I joined another 12 people for a tour of the famous Sidney Garfield Innovation Centre in Oakland, California. Housed in a warehouse in the airport district, the Centre provides space in which the Kaiser Permanente healthcare group brings together ideas, clinical and technological expertise to develop and trial everything from new work practices to new devices to new physical environments. They have a number of workspaces set up - a ward, an operating theatre, a set of clinic spaces, the home and a large space that can be turned into anything required.
They demonstrated the current technologies under development and/or evaluation - exciting ideas such as using the XBox Kinect technology to allow scrubbed surgeons to use gestures to look up information, or to control equipment, facial recognition for logging into hospital information systems (it took 3 seconds!) and a very cool robot that delivered supplies aound the hospital, saying "Excuse me" if it detected an obstruction! Some of the equally useful, but less flashy, innovations included the development of modular ward walls that incorporated all the required services (medical gases, suction, etc) and could be put up quickly. All the switches and wall mounts were mounted vertically so they were easily accessible. There was "telepresence' in every room, supporting all sorts of communication including allowing parents to observe their babies in NICU from home, consultations at a distance, and an interactive screen for patients to do everything from ordering their meals to seeing their medical record, learning from hotels where guests can order food, check services etc on their TV screen. There was a new device they were trialling that contained an accelerometer to detect patients moving out of their beds so that nurses could respond quickly and prevent falls.
I loved the new approach taken by Kaiser in establishing clinics connected to shopping malls, where patients check-in using a self-check in like most airlines now have.
The home environment was also fascinating, where they're looking at how smart appliances can support healthy living.
Much of their work is using the iPad as a platform. They're currently working with a number of different companies but the ubiquity of and ease of app development for the iPad means that it can't be ignored. The main issues they've identified are the need to be able clean the surface, and the poor ergonomics of the iPad for use carrying around all day.
Some of the attendees on the tour were actually from Kaiser's competition, and openly so. Kaiser encourages sharing of ideas, but is just this year, dealing with the issue of intellectual property rights.
Wednesday 18 January 2012
Friday 13 January 2012
Visiting the IHI - January 13, 2012
I visited the Institute for Healthcare Improvement today. I had the opportunity to ask three of their senior leaders about their career paths, what motivated them, what opportunities they had been given and what education, training or other support had helped them. I also spoke with the Open School team and the Triple Aim team. I approached my first meeting with some degree of trepidation as the IHI is such an icon in the healthcare quality and safety world.
And of course they're an icon for a many reasons, not least of which is the calibre of their leaders, who were welcoming, open and very humble. I was hard pushed to get anyone to admit to having leadership skills even in the face of their clear success!
I had loads of questions and each one was answered with such reflection and honesty. I was deeply impressed that they would take the time to debate issues with me, at times disagreeing but always with considered reasons. It was a great example of a 'safe space' in which to try to articulate ideas, have them considered by experienced people who then add breadth and depth. I looked for, and found, many parallels to the way in which Innovation Support works.
It was also great to be able to ask the Triple Aim team what they mean by each of the 3 terms that they use, and how they support and measure their achievement. They said that there were many groups who misinterpreted the Aims and some who reinterpreted them. In particular, they clarified their meaning of 'Improving patient experience' which is different to the way I had been interpreting it. The Director, Martha Rome, said that they mean the whole of patient care. They would like to be able to measure it across all the dimensions of quality but have tended to use a single question such as "How would you rate your health?" Martha described this Aim as a balancing one for the other two.
This is in contrast to the questions we ask in relation to patient satisfaction or patient expereince, which Martha described a measures of patient-centredness. Interestingly, one of the non-Triple Aim people also thought the same as us, so perhaps that's something the team could make clearer.
Another very interesting point was that the focus of IHI has really only recently expanded beyond hospital care. For example, the Open School has few resources for ambulatory care services and none aimed at primary care.
Overall, a very inspiring and enjoyable day!
