Wednesday, 14 December 2011

Biggest Lean Deployment in the World

The American Army has the largest lean six sigma deployed in the world.

The American army budget is currently more than $240billion
The US Army has deployed Lean since 2006 and saved $19.1 billion dollars
so far. In 2011 alone they are conducting 2111 lean improvement projects
to save $3.6 billion.
They have 5700 green belts, 2400 Black Belts and 175 Master Black Belts
and 48 Lean Deployment Directors. Their return on these investments have
been very good.

Most of the projects have been about logistics but their health care is
also heavily into lean. They have seen great successes.

Here is an interesting anecdote from one of their early projects -
obviously dated but the learning value is undiminished.

According to the principles of lean six sigma, US Army Medical Command
looked into high volume areas, 'waste' and 'customer satisfaction'
problems and found that they had:

The largest army call centre with more than 10000 calls per week
Low customer satisfaction at 68%
Average wait time of 3.14 minutes (wait is one of the classic wastes in
Call abandon rate of 26% - with a peak time call abandon rate of 49%

Obviously they found this very unsatisfactory and ran a lean project to
improve this. And they improved:

Average wait time reduced to 33 seconds (a six-fold improvement)
Call abandon rate reduced to 3% with peak time call abandon rate down to 22%
Call volume reduced 20% due to less call backs
and so on

These results were far better than the aims they set themselves for the

Apparently the customer satisfaction got worse!!

While people were getting their calls attended in record time they could
not get appointments to see doctors in clinics because the clinics had
capacity and scheduling problems - so the issue was, what is the point
in answering the phone quickly if they could not address the real need
which is patients to see doctors quickly.

Do not despair!

They have since addressed that issue and that has had an even bigger
effect on their call centre

The average waiting time has fallen to 3 seconds (yes, you read it right
THREE seconds - from their starting point of 3 minutes and 14 seconds)!!

There are two messages, a) system wide thinking is difficult but very
important b) it is even more important to solve the real issue (rather
than what is immediately apparent).


Note: The above is written from my recollection and notes of a brilliant presentation made at the WCBF Lean Six Sigma in healthcare conference 2011; with thanks to the presenters from the US Army Health Command and their collaborators.

Friday, 9 December 2011

Single Visit Surgical Service

When we look at providing healthcare services we should look at it from a patient's perspective. For instance, ''how often would the patient have to travel to the hospital to obtain healthcare services?'' is not the top question in any providers mind when they design the service.

This results in the patients traveling often to secondary care services even for obviously clear problems such as hernias, varicose veins etc.

At Goole Hospital we provide a single visit general surgery service for patients who need day case and short stay surgical procedures. This may mean procedures likes superficial lumps and bumps, toe-nails, etc. This also means patients who have groin hernias including recurrent groin hernias and gall stones (needing laparoscopic cholecystectomy).  Obviously there has to be a clear cut diagnosis based on obvious findings followed by some appropriate investigations by the general practitioners. These patients visit Goole Hospital only once to obtain their surgical care. The patients are telephone pre-assessed. They come to the hospital at about 8 am and are seen by nurses, anaesthetists, surgeons and residual simple investigations are performed instantly; they are operated during the day and discharged when they meet clinical criteria often within the day. They are not offered specific follow up out patient appointments but can ring to make one if they felt they needed it.

We do inguinal hernia repairs, laparoscopic cholecystectomies and many other procedures as a part of this service. The service has been running for a good few years.

My personal calculations are that this saves money overall, especially saves on travel costs for patients and their relatives. My feeling is many of the services provided by healthcare are currently very hospital focussed. When the processes becomes patient focussed there is a good chance that quality could improve while saving on costs at the same time. It is up to us to manage our services and processes maturely - our poor design should not trouble the patients.

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Warning & Disclaimer:
We do not claim superior clinical results. We only describe our process/pathway. Not all patients with any of the conditions stated above or with other similar conditions are suitable for this service. Your GP is best placed to advice the kind of pathway that could be suitable to you. This blog/website does not give clinical/medical advice. The views expressed are my personal views and not those of my hospital or the NHS.


