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- Background
- Introduction
- Health Reforms are the Springboard for a New Era of Positive Change
- Progressing from Administrative to Clinical Information Systems
- Overcoming the "Learned Helplessness" of Health Professionals
- System Thinkers Come To the Fore
- Recognition of the Damage Done by Repeated Structural Change
- Patient-Focussed Reform
- Evidence for Potential Gains
- The Importance of Clinical Leadership
- References
Background
"Our hopes for the health service bring to mind a little miracle that occurred on Christmas day, many years ago. Fred was an elderly man who had become increasingly withdrawn and immobile, barely responding to events around him. His wife recounted his gradual progression from an outgoing, cheerful and busy person to one in a state of apparent apathy and immobility. Thus he presented with features that even I could recognise as Parkinson’s Disease – a coarse tremor, rigidity of the limbs, shuffling gait, general immobility and lack of facial expression. On Christmas Day he had his first dose of levodopa and the effect was miraculous. He sprang from his chair with a huge smile and greeted his astonished wife who wept with joy at the return of her husband.
I often think of Fred because it seems that our New Zealand Health Service has been locked into a kind of Parkinsonian state and I’m optimistic about a cure. Pressures for change have been met with a kind of cogwheel rigidity and spasmodic dislocations rather than smooth evolution. The imposition of commercial and market place values has also meant that the health service has lost some of its human expression. I’m optimistic because I see the re-emergence of strong clinical leadership and a focus on patient-centred reform. The values and goals of clinicians and managers are becoming better aligned and we have great opportunities for "unlocking" the health service and making large gains in patient care."
Introduction
Out of the struggle of the last decade, a buoyant sense of optimism, direction and purpose for clinical leaders has emerged. The key change has been the creation of a multidisciplinary network of health professionals who are passionately committed to patient-centred values and goals. Until recently, clinicians have struggled in isolation in a hostile environment that emphasised competition and commercial values rather than patient outcomes. Many clinicians reacted defensively to the imposition of structural reforms and cost-control. Rather than seeking opportunities for better care within the limited resources, many blamed the Government for inadequate funding.
Emerging leaders now see huge opportunities for improving care. This paper examines the compelling evidence that underlies this belief.
A more sophisticated "systems" approach to problems, improved business disciplines, and closer alignment of the values between managers and clinicians provide a platform for a new era of patient-centred reform. Reform then becomes a continuous process of self-improvement for clinical services instead of externally imposed change.
This paper also defines the personal qualities required in clinical leaders and how clinical leadership might be supported, for example through training and opportunities for personal development.
Health Reforms are the Springboard for a New Era of Positive Change
It is worth reflecting on the gains of the last decade. It now seems incredible that in 1989 the amount spent on surgical services versus medical care was unknown. Information systems, management structures, financial accountability and the efficiency of public hospitals have been transformed out of all recognition. It is now possible to compare access to, and the cost of, individual clinical services in different regions of the country. The volume of health care continuously increased even during the time (1989–1995) when public health expenditure was falling in real terms. There has also been a steady fall in the average length of stay in hospital for many conditions. Advances in medical technology, such as laparoscopic surgery and radiological interventions, have reduced the overall costs of treatment and increased the proportion of day-stay procedures. 1 The emergence of IPAs has done much to support systems and standards of care in the primary sector.
Ironically, the negative aspects of the reforms have created the conditions for the re-emergence of clinical leadership as a very powerful and strongly motivated force. In the hospital sector, artificial divisions were created between health professionals and those responsible for allocating health funding. This purchaser-provider split and the appointment of professional managers, with no knowledge of health care, created the bizarre situation where hospital Boards of Directors could deny any interest in the outcomes of patients. The job of the Board was defined in purely financial terms: meeting contract volumes and reducing deficits. Those few doctors who ever met the Board were bemused to be told that patient outcomes were the business of the purchaser, not the health provider! Since almost all contracts were negotiated by professional managers with no knowledge of clinical matters, the pretence was complete. Alice in Wonderland would have felt quite at home. The tide is turning, however, and both hospital managers and purchasers now see the need to re-engage clinicians.
