, onset of labour or other unpredictable event. Also those who have a long stay in hospital will be there over the weekend and they should expect the same standard of care and medical cover every day of the week.

The NHS should have been set up from the beginning to serve the need of the public, at the time they need it. Not to mention the waste of the theatres and diagnostic facilities that must lay dormant between Friday evening and Monday morning.

However, is this an easy thing to change, given how entrenched a five-day week is in the NHS? No, of course not.

The other thing to point out is that Sir Bruce Keogh, medical director of the new NHS Commissioning Board, is quoted in the article as saying that “the NHS had to learn from private sector companies such as Tesco”. Pointing to private sector companies may be a way to justify a change but it shouldn’t be the driver for action. In this case the NHS only needs to look at the requirements of its patients. What Tesco or anyone else does is irrelevant. It is your own system that should be the primary place to learn how to improve your own system.

Best,

Rob

Two worlds in the NHS

Quick one from me today. Just thought I’d point out this nice little comment piece called There are two worlds in the NHS: policy and practicality on the Guardian website. One little quote to whet your appetite…

Last month, I accompanied a frail 85-year-old neighbour to a pre-op session in a sub-hospital of one of the local trusts. This place seemed to be entirely made up of half-empty WW2 barrack rooms like the ones where I did my national service 66 years ago.

The nurse told him that he needed blood and urine tests, and an echocardiogram, none of which could be done in that hospital. He presented himself at the main hospital the next day, and was told he would have to book the echo test for the following week. Thus, he had to take three bites at getting a simple pre-op done. Is this a cost-effective or humane use of using NHS resources?

Best,

Rob

Good service, dumb system

The charger for my Apple laptop conked out this morning. The laptop has a good battery life so I was able to do a morning’s work before calling my local Apple reseller to see if they had one in stock. They did, so I headed into town all ready to pay for a new one.

When I arrived I asked if I could test both the charger and the laptop to make double sure it was the charger and not the charging point on the laptop itself. The assistant was very helpful and said, “Of course,” and helped me to test both bits of kit. It was the charger. (I was relieved it wasn’t the laptop.)

I asked her to help me make sure I was buying the right type of charger, but before we got to that she stopped and asked, “Do you have AppleCare?” I do have AppleCare on this laptop, I always get it for business machines, it is really just an extended warranty. “Great,” she said, “Your charger will be covered by that.” I was very happy. She had saved me a considerable amount on the cost of a new charger by asking if I were covered, when the store would profit by me buying a new charger. Excellent service.

So we went over to the computer to double check my AppleCare status, which was fine, and she said that the new charger would arrive by Saturday. I asked if I could just take a new charger from the store. She said that they had sale stock and repair stock and they couldn’t turn one into another. But, I asked, they are going to just send a brand new charger, just like those on your shelf? “Yes,” she said. I said that I really needed a charger now, and she was happy to loan me one, which is more good service.  But actually, it only good service because they couldn’t give me a new one straight away.

So this is a perfect example where a store gives excellent service, given the dumb system that they have to work with. They did everything they could to solve my problem, (and their repairs system has already sent me two texts to keep me up to date with the “repair”) but if they had a more sensible system then I wouldn’t have to go back to the store on Saturday to pick up my new charger and give back the loaner. Moreover, they would have an even happier customer and have to spend less time with me. This would save them money and give them more time for other customers.

As always, better service costs less.

If you have an example of a similar experience, then feel free to leave a comment below.

May your charger last longer than mine,

Rob

Hearing service cuts will lead to higher costs

The BBC website reports on NHS hearing services being ‘cut’ all over the country after a report by Action on Hearing Loss. Apart from the loss of services like follow-up appointments to ensure that hearing aids are adapted and used correctly which may mean that a hearing aid is less effective, Paul Breckell, the chief executive of Action on Hearing Loss said,

“Making savings from hearing service cuts right now is a false economy because it will only lead to higher NHS and social care costs to support people with untreated loss in the long run.”

This is the crux of problems about cuts to public services, that they will lead to higher costs next year and in the years to come. This is true in Greece, true of diabetes and true of youth services.

It won’t get any better while we focus on simply cutting cost, we must turn to improving services.

Best,

Rob

The Whistleblower Problem: They Exist

There is a very worrying article in the Independent about the treatment of Kay Sheldon, who is a whistleblower and a non-executive director of the Care Quality Commission (CQC). It seems her mental health was called into question after she raised concerns about leadership of the CQC.

This raises issues about how we treat whistleblowers in public life. However, the real problem is not that whistleblowers are treated poorly, but rather that they feel they need to blow the whistle at all.