Thursday, 1 December 2011

Laser surgery for piles

Many of you will be aware that piles is a very common problem presenting usually as bleeding and/or swelling from the anus. If the piles involves an external swelling at the anus along with the bleeding then a surgical operation may be indicated.
Currently the standard method of doing a piles operation involves a general anaesthetic, cutting out the piles (called open haemorrhoidectomy or Milligan-Morgan technique) and possibly an overnight hospital stay though more centres are doing piles operations as day cases.

We (Peter Moore, Consultant Surgeon, now retired and I) have been performing a technique called Laser Seal Haemorrhoidectomy for a few years where we use a local anaesthetic with mild sedation and use a laser to seal the cut edges of the piles. Patients are able to go home about 2 hours after the operation (they may be able to go home earlier but sedation guidelines kick in I suppose), we believe that this procedure gives better pain relief in the early days  

We learnt this procedure a few years ago from Peter Thomas from Arizona; of course we don't do it exactly like him and he has been doing it for 25 years.  A public thanks to Peter.

I think to change an operation that involves a general anaesthetic and often one or two nights of stay in the hospital to a local anaesthetic (with mild sedation) with a two hour stay is our local technical example of Success in Healthcare. Surely not an earth shattering example, only a small one but hopefully relevant for some. The point is to try and pursue every activity that improves quality and decreases cost at the same time.

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Warning & Disclaimer
1) There are many causes of bleeding from the anus and many causes of swelling in the anus, some of those may be more serious conditions than piles - please consult your doctor whose advise will be the only thing relevant to you personally. This blog does not give you medical advise.
2) We do not claim scientifically superior results. We describe only our process and some of our beliefs.We use the laser seal haemorrhoidectomy as a clinical process improvement example not as scientific proof of any treatment.

Amended on 30 August 2014

Monday, 21 November 2011

Shell & Healthcare


Learning from other industries is important, airlines and pilots have been the common sources for healthcare; the oil industry, especially SHELL is also a very good source.


The oil company SHELL has an extremely high priority for safety. When SHELL do any construction work the area is marked 'This is a safe work place'. It is not a warning or an advisory, it is a statement. At the International Forum for Quality and Safety in Healthcare at Amsterdam in 2011, the question and the challenge that was posed was, which hospital actually has a sign that says 'this is a safe hospital' and which hospitals are working towards that explicit goal?

That is very interesting. Would it be possible to guarantee safety in healthcare? As an enthusiast I would argue that it would be possible in many areas, well at least in some areas, but as a realist I know it would be difficult.

Mr. Rein Willems was the Chairman of SHELL and is now a member of the upper house in Netherlands. He has authored the brief but powerful report which is now the basis of improving safety and quality of healthcare in Netherlands. He spoke at the Forum in Amsterdam. I share some of the messages here.


In Shell, the by-line for 'this is a safe work place' is ''here you work safely or you don't work here at all''. Willems said that there was an occasion when a worker despite adequate warning and training persisted in the unsafe practise of smoking in a non-smoking zone in a production site and the CEO physically escorted that employee out of the premises and the employee was sacked on the spot.

Though it is a dramatic example it illustrates the seriousness with which safety is taken in Shell. What is our equivalent example in healthcare? We may do that for fraud or for smoking near the oxygen tanks – those are important but are general to any facility – what is the example that relates to clinical care delivery?


Willems went on to use the iceberg analogy that for every single fatality there were 50s of 'lost time accidents', 100s of property damage or minor injury, 1000s of accidents/incidents with no injury and 10000s of small events/breaches. To avoid that single fatality the underlying causes of 'small incidents' have to be fixed. Managing small events without fixing the underlying causes will eventually escalate into major problems.

In healthcare we are very good at emphasising on 'risk management'. As far as I am aware risk management is about identifying and understanding risks and minimising them. Which is at least a bit different from enhancing safety – which is about continuously increasing the standard of practice to the best that is currently possible. In terms of quality, risk management could probably equate to the principle of quality control by checking the products. Safety in healthcare would probably be the equivalent of getting it right as we go along. There lies the difference.

