Article 3: The qualities and benefits of collaboration
This is the third of three articles concerning the way professionals work together and how the results of that work may be improved through a systematic approach to assist with coordination and collaboration.
The first article in this series described some examples such as Peter Pronovost's hugely successful programme to improve central line infection rates with a simple five point checklist, the impressive results of the WHO's single A4 theatre checklist and the results of our own work with electronic rotas to improve how large clinical teams work together. Techniques such as these can effect profound improvements in how, for instance, care is delivered or how effectively tasks are performed. However, as discussed in the second article, there are often several barriers to the adoption of such approaches including the "vertical" or specialist focus of professionals and the way expertise is often guarded by institutional fiefdoms.
The focus of this article is the benefits a collaborative approach can bring both to individual professionals but also the clients they work for and the institutions in which they work. It is instructive first to consider the problems that arise in attempts to adopt systems such as the central line checklist or the WHO theatre protocol.
Atul Gawande reports in "The Checklist Manifesto" that Peter Pronovost, right at the beginning of his revolutionary project to reduce central line infections, organised staff to track how often doctors at the prestigious John Hopkins Hospital carried out all five steps in the protocol. To be clear, the central line protocol steps are "...no brainers; they have been known and taught for years." Still, in more than a third of patients, doctors skipped at least one step. Pronovost and his team had to get the hospital administration involved in the next step, which was to authorize nurses to ensure that doctors followed the protocol. As Gawande reports, despite a culture of deferring to doctors, the "...new rule made it clear: if doctors didn't follow every step, the nurses would have backup from the administration to intervene." The extraordinary results of this initiative in reduced mortality, infection rates and cost are therefore partly due to an important cultural shift.
Walker, Reshamwalla and Wilson in their 2012 British Journal of Anaesthesia article "Surgical safety checklists: do they improve outcomes?" report that the initial improvements reported by the WHO pilot studies are reinforced by further studies. But while surgical checklists, when properly implemented, "can make a substantial difference to patient safety", they go on to write that "however, introducing surgical checklists is not as straightforward as it seems, and requires leadership, flexibility, and teamwork in a different way to that which is currently practiced." In the article the authors note that there is a strong relationship between the non-technical skills of the surgeon and death or near misses, or both, leading in part to the conclusion that such "non-technical skills" have been shown to improve patient outcomes. The authors also set out that central to the events most likely to cause adverse results are communication problems. "For instance," they write, "information does not reach the right person, or is inaccurate, or issues remain unresolved until they become critical. In the operating theatre, this leads to mistakes, inefficient use of resources, wasted equipment, frustration, poor morale, delays, and cancelled operations."
Simple checklists and coordination tools form possibly the simplest way of encouraging people to coordinate, particularly when traditional hierarchies need to be challenged, such as ensuring that every person around the operating table introduces themselves. Conveniently, checklists are also simple to audit. Yet if they are adopted effectively there is a strong likelihood that if such protocols bring about a positive change in results then the associated cultural change will accelerate because the benefits are clear. As Dr Mark Cox from Chelsea and Westminster Hospital in London explains about the adoption of the Rotamap service for anaesthetics, "there's the simple housekeeping stuff, which is that you don't make mistakes such as having someone who is on holiday down for lists, or the someone on oncall who is also down to do their list the next day. Immediately after you have implemented it you win by several sessions a week, an immediate gain."
In the case of adopting an electronic rostering system such as one of our Rotamap systems, the major cultural shift is persuading people to abandon a paper rota and manual forms of coordination. When the department is no longer encumbered by the results of such inaccuracies individuals benefit from better communication and the organisation has a better sense of how it is performing on a corporate basis, leading to better plans for the future.
As Dr Neil Braude of the University Hospital of South Manchester, instrumental in the early design of the CLWRota system, explains: "Once we realised we had an accurate record of what had taken place it opened up a whole new area which I hadn't anticipated -- not just its use as a rostering system but as a form of management. We could manage people's activity. One could see what people had done in the last year and how many times things had been missed. One could look at last-minute sick leave and other last-minute changes. One could reach the conclusion that we are allowing too many people to be on leave at certain times causing peaks and troughs in the availability of staff... Having started off with a fairly modest project to run our day to day activity, it became pretty obvious that we could get some really useful data out of it."
The data that is produced through the plan, adjust, report cycle of rota weeks in the Rotamap systems is used for in-system reports but also for periodic reports sent to departments showing important factors such as "hot spots" in the week where clumping of sessions tend to occur (such as sickness on Monday mornings, or too many trainee sessions on Friday afternoons). Similarly, statistical process control charts (or "pcharts") can illuminate if certain factors of department behaviour are outside of normal variance. Controlling variability is an important aspect of ensuring that a system is stable and where it is not, where improvements can be made. Good control of variability normally leads departments to run in a more stable way, and are likely to provide its members with a better quality of life with less stress due to unexpected change. Conversely, it may be more adaptable and more capable of absorbing both troughs and peaks in demand through better controls.