And of course they're an icon for a many reasons, not least of which is the calibre of their leaders, who were welcoming, open and very humble. I was hard pushed to get anyone to admit to having leadership skills even in the face of their clear success!
I had loads of questions and each one was answered with such reflection and honesty. I was deeply impressed that they would take the time to debate issues with me, at times disagreeing but always with considered reasons. It was a great example of a 'safe space' in which to try to articulate ideas, have them considered by experienced people who then add breadth and depth. I looked for, and found, many parallels to the way in which Innovation Support works.
It was also great to be able to ask the Triple Aim team what they mean by each of the 3 terms that they use, and how they support and measure their achievement. They said that there were many groups who misinterpreted the Aims and some who reinterpreted them. In particular, they clarified their meaning of 'Improving patient experience' which is different to the way I had been interpreting it. The Director, Martha Rome, said that they mean the whole of patient care. They would like to be able to measure it across all the dimensions of quality but have tended to use a single question such as "How would you rate your health?" Martha described this Aim as a balancing one for the other two.
This is in contrast to the questions we ask in relation to patient satisfaction or patient expereince, which Martha described a measures of patient-centredness. Interestingly, one of the non-Triple Aim people also thought the same as us, so perhaps that's something the team could make clearer.
Another very interesting point was that the focus of IHI has really only recently expanded beyond hospital care. For example, the Open School has few resources for ambulatory care services and none aimed at primary care.
Overall, a very inspiring and enjoyable day!
Monday 9 January 2012
On loyalty
One of the striking things that I've noticed in the UK, Denmark and Sweden is the emotional tie that clinicians appear to have with their health systems. Ask an Australian doctor or nurse what they think of the Australian health care system, and you're likely to be met with eye-rolling and head-shaking, and a litany of shortfalls. The 'government' and its tight-fisted short-sightedness would be named as the root cause.
In contrast, the words "We love the NHS and will fight to save it" were uttered by not one, but many speakers during a conference on clinical commissioning in Manchester, UK. A national health service that provides care to all was an important step in the UK following World War II, and it is viewed, it appears to me, by the public and clinicians as both a right and a privilege. Access to health care is a human right, but the maintenance of the system to deliver such care, is a joint effort, between government, health service workers and the community.
In Denmark, the majority of clinicians belong to one of the Danish Unions. These groups not only exist to protect workers' rights, but are involved in decision-making at hospital level, along with clinical leaders. It was clear that individuals were loyal to their union, not just for their individual needs but also because the union provided a means for their clinical voice to be heard.
A change in government in Sweden has seen a major change in the healthcare landscape. The new regime has introduced competition for the first time, allowing doctors and other health care workers to establish private clinics as an alternative to the previous state-run monopoly. When I asked a hospital cardiologist how this was working out, he said that many hospital doctors felt a sense of loss, that the previous monopoly over the continuum of care had allowed them to deliver coordinated, integrated care. The stated goal of competition was to provide choice for patients and to stimulate change and innovation. The main group to take advantage of this was GPs, with some specialists and allied health workers opening up clinics. It was too early to say whether the goals of the government or the fears of the hospital clinicians would come to fruition.
In contrast, the words "We love the NHS and will fight to save it" were uttered by not one, but many speakers during a conference on clinical commissioning in Manchester, UK. A national health service that provides care to all was an important step in the UK following World War II, and it is viewed, it appears to me, by the public and clinicians as both a right and a privilege. Access to health care is a human right, but the maintenance of the system to deliver such care, is a joint effort, between government, health service workers and the community.
In Denmark, the majority of clinicians belong to one of the Danish Unions. These groups not only exist to protect workers' rights, but are involved in decision-making at hospital level, along with clinical leaders. It was clear that individuals were loyal to their union, not just for their individual needs but also because the union provided a means for their clinical voice to be heard.