Having said that, it is possible that some of the people who are currently doing governance and risk are also doing safety; hats off to them since they have to cope with varying threads within a concept. I suspect most people may not be doing this.

Willems also touched on the concept of uniformity of shared practices. In Shell they have a policy where 'all employees should have one hand on the stair rail when they are going up or down stairs' this was implemented in their sites (oil fields and refineries). On one occasion Willem and his CEO were photographed in the head office walking the stairs with papers in hand without holding the side-rails. An employee wrote to Willem querying if the rule applied only to lower level staff. With a view to leading by example and with a view to having similar rules for everyone in Shell it is now the policy that whether one is on the field/rig/factory sites or in offices that one hand must be on the rails while going up or down stairs.

We in healthcare are no SHELL but to be fair I have seen a senior board director removing her jewellery before entering a ward, though she was there for administrative reasons. That is a good sign.

I think the core idea was that senior leadership has to play a very visible, proactive and hands-on role in the area of shared baselines, analysing data, resolving issues and safety. These concepts are essential for safe healthcare but are not often done in comprehensive or meaningful ways; that is what we ought to get right.

Shell and Willems do have generic lessons for us in healthcare.


NOTE: The writing in italics are my personal views. The normal type is what Mr Willems said or his views.

Thursday, 3 November 2011

Duty of candour: Voluntary or statutory?

Duty of candour: Voluntary or statutory?

Candour is the quality of being honest and telling the truth, especially about a difficult or embarrassing subject[1]. When things go wrong and especially when patients are harmed whether it is due to natural circumstances or due to error by individuals or systems candour becomes very important. One of the components of such candour is to offer an apology to the patients and their families. It is important to understand that as clinicians we may not be apologise for in a ‘conventional’ sense when there is no individual error is involved; what we would be apologising for in all cases is for the fact that the patients’ expectations were unable to be fulfilled on that occasion.

Compensation Act 2006 states: ‘An apology, offer of treatment or other redress shall not of itself amount to an omission of negligence or breach of statutory duty. The medical indemnity providers have always held a similar view that apologising does not put a clinician at risk of being accused of anything in the future – it is not an admission of liability.

In the document ‘The Coalition: our programme for government’[2] it says "We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong".  The words ‘will’, ‘require’ and ‘always’ seems to indicate that the government is inclined towards introducing  statutory candour or some version of it.

The CMO has been recommending a statutory duty of candour for a good few years and there are currently deliberations including the GMC on this subject. There has been parliamentary health select committee recommendation to consider this subject.

Understandably patient groups especially the AvMA are in full support of a legal duty of candour; understandable because of the powerful case studies[3] they use where a statutory duty could have either avoided prolonged and vexatious interactions with authorities involved in those case studies or would have helped to bring events to a closure quickly. 

The MDU does not support the consideration of a statutory duty of candour based on the argument that there is already an ethical duty backed up by adequate GMC sanctions.[4] The MPS also seems to take a similar view. The NPSA’s new ‘being open’ policy (as opposed to its ‘open disclosure’ policy) is based on the premise that doctors apologising would prevent many unnecessary complaints and possibly some of the litigation that follows. There is international evidence that litigation occurs less often when an apology is offered and accepted upfront.

The GMC guidance on good medical practice[5] states ‘‘if a patient under your care has suffered harm or distress, you must act immediately to put matters right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened and the likely short-term and long-term effects’’. However, a 2008 survey by the MPS[6] showed that while more than 90% of professionals believed that patients are less likely to litigate after errors if they received an explanation and an apology but only 68% were willing to be open when something went wrong. Clearly the issue of liability and blame still plays in the minds of doctors.

This raises the question whether the duty of candour should be statutory or mandatory.