Progressing from Administrative to Clinical Information Systems
The purchaser-provider split and the imposition of general management have driven the development of information systems in support of management and administrative tasks. A new focus for information services managers is the development of information systems to help clinicians care for patients. Despite the fact that most of medical practice consists of gathering, sifting and analysing information, clinical information systems are almost non-existent in the public hospitals. Electronic decision-support systems, monitoring systems and electronic medical records have the potential to transform the effectiveness of patient care, reduce costs and prevent much harm. The purchaser–provider split made it almost impossible to construct a business case to support investment in clinical information systems because providers were not rewarded for clinical effectiveness. Furthermore, there has been little appreciation among health service managers of the potential benefits of clinical information systems. The gradual change in purchasing strategy from health outputs to health outcomes will support investment in clinical information systems and it is heartening to see the Health Funding Authority (HFA) seeking clinical advice on these matters. In the UK, the government has recently committed one billion pounds sterling (NZ$3million) to a seven-year programme of clinical information system development. 2
Overcoming the "Learned Helplessness" of Health Professionals
Bill English, while Minister of Health, often remarked on the "learned helplessness" of health professionals. "There could be no comparable group of people", he said, "selected for high intelligence, given the best of our education system, and held in high esteem by the public, who none-the-less behaved as if they were powerless to improve the health service". 3 This is a provocative challenge for clinical leaders who feel the need to re-assert themselves in their role of creating positive change rather than defending existing systems.
Health professionals have felt threatened by many changes in the last decade, including increasing expectations from patients, challenges to their authority from consumer advocates, threats of deregulation, and even investigation by the Commerce Commission. The exclusion from health service governance and the imposition of commercial rather than clinical values further disempowered clinicians. The defensive response of professional organisations allowed politicians to make accusations of patch protection and self-interest. Within hospitals, the imposition of financial restraints and devolution of budgets to independent business units created a structure which fragmented clinical care and discouraged co-operation in the care of patients. It became much easier to blame others for problems than to find solutions that met the needs of patients.
One social defence against such threats has been the righteous adoption of an individual patient ethic, under which physicians have advocated the rights of their individual patients, regardless of opportunity costs for other patients. A recent well-publicised example was the Wellington surgeon who proclaimed his intention to cheat the Booking System to allow his patients to jump the queue. However, clinical leaders believe such a stance, which ignores the limitation of resources, conflicts with broader notions of societal justice and fairness. 4 As a consequence, it creates an adversarial position that worsens relations between clinicians and managers.
System Thinkers Come to the Fore
The increasing specialisation and fragmentation of medical practice has diminished the appreciation of the complex systems of care that patients must negotiate. One consequence is the failure to recognise that many poor outcomes for patients are the result of systems failure, not individual incompetence or errors.
Often the care of patients is shared between a number of teams. Inadequate protocols governing the hand-over of care, compounded with poor communication, can have disastrous consequences. One such example was a young man admitted to the gastroenterology ward with a bleeding stomach ulcer. Most patients settle with medical care but some require urgent surgery for life-threatening haemorrhage. In this case, there was a protocol that mandated referral to the surgical team if the patient required more than six units of blood transfusion in a given period. Like many young people, this patient was able to make a physiological compensation for large blood loss without a reduction in blood pressure. The more subtle signs of haemorrhagic shock were not appreciated by the junior doctor on duty in the small hours of the morning. Because the extent of blood loss was not recognised, the patient was given only a small blood transfusion and was not referred for surgical assessment. At 4am, he suddenly collapsed. Surgeons were called by the intensive care team responding to the emergency and the patient was rushed to the operating theatre. In the haste and confusion, no one had thought to warn the only anaesthetist in the hospital, who was just starting a case for a different surgeon. The back-up anaesthetist had to be called in from home. The patient, who had been in hospital for six hours, almost died of severe haemorrhagic shock before surgery could commence.
The system failures here are numerous: inadequate training and supervision of a junior doctor left alone at night to care for seriously ill patients; inadequate monitoring of a bleeding patient; a protocol for surgical referral based on treatment measures, not patient measures; a failure of communication; and delays in life-saving treatment. The hospital was staffed with highly competent and experienced doctors, and had the best equipment and facilities, yet none of the right people saw the patient at the right time.