A change in government in Sweden has seen a major change in the healthcare landscape. The new regime has introduced competition for the first time, allowing doctors and other health care workers to establish private clinics as an alternative to the previous state-run monopoly. When I asked a hospital cardiologist how this was working out, he said that many hospital doctors felt a sense of loss, that the previous monopoly over the continuum of care had allowed them to deliver coordinated, integrated care. The stated goal of competition was to provide choice for patients and to stimulate change and innovation. The main group to take advantage of this was GPs, with some specialists and allied health workers opening up clinics. It was too early to say whether the goals of the government or the fears of the hospital clinicians would come to fruition.
On "speaking up"
Many of the people who've kindly spoken to me have been in leadership roles for many years. They attributed their success and longevity in the role to a many things - learning from mistakes, education and traing, keeping the patient at the centre of what they do, support from above, and very importantly, support from their peers and teams.
One aspect of this support is the willingness of team members to speak up when they are concerned that something is unsafe, or that a practice or process is inefficient, inappropriate or ineffective. In Denmark, one senior clinician manager laughingly said, "When I ask my team to do something, they don't ask 'When?' they ask 'Why?'." He relies on this questioning to help him to make good decisions and he sees this behaviour as evidence that "Danish people are the most democratic in the world".
I met with a clinical leadership teamat department level, consisting of doctors and nurses, also in Denmark. I asked about the relationships between different professional groups, both as leaders and followers. This team described their structure as being very flat, with nursing and medical co-directors. Speaking up to each other was commonplace, and none felt that there was likely to be any negative consequences from doing so. They agreed that bullying existed but it was not commonplace.
In Sweden, a radiology nurse told me about their Monday morning meetings in the Radiology Department. Nurses (the nurses are radiographers) and doctors discussed any issues from the week before and in preapration for the week ahead. It was also a time that nurses might raise a point of variability that they observed - why does Dr A use Xmg of a drug, while Dr B uses Ymg? The doctors present would then discuss the evidence available and agree to standardise practice. This form of continuous quality improvement was seen as a normal part of being a good department.
Finally, I spoke to the Vice-Director of a large hospital in Denmark who commented "Why wouldn't I listen to them? They're spending the money!" He quickly followed that his main concern wasn't money, but that those "below" him saw problems well before he did. Encouraging his clinicians to 'speak up' to him meant that he could mitigate or prevent serious consequences.
One aspect of this support is the willingness of team members to speak up when they are concerned that something is unsafe, or that a practice or process is inefficient, inappropriate or ineffective. In Denmark, one senior clinician manager laughingly said, "When I ask my team to do something, they don't ask 'When?' they ask 'Why?'." He relies on this questioning to help him to make good decisions and he sees this behaviour as evidence that "Danish people are the most democratic in the world".
I met with a clinical leadership teamat department level, consisting of doctors and nurses, also in Denmark. I asked about the relationships between different professional groups, both as leaders and followers. This team described their structure as being very flat, with nursing and medical co-directors. Speaking up to each other was commonplace, and none felt that there was likely to be any negative consequences from doing so. They agreed that bullying existed but it was not commonplace.
In Sweden, a radiology nurse told me about their Monday morning meetings in the Radiology Department. Nurses (the nurses are radiographers) and doctors discussed any issues from the week before and in preapration for the week ahead. It was also a time that nurses might raise a point of variability that they observed - why does Dr A use Xmg of a drug, while Dr B uses Ymg? The doctors present would then discuss the evidence available and agree to standardise practice. This form of continuous quality improvement was seen as a normal part of being a good department.
Finally, I spoke to the Vice-Director of a large hospital in Denmark who commented "Why wouldn't I listen to them? They're spending the money!" He quickly followed that his main concern wasn't money, but that those "below" him saw problems well before he did. Encouraging his clinicians to 'speak up' to him meant that he could mitigate or prevent serious consequences.