Clinicians especially doctors really would not want statutory duty of candour as they would like to think that they are doing the right thing because it is the right thing and not because it is simply required by law. The GMC and other bodies, regulatory or not, take a very poor view of lack of transparency. Actioning after an event of low transparency is like many other triggers may turn out to be subjective, discretionary and inconsistent. However, in practice once the issue reaches the 'authorities' there are significant consequences which inevitably follow. Therefore a culture change route is preferable for clinicians.

The next issue to consider is how we design a response to the call of ‘duty of candour’. What the profession needs to understand is whether there was a rising trend that doctors and other clinicians are getting less transparent, if there is no such trend whether there are frequent examples of lack of candour. There seems to be no general trend that doctors are getting less transparent. Hence, a culture change approach using the voluntary duty supported by a strong view from the GMC and other bodies would certainly make a difference from the perspective of clinical professionals; with aberrant doctors dealt with strongly by using the full force of current systems. 

There are however, very frequent examples of outliers. This is when we have to recognise that institutional candour is a different situation. While individuals are all for openness, the current system of risk, clinical governance, complaints and legal actions inevitably raises doubts on the relevance of the extent of candour and its impact on future action against organisations. Further, often in inefficient and overspent circumstances or in situations of poor organisational vision, what is not required by the force of law or the force of higher authority is actively prevented from happening. This is understandable from an organisation's perspective but would be unacceptable to patients. There are examples of individual clinical candour followed by organisational resistance that happen in sequence. This is obviously unsatisfactory.

On balance, it seems that under current moral mores of our society a statutory duty of candour is probably going to be inevitable.  The question is of course is whether individual clinicians or the organisation would be legally responsible for the statutory duty of candour. It would make sense for the organisation to be responsible for such a statutory duty. The issue of candour after serious untoward incidents has extremely personal and wide ramifications at the same time, that it becomes clearly outside the remit of individual personal clinical responsibility. Further, organisations and organisational responsibility is likely to cover everyone in the organisation which would include doctors - any aberrations on the grounds of candour by doctors would therefore be dealt with by their organisation and by the GMC.

There might be a case for parallel dual responsibility (which has the risk of diluting responsibility) or for purely individual responsibility (where it could become 'fault', 'witch-hunt'  and 'scape goating' usual suspects). In a broad sense since the responsibility for quality moved from consultants to chief executives in the mid 80s, candour as such should therefore be an organisational responsibility delivered by individuals rather than individual responsibility enforced by personally applicable law.

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The department of health has launched a consultation on duty of candour: Please respond to it.

Friday, 28 October 2011

A 0% complication rate procedure. Is it time to try it?

When a patient’s large bowel is brought out through the abdominal wall it is called a colostomy. This colostomy is placed usually on the left side of the abdomen. Many patients develop a bulge/hernia around this colostomy upto 70%. These bulges results in patients’ colostomy bags not fitting them properly, leakage and sometimes bowel obstruction needing emergency surgery. Very expensive, very risky. These hernias can be mended surgically but sadly the results are not so good with upto 77% recurrence of hernias around the colostomy after surgical repair.

But what really fascinated me was that

In 1977 it was published in the journal Disease of Colon and Rectum, American surgeons found that in 106 patients they had 0% parastomal hernia rate - no parastomal hernia - when the colostomy was brought out through the umbilicus (with an overall complication rate of 3.9%). The difficulty for open surgery in current practice would be the non-availability of the umbilicus because of the mid-line incision. That was the meeting's view.

My personal view is that this is mind blowing. Given the anatomical and evolutionary fact that intake and output orifices are in the midline (including the umbilicus before we are born), it now strikes me as strange why surgeons ever thought of placing stomas away from the midline. However, with the advent of laparoscopic surgery, the umbilicus is now available for stoma placement.  With a published 10% to 70% parastomal hernia rate and up to 77% recurrence of repaired parastomal hernias, the resources taken up in dealing with these are enormous; it looks like we could have a winning situation for everyone if we placed end stomas through the umbilicus. We could have dramatically better results.

I am not sure if anyone is willing to take this up but I wish someone would.