Another example is the recent death of a patient through anaesthetic equipment failure. At least six independent factors contributed to the death of the patient and harm would have been prevented if any one of the system faults had been corrected. The fatal factors included an equipment design fault, a servicing error, failure to check serviced equipment, the lack of a pressure monitoring gauge in the breathing circuit and the lack of regular training in emergency protocols for dealing with life-threatening equipment failures.
Following such a disaster, the adversarial and disciplinary processes faced by clinicians promote a defensive reaction, which obscures the truth and does not address the system problems. However, there is growing recognition of the importance of a "systems approach" as illustrated by two speakers at the recent Annual Medico-Legal Conference. 5 Professor Alan Merry, an anaesthetist, spoke eloquently about improving patient safety through system changes. His examples ranged from computerised checking of anaesthetic drug administration to law changes governing medical manslaughter. Likewise, the New South Wales Health Commissioner showed how the analysis of patient complaints led to the recognition of system problems that could be corrected, improving the quality and safety of patient care.
Recognition of the Damage Done by Repeated Structural Change
Although the official Health Policy of the New Zealand Labour Party 6 still proposes abolition of the HFA and the re-creation of elected regional Health Boards, there is growing doubt about the wisdom of further structural change. The recent restructuring of the HFA has done incalculable harm. The loss of local health service knowledge, the destruction of purchaser–provider relationships and the mass exodus of clinical advisers have set the health service back several years. It seems unlikely that any government would risk further major change and the aim is for a period that avoids the extreme turbulence of the last decade and allows solid gains to be made in patient-focussed reforms.
Patient-Focussed Reform
What has been missing from the reforms to date is a clear statement of the goals of reform in terms that have meaning for patients. Berwick 7 states the following goals of reform:
- better outcomes for patients
- greater ease of use (information, access, promptness, cultural sensitivity, etc)
- lower cost
- more social justice.
It is hard to see how further structural change would meet these goals. An alternative manifesto for health reform could focus on the many opportunities for improving patient care within current resources. Such reform requires strong clinical leadership and a fundamental realignment of the values and goals of managers and clinicians. There is reason for optimism here, as shown by the increasing recognition and support for clinical leadership and by a substantial body of evidence that impressive gains in patient care can be made within current resources.
Evidence for Potential Gains
Many health professionals perceive that they can do little to improve patient care given the restricted health funding. Such a belief underlies the demands made by the Coalition for Public Health to increase public health spending to 7.5% of GDP. Nothing could be further from the truth. A systematic review of the potential for improvement identifies huge opportunities. The few mentioned below are just a beginning.
Reducing Inappropriate Surgery
Variation in rates of procedures such as tonsillectomy, circumcision, and hysterectomy suggest that many patients may not benefit from the procedure. Radical prostatectomy, an expensive procedure with considerable morbidity, may have little or no influence on mortality from prostatic cancer. 8 Caesarean section rates vary markedly between centres 9 and in most institutions rates have steadily risen. Systematic review of the evidence predicts an improvement in outcomes for mothers and babies if caesarean section rates were reduced.
Inappropriate, Unnecessary and Preventable Hospital Admissions
A recent report by the New Zealand Clearing House for Health Technology Assessment (NZHTA) identified interventions in community and primary healthcare to reduce acute hospital admissions. 10 The "Westkids" integrated care project in Auckland achieved a 44% reduction in acute admissions for asthma. "Hospital in the home" initiatives allow patients being treated for venous thrombosis, or those requiring intravenous antibiotics, to be kept out of hospital. There are many similar examples.