Wednesday 21 December 2011
December 13, 2011
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| Lucia with real candles in her crown! |
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| The Folk Music Group (sounded suspiciously like Irish folk music). The guitarist is the Director of Public Health. |
Wednesday 14 December 2011
December 9, 2011
I met today with staff from Bispebjerg Hospital, one of the main hospitals for the Capital Region of Denmark. The area around the hospital is home for the migrant population and other disadvantaged groups.I first met with the Director for Orthopaedics (and president of the national orthopaedic body) who rose very quickly to a senior role in the Danish Health Board but was required to relinquish his clinical work. After a few years, he realised that he missed this work and returned as Director, where he has been able to mainatin a small amount of subspecialty work. He has a nursing co-director and feels that it's a fairly equal relationship between them. Further to this he described Danish people as 'the most democratic people in the world' who have no hesitation in speaking up to him. His phrase was 'When I ask someone to do something, they don't ask "When?", they ask "Why?"'.
I was interested in his view of the major structural and functional changes in Danish healthcare over the last few years, in particular, the fact that a number of hospitals had been closed. He felt that Danish people and clinicians, in particular, understood that these moves were important to maintain quality and to reduce waste. He said that, as Head of Dept, he has had to find ways to increase productivity for a reduced budget. They have an ALOS of 3 days for joint replacement surgery and have increased productivity by 17% over the last few years. He felt that he had a strong voice in hospital decisions and at Region and national level. This was partly because of his own leadership qualities but also because the structure of the system allowed him clear opportunities. Another interesting thing was that he was asked by the Danish Health Board to provide criteria for referral to specialist orthopaedic clinics for OA - a similar process to our HealthPathways.
I spoke after this with the Medical Director of the hospital. He no longer has any clinical role but he has a very structured approach to involving his clinical directors in decision making in his hospital which includes regular meetings as individuals and as a group. The clinical directors are responsible for the quality and efficiency of their departments and no decision about their departments is made without them present and part of the discussion. The medical Director could not envisage a situation where his clinical leaders would not be part of the decision-making process.
I then had the opportunity to meet the 2 clinical leads for the Dept for Integrated Care - a general physician and a geriatrician who no longer worked clinically. They are trying to work through pathways with their GPs and are working on ways of evaluating any changes they make. They were very interested in the HealthPathways program. To me, their work was the evaluation side to our implementation work so I'm hoping to speak with them again when they're closer to developing their assessment tool.
I was interested in his view of the major structural and functional changes in Danish healthcare over the last few years, in particular, the fact that a number of hospitals had been closed. He felt that Danish people and clinicians, in particular, understood that these moves were important to maintain quality and to reduce waste. He said that, as Head of Dept, he has had to find ways to increase productivity for a reduced budget. They have an ALOS of 3 days for joint replacement surgery and have increased productivity by 17% over the last few years. He felt that he had a strong voice in hospital decisions and at Region and national level. This was partly because of his own leadership qualities but also because the structure of the system allowed him clear opportunities. Another interesting thing was that he was asked by the Danish Health Board to provide criteria for referral to specialist orthopaedic clinics for OA - a similar process to our HealthPathways.
I spoke after this with the Medical Director of the hospital. He no longer has any clinical role but he has a very structured approach to involving his clinical directors in decision making in his hospital which includes regular meetings as individuals and as a group. The clinical directors are responsible for the quality and efficiency of their departments and no decision about their departments is made without them present and part of the discussion. The medical Director could not envisage a situation where his clinical leaders would not be part of the decision-making process.
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| Most staff ride their bicycles to work. |
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| Bispebjerg Hospital, Copenhagen |
Saturday 10 December 2011
December 6, 2011
I had the opportunity to meet with ten senior leaders in the Danish healthcare system for 2 hours. They established a
learning and support network 2 years ago, facilitated professionally. The
network consists of doctors, nurses, a midwife, a physiotherapist, an economist
and a bureaucrat, all of whom had positions of leadership at the region (=state)1 or national level. They meet regularly for an afternoon and dinner and the agenda
may include talks by invited speakers or journal articles that lead on to
further discussion. I was asked to lead a discussion around leadership stories
and what they told us about the way leaders can be developed or supported. While
there are many similarities between Denmark and Australia, some of the many differences I heard were:
1) Union membership is very important to Danish people, including the doctors. The unions have a strong role in determining the quality of involvement and the consensus views that are projected from the clinicians.