In addition to such internal department reports, anonymised inter-departmental benchmarks are presented at six-monthly intervals at the Rotamap forum events. These benchmarks allow clinical departments to gain insights into how the pattern of their activities compare to their peers which are invaluable as, very often, the department is unable to easily contextualise its activities. A department normally has to invent how to manage itself within its Trust as, except for certain multi-hospital Trusts, it is likely to be the only department of its type in the larger organisation. In other words, despite being a department with a 10-20 million pound annual salary budget in a larger Trust with an annual turnover of over a billion, departments may not have many waypoints with which to navigate the design of their service, or perhaps the context with which to defend a very well run outfit. Comparison with other similar departments can help clarify these issues.
If groups of professionals are able to take the step to start taking a more systematic approach they can bring their professional skills to extending the reach of the group, as David Waboso, Engineer and London Underground's Capital Programmes Director, explained at the Rotamap March 2015 event "Its quite interesting that when something has gone wrong usually it has gone wrong somewhere else. Its just that the opportunity to learn the lessons and share the lessons hasn't been taken. So it's really important that if you are a leader or part of a team doing something challenging in collaboration or working across, that you try to find out if someone has done it before. The lesson is usually out there somewhere." In other words, the research and focus that professionals such as doctors typically bring to bear on work in their speciality is equally important when trying to improve the performance of the group. The inter-department benchmarks and debates at the forum events help with just that investigation.
As Mark Cox puts it: "One can benchmark departments against each other and there is actually quite a large variation between them, even though they are nominally doing the same job. One can ask the question 'how much work should an anaesthetist be doing in a year of clinical work and how much training should we be delivering?'. Answers to these questions aren't terribly well defined and it is interesting to see which departments might be getting it right, or doing a lot or too little. Its fascinating for the first time that you can actually see what people did in a reliable way and compare departments".
This ability to gather data might seem a threat to individuals who may feel that their activities are being monitored to ensure they meet targets, an intrusive form of command and control. If systems such as these are implemented sensitively, as was done at John Hopkins, a more open environment can be created where every member of the team feels valued and takes responsibility for their role. More than that, individuals can help improve the tools and what they are used for. David Waboso: "You've got to be inclusive. You've got to make sure that everyone in the team feels they are included; feels they are empowered. You can't have collaboration where people feel shut out or excluded."
The effect of more collaborative working through the Rotamap system is reported by Mark Cox: "It's much more egalitarian because multiple people can work on it simultaneously and write different bits of it, and can see what other people are doing. It allows people responsible for training to allocate the trainees and those responsible for service delivery to allocate consultants. It allows different groups of people to write their own on-call rotas and own them -- we can all see how they're working."
"I think it's a case of multiple eyes. Everyone sees it. As soon as the rota is out, everyone can see it. Whereas before it was a case of putting a piece of paper in someone's pigeonhole at 17:00 on a Friday, which they didn't get to look at until the end of the following week. Now if there's a problem, someone will spot it."
"Everyone can see what's supposed to be happening. It's human nature to look at what you're doing, what everyone else is doing; whether your holidays are booked, whether you are on call and so on. It does seem more egalitarian because you not just being told what to do on a piece of paper. You see it as it's written."
An inspiring example of how such an egalitarian approach, the antithesis of command and control, can be found at Buurtzorg, a Dutch provider of nursing for the elderly. Jos de Blok, a community nurse by training started the organisation in 2007 with a handful of colleagues after deciding the way the sector did its work was bad for patients and unfulfilling for nurses. Built on a system of small teams, Buurtzorg has grown to over 9,000 nurses working with 70,000 patients a year, capturing about 70% of the market. Not only is the organisation successful but patients are happier as they receive more consistent and meaningful care which, perhaps unintuitively, is more cost-effective.
Buurtzorg's organisational growth is built around clear concepts (the Buurtzorg "Onionmodel" with the client at the centre) and effected through sophisticated quality control systems and ways of supporting independent teams with a small central staff of around 40, mostly coaches, and "Buurtzorgweb" a multi-layer, integrated ICT system that helps sustain the Buurtzorg community. Says Jos de Blok: "Because of this platform, they feel like one, like part of Buurtzorg. But they don't feel Buurtzorg is an organisation that gives them trouble; but as a network that gives them presents."