0% complication is what Successful Healthcare looks to me. It may not be possible in many areas but where we get a link to such a course we ought to vigorously pursue it


Tuesday, 4 October 2011

Healthcare desparate to spend more

I wonder if the NHS desperate to spend more
Two examples
If you look at old reports the NHS is supposed to save £337million by using Microsoft products. That is not an issue if Microsoft was the only software producer of exclusive products. Let us take the example of common office use software such as writers, spreadsheets, presentations etc. It is no secret that Open Office has been available for a long time now and is completely free; there are others such as Libre. They are all fully compatible with MS word. What prevents the NHS from using it? The arguments we get are usually as follows, the support provided by Microsoft which is crucial will be lost and the office software is only a small component of the services provided by Microsoft and is unlikely to make a difference. 

To be frank I have nothing against Microsoft or their products, I like them and use them. The point I am trying to make is that the NHS seems not too keen to look at every possible saving.

The recent re-organisation
From about 150 Primary Care Trusts the recent changes mean that NHS could end up having 500 commissioning organisations. Which could translate to 500 CEOs, 500 finance directors, 500 new logos and 500 new of everything.  Cannot be sure that it exactly translates like this, but at a superficial level it seems so. I sincerely hope that the improved quality that is aimed for is achieved.

These are surely an over simplification of issues but it is possible that we in the NHS have forgotten that it is small drops together that make an ocean.

Thursday, 15 September 2011

My friend who did not join the party - What was he doing?

My friend who did not join the party – What was he doing

Earlier this month, I returned from my annual holiday in India – two weeks, never enough, but very refreshed all the same.

One the things I managed to do was to get back in touch with my class mates at school many of whom I have not had contact for 30 years. We did manage to get together about a dozen of us and met at early dawn in the Marina Beach, Chennai (

There was one guy whom we thought would come but he did not. He apologised for not turning up. We wondered what kept him so busy that he could not join in? And boy it was really something big...

It turns out that my old friend Dinakar is the project manager for CDiC India. CDiC is Changing Diabetes in Children where the insulin manufacturer NovoNordisk provides diabetic clinics, diagnosis, monitoring and treatment for children with type 1 diabetes, all completely free for 5 years. Novo piloted this in Africa and has an ambition to roll it out in all developing countries. Their website gives a lot more information. There are more than 250000 type 1 diabetic children in the developing world and if you are a child diabetic in Africa the life expectancy post-diagnosis is about 1 year. CDiC is a very innovative and noble idea. The aim is that once Novo establishes these, in time the countries would adopt them as a part of their healthcare delivery.

A private company providing comprehensive free service already for nearly 10000 children and counting resulting in huge benefits for the society and large savings for someone else (the government, the families etc and not the private company who does this) in terms of future healthcare costs (due to complications of poorly managed type 1 diabetes); absolutely great. Wish them all success.

Of course we missed my friend Dinakar at the beach but he was only a few days away from the CDiC inauguration and those children needed him more.


Changing Diabetis in Children

The CDiC program in India was inaugurated on 8 September 2011.
Roche, another drug manufacturer, have extended their support for this program.

Friday, 29 April 2011



Hospital Standardised Mortality Ratio


This is written on the basis of my understanding of the HSMR after attending a mini-course at the International Forum on Quality and Safety in Healthcare, Amsterdam 2011, taught by Sir Brian Jarman the original designer of HSMR, Paul Aylin of the Imperial College Dr Foster unit and Andre van der Veen (of de Praktijk index the Dutch collaborator of dr Foster). Their methodology and descriptions are publicly available and links are provided at the end.

Death is a definite unarguable outcome; that includes deaths in hospitals. Though hospitals are essentially to provide care and save lives there will be some patients who will die in hospital despite the best possible care provided by the hospital and its staff. Using risk assessment models it is possible to calculate the number of patients who could be expected to die in hospital.
The number of actual patients who die in a hospital can obviously be accurately measured. The number of patients who are expected to die in the hospital can be calculated by risk assessment and risk adjustment models. These values are converted into a ratio and expressed as a value. That value would be the value of the Hospital Standardised Mortality Ratio.
In this write up, the basis of the calculation of the model is explained, some questions about the way it works are explained and the implications of the ratio are explored.

