Article 2: The many challenges that confront adopting a systematic, collaborative approach

We work at our company Rotamap to help clinical departments, mainly in the NHS, to perform better. Our aim to provide useful software services has led us to investigate the benefits that systems like checklists and rotas can offer to professional groups. As described in the first article in this series, such systemised approaches have been shown to result in impressive improvements in the results of individual clinical departments, as evinced by Peter Pronovost's 5-step central line checklist and the WHO theatre checklist. They can also yield valuable insights on how best to organise teams made up of skilled individuals with different areas of practice.

This article explores the many challenges facing the introduction of a systematic, collaborative approach. Our argument is that how professionals work together is as important as the expertise that they bring, and that individual performance is inextricably linked with that of each member of the whole team involved in a procedure.

Yet historically the way professionals are trained does little to prepare them for collaborative working. As David Waboso, Engineer and London Underground's Capital Programmes Director, explained at the Rotamap March 2015 event, "People are rewarded in academia by being quite 'siloed' in what they do, and by being very expert in what they do. If you go through any vocational professional training at University it encourages you to have very deep knowledge in that [specific] area. As an engineer you can come out with a First because you really know Castigliano's theorem of bending moments. But that doesn't help you when it comes to managing large teams... I guess the same is true of healthcare and medical professions. You are rewarded academically for being very good at your subjects ... [but] ... we've got to make sure that training encourages the system view."[1]

It is not simply that those who manage teams may lack the ability or desire to cooperate. Most professionals are encouraged to consider themselves independent-thinking specialists. Traditionally the place of the professional has been protected by law, and his or her standing in society has been based on an ascribed command over their field of influence, promulgated through the Chartered status of such groups and the operations of Learned Societies and Professional Institutes. As a result, professionals can be accused of being proprietorial about their fields of expertise, as is illustrated by the recent Morrel report on those who practice in the built environment sector: "...the standing and perceived value of the professions is being challenged, with detractors seeing in their conduct and practice a tendency towards protectionism, resistance to change, the reinforcement of silos and the preservation of hierarchies."[2]

As David Waboso argued, the public perception of professionals (and their own self-perception) is inimical to collaboration: "The pressures always go against people working together. When the pressure is on, people tend to retreat to their specialisms, to their silos, to their particular group. So it does require a lot of intense management and leadership to make sure that that doesn't happen."

It is natural that individuals who have studied for many years to accumulate the skills and expertise to carry out their work should wish to be recognised for their achievements, and consequently to protect their status. Quite often professionals also expect to take the initiative in taking charge of addressing problems. In such a context, the systematic, collaborative approach can seem both alien and humdrum, and therefore to be disregarded. However, systems such as our Rotamap software services for helping departments work more effectively show that such routine arrangements can help professionals to achieve more as individuals.

Dr Mark Cox, Consultant Anaesthetist at Chelsea and Westminster Hospital, who has contributed greatly to the development of Rotamap's CLWRota service, points out that not all clinical groups work in the same way. Surgeons, for instance, have traditionally been able to work as individuals and decide when to cancel theatre lists (although this is starting to change). In comparison, "Anaesthetics is a service specialty. We've always had to be much more coordinated, have a diary and a rota, and manage absences in a way that other specialities don't. Anaesthetists work in big departments and they're quite used to organising and co-ordinating themselves into a consistent service. If there's an operating list, the work statement is that you provide anaesthesia as it's needed through[out] the hospital. We can't cancel what we do."

Despite the apparent incentives for doctors to collaborate, however, Cox suggests that this is the exception rather than the rule. "I think we're quite good at collaborating over challenging cases. If there's a particularly complex case on, then we all respond to that because we like working together to do complex, clinical work. If we've got a really difficult case in three weeks' time, we'll usually move things around to get the right people together. We're also good at training clinical teams to work together for specific emergencies, and we all respond to that. But hospitals haven't really been brilliant at getting us to collaborate over more mundane stuff." The reason, he surmises, is that "I think we can be difficult to manage."