2) All hospital leadership teams consist of a doctor, nurse +/- an 'economist' as they were referred to. These leaders do not have any clinical work (or very minimal) - the role of leadership is considered too busy and too vital to allow such indulgences! The medical department leaders and the medical and nursing hospital and regional leaders felt that they were recruited for their specific skills to roles that had very clear responsibilities and accountabilities. Their financial and quality goals are both considered to be vital parts of their roles. The average department (eg anaesthetic dept, orthopaedic dept etc) would consist of around 300 people -doctors, nurses, scientists etc.
3) In one of the 5 Regions of Denmark (the Capital region), the executive and the clinical leadership have decided that leadership training is essential for all clinicians. They had developed 5 different leadership courses which lasted between 10-12 days (5-6 x 2 days) and were tailored to the different roles in the system. I was told that almost 70% of clinicians had been trhough this training so far.
4) I asked about the challenge of leading toward goals that were of benefit to the whole population rather than a department or hospital. They agreed that this has been an ongoing discussion but that they were making headway here. In one specialty, a senior leadership group makes decisions about the adoption of new technologies for the country. This takes into account the cost benefit of the intervention within the limits of the prevailing financial context. They will sometimes make decisions about what interventions should stop being delivered, but agreed that this was very difficult. All of them agreed strongly that Denmark has a limited health budget and that they were tasked with getting the best they could for as many people as possible within the budget.
A little observation - this senior leadership meeting was held in a community owned space, a lovely old building with wooden floors and odd shaped rooms that overlooked a central courtyard through huge windows. The rooms occupied by the group contained colourful, mismatched chairs. In one room was a large old wooden table. In the other, chairs were positioned in a chatty circle. On the narrow shelves around the perimeter of the room, and on little low tables, there were candles and tea lights and big bowls of fruit. It was impossible not to feel relaxed and welcome in this space, and this was evident in the warm, open conversation that ensued.
1) Union membership is very important to Danish people, including the doctors. The unions have a strong role in determining the quality of involvement and the consensus views that are projected from the clinicians.
2) All hospital leadership teams consist of a doctor, nurse +/- an 'economist' as they were referred to. These leaders do not have any clinical work (or very minimal) - the role of leadership is considered too busy and too vital to allow such indulgences! The medical department leaders and the medical and nursing hospital and regional leaders felt that they were recruited for their specific skills to roles that had very clear responsibilities and accountabilities. Their financial and quality goals are both considered to be vital parts of their roles. The average department (eg anaesthetic dept, orthopaedic dept etc) would consist of around 300 people -doctors, nurses, scientists etc.
3) In one of the 5 Regions of Denmark (the Capital region), the executive and the clinical leadership have decided that leadership training is essential for all clinicians. They had developed 5 different leadership courses which lasted between 10-12 days (5-6 x 2 days) and were tailored to the different roles in the system. I was told that almost 70% of clinicians had been trhough this training so far.
4) I asked about the challenge of leading toward goals that were of benefit to the whole population rather than a department or hospital. They agreed that this has been an ongoing discussion but that they were making headway here. In one specialty, a senior leadership group makes decisions about the adoption of new technologies for the country. This takes into account the cost benefit of the intervention within the limits of the prevailing financial context. They will sometimes make decisions about what interventions should stop being delivered, but agreed that this was very difficult. All of them agreed strongly that Denmark has a limited health budget and that they were tasked with getting the best they could for as many people as possible within the budget.
A little observation - this senior leadership meeting was held in a community owned space, a lovely old building with wooden floors and odd shaped rooms that overlooked a central courtyard through huge windows. The rooms occupied by the group contained colourful, mismatched chairs. In one room was a large old wooden table. In the other, chairs were positioned in a chatty circle. On the narrow shelves around the perimeter of the room, and on little low tables, there were candles and tea lights and big bowls of fruit. It was impossible not to feel relaxed and welcome in this space, and this was evident in the warm, open conversation that ensued.
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