Reduction in Length of Hospital Atay and Increasing Throughput
Striking reductions in hospital bed occupancy are possible through a combination of changes in areas such as day-of-surgery admission, better discharge planning, increase in the proportion of day-stay procedures, hospital-in-the-home support for earlier discharge and better scheduling and co-ordination of inpatient services. Queen Elizabeth Hospital in Adelaide reduced surgical bed numbers by 40% while increasing case volumes. 11 The average pre-surgery admission for cardiac surgical patients at Green Lane Hospital was reduced from six days to less than two days by re-scheduling the resources of intensive care and theatres (internal report). A trial of day-of-surgery admission at Auckland Hospital proved the quality of patient care could be greatly improved, the cancellation rate drastically reduced (12% to zero) and annual cost savings of $800,000 were predicted. 12
Inappropriate Diagnostic Tests
There is no evidence that prostate-specific antigen (PSA) screening or digital rectal examination (DRE) reduces mortality rate from prostatic cancer, yet the majority of New Zealand GPs surveyed are screening patients aged 50 years or over using PSA and/or DRE. 13 Re-engineering of the pre-operative screening process at Auckland Hospital showed a 53% reduction in the costs of routine screening tests, representing an annual saving of $500,000, while standards of patient care improved. 12 Evidence-based practice suggests that urine culture for uncomplicated cystitis in women is unnecessary. Patients treated on symptoms alone had a higher rate of cure and fewer complications. 14 There is a large amount of evidence of inappropriate testing and of the harm done to patients in the follow-up management of false positive results. Anecdotal evidence suggests that duplication of tests between GPs and hospital services is commonplace and yet an audit of GP referrals to Auckland Hospital showed that no test results were conveyed in the referral letter in 39% of cases (internal report).
Reducing Harm to Patients
The Quality in Australian Healthcare Study showed that 16.6% of inpatients were harmed in the course of healthcare interventions and 51% of this harm was judged preventable. 15 The study is being repeated in New Zealand, following a major Health Research Council research award to Professor Peter Davis of Canterbury University. Similar results to those in the Australian study might be expected here but there is little evidence to date of the risk to patients in the New Zealand health service. Auckland Healthcare found that 12% of inpatients contracted infections in hospital 16 . Crude calculations suggest that the additional cost of treating these infections (in many elderly and compromised patients) might run to $10m to $20 million per annum and the excess morbidity and mortality for patients is considerable. Patients are harmed in many other ways, including adverse drug reactions, surgical complications, incompetent practice by unsupervised junior staff and physical accidents. All these causes of harm are potentially reducible.
Other Opportunities for Improving Care
The list is extensive and includes:
- reducing unwanted and futile treatment/procedures at the end of life
- improving effectiveness and reducing costs of drug prescribing
- patient and community participation in health care (eg, weight control programme for South Auckland Pacific Islanders)
- reducing waits and delays for patients
- reducing the racial gap in health status
- preventing disease complications and injury (smoking, alcohol, drugs, obesity/diabetes, lack of exercise, accidents and violence, suicide, communicable disease, abortion)
- recording useful information only once
- implementing electronic decision-support systems
- reducing hospital inventory and costs.
David Blumenthal, writing in JAMA, went so far as to say that medical errors could be turned into "medical treasures" in an editorial that highlighted the opportunities for improving care. 17
The Importance of Clinical Leadership
None of these opportunities for improving the care of patients can be realised unless health professionals lead the change. No amount of structural reform, policy development or management change will achieve the patient-focussed goals outlined above. Why have clinicians neglected so many of these opportunities?
Those who have attempted change can provide an answer. The health service environment has been very hostile to innovation and patient-focussed reform. Rigid funding structures have shackled change and potential improvements in clinical services were often defeated by issues of cost-shifting. Patient-focussed care challenged existing roles and privileges. In one example, consulting rooms in a clinic were allocated to patients, rather than doctors, and all services were brought to the patient who stayed in one location. Those groups more concerned with self-interest than patient welfare resisted change. Even well motivated doctors, faced with evidence that expert treatment was useless or even harmful, found it easier to cast doubt and dismiss the evidence than to abandon practice that had been refined over many years.
There has existed a kind of "no-man’s land" between clinicians and management and any clinician who stepped into that space was likely to draw fire from both sides. Clinicians with management responsibility have felt duty-bound to criticise the commercial values of corporate bosses and have been accused by managers of being disloyal to the institution and creating conflict. Simultaneously, they were reproached by their own colleagues for "selling out" to management. The conflicting sub-cultures in hospital organisations have been well documented by Pieter Degeling. 18 Managers are coming to realise that business success ultimately depends on changing the behaviour of clinicians, as clinicians drive 75% of the costs. Issues of organisational development and change management are increasingly on their minds. There is growing understanding of the need for health providers to adopt values and goals which relate to patient outcomes and which can be shared with their clinical staff. Those clinicians with leadership potential are being trained for roles that allow them to close the gap between clinical practice and management.