Most professional organisation are a long way from providing this sort of organisational "glue". As discussed in article two, that may in part be because in the traditional, GM-style, management structure the interstices between groups are patrolled by managers, auditors and administrators. When, in reverse, systems help people to communicate and collaborate (and possibly also help check and reinforce standards) the results can be unexpected, as Dr Neil Braude reports:
"It's now difficult to think back a decade to when, to be honest, we weren't sure how much leave people were taking and you weren't really sure where someone was. This, I think, has been the major cultural change in our department. Now each individual accesses the rota on a smartphone and can see what they are doing and receive text alerts; the whole department moves in a streamlined system. Another major aspect is that it is perceived as being transparent and fair."
Or, as Mark Cox describes, a system like Rotamap evolves from being a chore or a challenge to an unconscious habit: "People find it intuitive now. Everyone has the app on their phones. It's become such a part of the way we work that I don't think people walk around thinking 'Wow, this is amazing' because they're just completely used to it. And that's incredible if you think that we've only had it running for a little under 7 years. It's astonishing that the culture has changed completely to people having web-based electronic systems that's being updated in real time, and they don't even notice. They don't notice because it's fit in so well."
Quite often senior management don't understand or appreciate the shifts that groups who are working in such a way have achieved, and one can understand why when "corporate vision and leadership" is still considered the sine qua non of most large corporates. A progressive and inclusive alternative approach was engendered by a small group of Japanese engineers accompanying Eiji Toyoda's 12-week study tour of US powerhouse automotive manufacturers. The Japanese, dealing with outdated machines, few resources and constrained workspace were horrified to see the huge amounts of waste generated by American mass production. By putting their staff at the heart of the enterprise, Toyota were able to make frugality both a moral pursuit but also an enormously profitable enterprise through institutionalising some deeply counter-intuitive thinking.
As an illustation: the "letter test". Given a pile of letters to sign, fold, put in envelopes, address, and then affix stamps most people would do those steps in that very order. In fact it is much faster to do each letter one at a time. Not only is there less handling of each item but one can improve as one goes along. Ever sent a Christmas card to Auntie Edna that should have gone to Uncle Ned?
Playfulness aside, the insights of Taiichi Ohno, progenitor of the Toyota Production System, into what he called "one piece flow" and related just-in-time, kanban, heijunka and similar systems have led to several important modern management techniques that have heavily influenced modern manufacturing and services organisational techniques, including software development. For this discussion his approach made an extraordinary virtue out of working across the organisation in a coordinated and rhythmical way that was open to individual and group improvements.
Ohno's eloquent analogy, set out some 65 years ago in "Beyond Large Scale Production" is between a business organisation and a human body. "The human body contains autonomic nerves that work without regard to human wishes and motor nerves that react to human command to control muscles. The human body has an amazing structure and operation; the fine balance and precision with which body parts are accommodated in the overall design are even more marvelous...At Toyota, we began to think about how to install an autonomic nervous system in our own rapidly growing business organization. In our production plant, an autonomic nerve means making judgements autonomously at the lowest possible level; for example, when to stop production...what sequence to follow in making parts.
"These discussions can be made by factory workers themselves, without having to consult the production control or engineering departments that correspond to the brain in the human body. The plant should be a place where such judgements can be made by workers autonomously."
It is possible that professionals in organisations even as large and complex as the NHS can help construct the systems required to make it better coordinated and more "autonomic" as Ohno describes. If such an approach was to take hold it is likely that the individual creativity of professionals would be a major asset, which proffers a new horizon for professional endeavours.
Mark Cox comments: "The holy grail would be to coordinate our rota with the surgeon's rota so we can all see what the other is doing. I suppose that's a marker of how separately we are organised. You might have thought as an outsider you could draw a rota that had all the anaesthetic and surgical activity in it from day one, but that's just not how hospitals work...A huge step forward would be to get all those rotas to populate each other, so we could all see what everyone was doing. Because our management structures are quite separate. It's a huge goal."
-  Atul Gawande "The Checklist Manifesto" Chapter 2
-  Walker, Reshamwalla and Wilson, BJA, "Surgical safety checklists: do they improve outcomes?" at https://bja.oxfordjournals.org/content/109/1/47.full?sid=86f91188-010b-4101-82ef-ac3af27df426
-  Statistical Process Control was pioneered by Walter A. Shewhart at Bell Laboratories in the early 1920s, and had a close association with W. Edwards Deming. See https://en.wikipedia.org/wiki/Statistical_process_control
-  King's fund Buurtzorg slidepack http://www.kingsfund.org.uk/sites/files/kf/media/jos-de-blok-buurtzorg-home-healthcare-nov13.pdf
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