For these reasons, even in anaesthesia, where the benefits of being clear about who is going to do what, and when, might have seemed obvious, the take-up of the Rotamap system seemed unlikely. The grounds for its adoption came from an unexpected quarter. As Dr Neil Braude of South Manchester University Hospital, who was instrumental in the early design and development of Rotamap's CLWRota service, explains: "Trainees don't have a set pattern. If they are doing trauma anaesthesia for example, there might be multiple trauma operating lists taking place each day, such as plastics trauma, orthopaedic trauma and so forth -- perhaps any one of five possibilities for where they might end up. The trainees have to look every day to see what they are doing, so they use the system constantly."

The development of Rotamap's systems coincided with the advent of the mobile internet, and consequently technically-precocious trainees who had to deal with constant changes to their activity schedules could espouse the benefits of viewing a single up-to-date rota also accessible to their consultant supervisors. Slowly, people who had depended on paper rotas, which were invariably out-of-date, were encouraged to adopt the digital replacement by the proof of its usefulness.

As Braude puts it: "The only way [to run the rota] initially was to have an interim arrangement whereby we had a paper rota, which had been the historical way of doing it, produced each week at the end of the previous week. So we ran in parallel for a while. This didn't last that long because within a relatively short period of time people realised that the old system was anachronistic; it didn't reflect what was actually going on. And when you realise that, even if you only get to a computer once in a while, it’s a lot better than looking at a piece of redundant, anachronistic paper".

While there are different ways in which departments may take up the Rotamap systems, we argue that the immediate benefits of better communication are dwarfed by the capacity of the system to accommodate unexpected events such as several staff members being struck down by flu, and its use to manage and improve the department. The rota can help the department set up a pattern of activity that is less vulnerable to change, and therefore easier to coordinate with the work of other departments.

Advantageous as such facilities may be, they pale in comparison with the sophistication of airline checklists. In Atul Gawande's book "The Checklist Manifesto", Gawande tells the story of BA Flight 38, which on January 17 2008 lost power about two miles from the airport and landed short of the runway, narrowly missing several houses and the car-borne then Prime Minister Gordon Brown. Following the accident, in which the right landing gear penetrated the cabin but no one was seriously injured, air accident inspectors finally concluded that on long turbulence-free arctic flights ice accumulation in the fuel lines might have caused the loss of power. In September of that year, the Federal Aviation Administration in the United States issued a detailed advisory outlining procedures for doing the reverse of what most pilots would do in a similar situation, which was not to increase thrust, but to idle the engines momentarily to let the fuel piping heat exchangers melt the ice. Within a month, the checklists of airlines around the world had been updated with the new protocol. As a result, when on November 26 of that year a Delta Air Lines flight from Shanghai suffered an engine failure, the flight crew knew exactly what to do.

Faced with this level of coordination, and the synchronisation of planning and information flow in the airline industry, it seems natural to ask why the the same isn't true of health care. Gawande said in his second 2014 Reith lecture that "across the United States and Europe, we know despite all of the money we put into healthcare that the 40% of our population who has coronary artery/heart disease receives incomplete and inappropriate care".[4] He goes on to suggest that close to 90% of health care for mental health conditions is similarly inadequate. Most similar information concerning health is distributed through professionals writing journal articles, which isn't a system guaranteeing communication or compliance.

Currently professionals such as doctors prize their individuality and freedom. As Dr Cox says, "I think doctors like their freedom. If someone says, "Will you please fill in this form?" a lot of consultants would have the reaction, 'Well, I don't feel like doing that, especially if it might control what I am allowed to do next week'. Everybody likes to be able to do what they want, don't they?". This attitude sums up the problem for those seeking to coordinate across professionals and large teams of people skilled in a variety of fields, as David Waboso needs to do on large infrastructure projects.