People who end up as whistleblowers nearly always go through the proper channels first to try to raise concerns within an organisation. It is only when that organisation ignores or as in the case above, blocks and harasses them, that they feel the need to go outside and broadcast what they see to the world.

Now, are there a very few people who are trying to damage their organisation for some personal reason? Of course, but the majority realise they are risking their reputation by going public. It is these brave people who we are thinking about here.

If an organisation has a whistleblower, that shows two problems:

1. The situation that the whistleblower points out, and
2. That the organisation is not capable of listening constructively to its staff to resolve serious situations

And it is inevitable that any situation that a whistleblower raises is going to be serious because they wouldn’t take that risk for something minor.

So having a whistleblower is a double damning of any organisation and should be treated as such.

If an organisation can ignore and deny the most serious of situations then it really need to be changed drastically, both to prevent that situation happening again but also to be open to internal scrutiny such that people don’t feel the need to ever reach for their whistle.

Best,

Rob

Is Big Medicine the answer?

Just a quick post to point up Atul Gawande’s article,
“Big Med – Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?”, in the New Yorker. A very interesting exploration of standardisation and tele-control centres in healthcare and how hospitals could learn from restaurants.

I’m not sure I agree with everything in the article but one quote caught my attention.

“Patients won’t just look for the best specialist any more; they’ll look for the best system.”

That is true whether or not the changes described in the article come to pass on a wider scale.

Do you think the innovations described are the future or the road to ruin? Please leave your comments.

Best,

Rob

Classic example of cutting costs leading to costs going up

In the Independent article, ‘The Women Greece Blames for its HIV Crisis’ as well as detailing the plight of Greek women made desperate for money so that they turn to prostitution, it also describes a situation where funding for needle exchange programmes are being cut. This causes fewer drug users to have access to clean needles and hence a 1,450 per cent increase in HIV positive addicts.

The article quotes Dr Apostolos Veizis, head of Medicins San Frontieres in Greece,

“At the moment of crisis, the one thing you don’t need to do is cut the budget on the public healthcare system and a social welfare,” says Dr Veizis, warning that it will end up backfiring. “If you have tomorrow a spreading of tuberculosis, HIV, etcetera, the cost you need to pay to treat your patients will be even higher.”

In Britain, we are not yet in such dire straits as in Greece, with less stringent austerity measures. However, the principle still applies that simply cutting costs, and not just in healthcare, in any service, will lead to higher costs in the medium to long term.

Best,

Rob

What Drives Us? Dan Pink’s RSA Animate Talk

A reader and Deming Alliance colleague, Kevan Leach, kindly reminded me that I ought to re-watch this great RSA Animate talk from Daniel Pink, the author of Drive: The Surprising Truth About What Motivates Us. I write about Pink’s work in my book ‘Beat the Cuts – How to Improve Public Services and Easily Cut Costs‘ and this video adds to that in a really fun, succinct way and very neatly describes Pink’s ideas about autonomy, mastery and purpose.

It’s only 10 minutes and the format is great.

Do you think that your organisation is still stuck in the old carrot and stick mode of incentivising people? Why not add a comment below and share either how your organisation is still stuck or what is being done differently.

Best,

Rob

Efficiency is not effectiveness

People mistake efficiency with effectiveness.

From the Oxford Online Dictionary, the definition of efficient is:

efficient

Pronunciation: /ɪˈfɪʃ(ə)nt/

adjective

• 1. (of a system or machine) achieving maximum productivity with minimum wasted effort or expense: more efficient processing of information
  [in combination] preventing the wasteful use of a particular resource: an energy-efficient heating system
• 2. (of a person) working in a well-organized and competent way: an efficient administrator

And the definition of effective:

effective

Pronunciation: /ɪˈfɛktɪv/

adjective

• 1. successful in producing a desired or intended result: effective solutions to environmental problems

Let’s think of jumping in the car to go on a journey. If the car was efficient it would “achieve maximum productivity with minimum of wasted effort or expense”. It would be efficient if it covered the distance with the minimum use of fuel.

The journey would only be effective if it was “successful in producing a desired or intended result”. So if we got lost and ended up somewhere other than our desired destination then the journey is not effective.

Efficiency is a nice to have in comparison with effectiveness. If we get in the car and arrive at our desired destination then it is good if the fuel usage of that journey is efficient. But who, after ending up in the middle of nowhere, completely lost, has ever said to their fellow travellers, “Well at least we didn’t use much petrol to get to … well … wherever we are.”?

So if we are not being effective we should ignore efficiency until we are. Then of course we could turn to efficiency as a possible next focus.

If we are not doing what we are supposed to for the public, we should never try to remove waste.

Effective first, only then efficient.

Best,

Rob

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