Founder/creator of HSMR
Prof Brian Jarman was an exploration geophysicist who worked at Shell and later became a doctor. He is a qualified physician, general practitioner and public health doctor. He developed the HSMR in 1999 at the Imperial College. He was a Senior Fellow at the IHI (where he looked into American HSMRs). He was a panel member of the Bristol Enquiry. He is a former president of the BMA. He is of course the author of innumerable papers, book chapters, member of various committees and boards

Calculating the HSMR
HSMR = (observed mortality/expected mortality) X 100
Observed mortality is the actual number of deaths that happen in the hospital. The expected mortality is based on a reference population. The standardisation is the risk adjustment that is taken into account for the reference population.
In England, the HSMR is based on HES (Hospital Episode Statistics) data with 14 million records and 300 fields of information. The risk adjustments are made for numerous factors including but not limited to age, sex, elective status, socio-economic status, diagnostic subgroup, procedure subgroup, some co-morbidity palliative care, source of admission, ethnicity, month, number of prior emergency admissions and so on.
Clinical risk adjustment takes into account specific biometric data some of the models are Euroscore, ASA, APACHE, POSSUM and so on. But the HSMR risk adjustment model takes into account sociological and operational data. HSMR uses the 56 diagnostic groups which contribute to 80% of in-hospital deaths in England


The arguments about HSMR are about not including some of the preferred or favourite variables of some users. For instance, some hospitals feel that they have a palliative care/hospice ward within their premises and that could make their mortality rates high, some hospitals feel that there are no adequate hospice facilities in their area and hence more patients could come into hospital to die thus distorting their mortality rates by increasing it.
Research shows that firstly that the coding of palliative care is unreliable (more about it in an example below) and secondly that HSMR adjusted and non-adjusted for palliative care showed good correlation (i.e. no difference)

Another argument is that HSMR risk adjustments are based on HES data which does not include specific clinical data on co-morbidity and hence does not account for the clinical complexity of the patients who died. Interestingly, HSMR adjusted and unadjusted for co-morbidity still has a good correlation (i.e. no difference).
In the instance of vascular society data the data showed 8462 cases whereas the HES data showed 32242 cases.
In the case of the ACPGBI (colo-rectal), the database showed 7635 cases when the HES data showed 16346 cases. The ACPGBI/NBOCAP audit was voluntary (it has since then thought to be biased due to under reporting by the latest article on bowel cancer outcomes in Gut on 11 April 2011.)
It seems that the HES data is more complete.
In the ACPGBI database 39% of patients had missing data for risk factors. It seems that the HES data is more accurate for its (HSMR) parameters. (In the same article in GUT published on 11 April 2011 where they analyse cancer survival/mortality they admit they had Duke’s classification missing in 15% of cases – to show that even within the parameters/data they set themselves clinical databases seem to have incomplete data; whereas there was incomplete post code information only in 0.25%).
Research shows that HES-drFoster is as good as or better than clinical models/databases.

The cost of a clinical data base is up to £60 per patient whereas the HES general database is about £5 per patient.

Another common feeling is that admission diagnosis based coding could distort HSMR. Again interestingly in UK HES data apparently has no admission diagnosis and hence that is not taken into account in calculating HSMR.

Broadly speaking an increase or decrease in the HSMR in specialties with a small number of deaths may not indeed be a very useful way of understanding the issues – hospitals would be better off looking at the outcomes of specific process measures (and their compliance) within those deaths to obtain a better understanding on whether appropriate care was offered.
But for specialties with larger volumes, death as an outcome (increased or decreased deaths) is valid.

That is certainly possible. However change of coding could result in actually increasing the HSMR (due to change in the denominators of the new code)

One of the things we hear is mortality in private hospitals and mortality in private beds in NHS hospitals not being considered seriously.
Only 2% of bed usage in UK is non-NHS.
So obviously there is a substantial case for focussing on the NHS.