But a point that professionals themselves might miss is that systems are probably necessary in many of their areas of work, since the volume of knowledge and skill that they are expected to act upon would stretch the limits of the most capable mind. The question is how to work effectively across groups and teams, to make the most of what the group can do collectively.

This question leads one to consider the sort of management structure that would promote such collaborative working. The most likely model, for very large organisations at least, is the method Alfred P. Sloan used to manage General Motors (GM) in its glory days. Just 10 years after taking over management of GM in the 1920s, Sloan had enabled GM to "establish itself as the world’s premier automaker and the nation’s largest single employer. Moreover, Sloan did this by means of organizational mastery..." rather than engineering breakthroughs.[5] The structure he instituted was enshrined in Peter Drucker's "Concept of the Corporation", and many of Drucker's subsequent books. Management performance was boiled down to financial performance, and specifically Return On Investment or ROI.[6] Partly because of the success of this management approach, the efficiency of the industrial processes themselves was not the focus of similar innovation. GM and its US counterparts "attempted to lower costs by minimizing product diversity and maximizing economies of scale"[6]. Another aspect of US automotive industrial practice at the time was that armies of inspectors used statistical sampling techniques to check small samples, to determine whether the process met an acceptable level of quality.[7]

The NHS has many structural similarities to the GM of the 1950s, including its pyramidal structure, how it measures quality and the "management by objectives" paradigm. The current drive to further centralise NHS services seems to be similarly inspired. Perhaps this is no surprise, since GM was, for a time, terrifically successful. As Drucker suggested, Sloan had perfected "not a mere technique of management" but nothing less than "a universally valid concept of social order"[6]. Where else should an employer such as the NHS, the world's fifth-largest organisation[8], turn to for a model?

One counter-argument is that the division of work based on specialisation implicit in the Sloan/Drucker model can actively work against horizontal collaboration between groups. A system predicated on divisions between groups requires external control mechanisms to operate, and is likely to exhibit a lack of flexibility and the sort of crystalline structure that allows for rapid divisional change (for instance, when a new regime takes over), but is also less likely to be successful. Why? Because the actual mechanisms for doing things like making widgets, generating contracts, designing skyscrapers’ structures or operating on patients have not changed.

Evidence of these failings can frequently be found in NHS theatres, where theatre teams gowned and ready for an operation cannot proceed owing to a problem such as a bed not being available for the patient after surgery. Or the extraordinary fact that consultants, who code their patients' expected and actual theatre procedures in the private sector, do not do so for the NHS and are usually unaware of how their care has been recorded by the abstract armies of "coders" whose work determines what income the hospital will receive.

Yet despite these organisational restrictions, modest systems such as checklists and rotas can provide the incremental improvements that could lead to larger networks of interrelationship and cooperation. They can also establish patterns that can help to identify anomalies and problems. Technology can help make these systems easily available, and allow them to be put to widespread use. As David Waboso points out: "We're seeing a huge revolution in digital technology that is changing not only the lives of the professionals but the lives of the people who use those services and expect those providing them with care and services to use that technology in the same way they use it."

Currently the greatest obstacles to collaborative systems are the strong desire of most professionals to avoid the straitjacket of rules, and the divisive organisational structures they work within. But if professionals can take the step towards involving themselves in the design and implementation of systems to improve the way they and their teams work, it seems likely that big advances in performance can be achieved. Add to this the potential for organisations to loosen their structures so as to make the most of local innovations, and to broadcast these improvements more widely to develop collaborative networks. Then we can expect that organisation-wide improvements will ensue.

Tantalisingly, it might be that the systems approach can help solve both professional and corporate intransigence, by introducing "flow", so to speak. As David Waboso suggests, one solution might be putting the tools to aid collaboration into the hands of the professionals themselves.

The third and last article in this series discusses a more open and collaborative model of working that systems could help engender in professional teams and organizations such as the NHS.

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