Support and encouragement for emerging clinical leaders is needed to realise opportunities for positive change. The personal qualities required are: courage and integrity, commitment to public service, a strong drive to achieve, constant optimism in the face of difficulties, obstacles and even failures, and a self-depreciating sense of humour!
There is a need for:
- people who can see beyond individual patients to the broader issues of resource allocation and the overall systems of care;
- team-builders who promote relationships across the professional boundaries and who seek alternative viewpoints; and
- people who are open to change and who can lead others in reform, based on evidence of benefit, not on opinion or political ideology.
Many such people have struggled in isolation, fighting lonely battles. We need to embrace those people in a national community that provides peer support, networking, training and opportunities for personal development. Such an organisation or community should cross all professional and health sector boundaries and represent all those with a committed focus on better patient care. CLANZ, the Clinical Leaders’ Association of New Zealand, was founded for that purpose and the rapid growth in membership, and the passion and enthusiasm of its members, suggests it is meeting a deeply felt need.
For those interested in learning more about CLANZ, please see the web site at http://www.clanz.org.nz. CLANZ is open to all professionals (including managers) in the health and disability services.
References
- Health Funding Authority Report: Use of Public Hospitals by our People 1996/97, Auckland, May 1998
- Department of Health press release. Frank Dobson Announces £1 billion modernisation of NHS information systems. 24 September 1998. http://www.nds.coi.gov.uk/coi/coipress.nsf
- Hon Bill English. Speech to Inaugural meeting of CLANZ, Wellington, 30 July 1998. http://www.clanz.org.nz/
- CLANZ survey on issues of rationing and the booking system, October 1998. http://www.clanz.org.nz
- Merry A, Wilson L. How should we handle negligent injuries and accidents to best protect patients, the medical community and the healthcare system in New Zealand? Annual Medico-Legal Conference. Wellington, 22–23 February 1999
- New Zealand Labour Party Health Policy Statement. http://www.labour.org.nz
- Berwick, DM. Eleven worthy aims for clinical leadership of health system reform. JAMA 1994; 272:797–802
- NZGG: Prostate Specific Antigen (PSA) as a screening test for Prostate Cancer. Group Health Co-operative Guidelines published on NZGG web site. http://www.nzgg.org.nz
- Johnson N, Ansell D. Variation in caesarean and instrumental delivery rates in New Zealand hospitals. Aust NZ J Obstet Gynaecol. 1995; 35:6–11
- NZHTA Report. Acute Medical Admissions – A critical appraisal of the literature. 6 August 1998 http://nzhta.chmeds.ac.nz
- Maddern G. Surgical services at Queen Elizabeth Hospital Adelaide. Best Practice in Surgical Services Conference, Auckland, May 23 1997
- Youngson R.Trial of day-of-surgery admission. Best Practice in Surgical Services Conference, Auckland, May 23 1997
- Morris J, McNoe B. Screening for prostate cancer: what do general practitioners think? NZ Med J 1997;110:178–82
- New Zealand Guidelines Group. Acute uncomplicated dysuria or urgency in women guideline. Group Health Co-operative Guidelines published on NZGG web site. http://www.nzgg.org.nz
- Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian health care study. Med J Aust 1995; 163:458–71
- Nicholls TM, Morris AJ. Nosocomial infection in Auckland Healthcare hospitals. NZ Med J. 1997; 110:314–6
- Blumenthal, D. Making medical errors into "medical treasures". JAMA 1994; 272:1867–8
- Degeling P. Professional sub-cultures and hospital reform report. Centre for Hospital Management and Information Systems Research 1998. University of New South Wales, Sydney, Australia
- Department of Health press release. Frank Dobson Announces £1 billion modernisation of NHS information systems. 24 September 1998. http://www.nds.coi.gov.uk/coi/coipress.nsf