Mid Staffs were sent mortality alerts like dr Foster would do for any other hospital.
Mid Staffs internally looked into 200 deaths and explained it as coding errors – they may well might have been – but subsequently took no notice of overall deaths or HSMR.
At the same time or thereabouts dr Foster looked into coding and found it was average.
Mid Staffs were doing regular clinical audits.
Mid Staffs palliative care coding ('not curable' categorisation) went up from 2% to 60%

Of all the assessments and inspections reports 96% are dependent on self-reported quality measures and only 4% are by external/independent assessment and inspection.
2/3rds of self-reported quality measures are incorrect.

Hospitals with high adverse event reporting have low mortality. When hospitals start looking a mortality they start by encouraging increased adverse event reporting which then goes up by 4 times.

We will all recall the hospital where trial patients developed severe organ failure. That was as a result of a private company hiring the hospital facilities for their drug trial. The NHS hospital itself at that time was doing just about okay. One of the senior nurses there took the care bundle approach to move to the hospital with the lowest mortality in England.

Looking into mortality can be a threat to longevity.
Sir Brian says that there were assassination threats to the Bristol enquiry panel of which he was a member. Apparently there were people very upset that the panel refused to look into morbidity and stuck only to mortality investigation.

All the above is 'as heard' from the mini-course that I attended. My personal observations/views follow below from this point and hence cannot be attributed to the speakers of the course.
HSMR is a valid way of looking at mortality and is an excellent indicator of quality of healthcare provided by any healthcare organisation. Ignoring or explaining away HSMR and its related alerts have a huge underlying risk which may come back and bite very severely.

Michael Porter says measuring process is servitude and measuring outcome is liberation.
We should have a clear understanding of process measures and outcome measures. The new white paper's core theme is better outcome.
If we are achieving 4 hours, 31/62, 18 weeks, NPSA alert implementation, CQC points, Monitor requirements and so on; good for us but they are process measures.
Process measures have meaning only if they lead to improved outcome measures such as reduced mortality and reduced complications.

Hospitals that are at the higher end of the mortality ratio need to realise and accept that they do have the resources to deal with it. Having self confidence is the first and the best place to start.
That has to be followed by a very deep reflection on the activity, its explanations and results in the context of mortality.
Hospitals need to accept that the HSMR is mostly and broadly right and the alerts are relevant. When there is activity on internal validation of HSMR alerts it cannot be enough to explain coding issues/data validity; internal validation of HSMR alerts can only be accepted if they include a plan to reduce the subspecialty mortality (or risk as the case may be).
What should not be said is 'we are already doing this' or 'we are doing something even better’ when the mortality is not showing a downward trend.
If the mortality is high but regulator's ratings are good the questions to ask are about the accuracy/correctness of the internal reporting mechanisms – however uncomfortable those questions are. Similarly if care bundles are not working and the assumption should be that there is perhaps nothing wrong with the bundles or the patients, perhaps it is the way it is being done. If clinical audits are showing good results and but HSMR is increasing or procedure risk alerts are increasing that should trigger a reflection on whether the hospital is actually looking in the right direction.

A month on month continuous reduction in mortality (HSMR) should be the only acceptable proof. It looks like arguing with the data and explaining it away is no longer an option. If activity does not match the outcome data there may not be much point in attacking the data.

Dr Foster is not the only provider of analytical and comparative information; there are CHKS and others. It may or may not matter who the provider is; the point is to use the information in a way that makes a meaningful difference to the patients.

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Check out blog posts on 
Why High Mortality hospitals cannot afford to pay staff well (
What your hospital mortality was in 1998 and if it is any different now?

Mid Staffs public enquiry:

Sunday, 10 April 2011

Clinical Leadership 'Development' - have we got it right?

Development has two components; in order, first is technical skills (hard) and second is personal (so called soft).

Technical skills in my view has two steps core professional skills (how to do the best) and core generic skills (how to do the best for everyone, every time, everyday). Many of us are good at our core professional technical skills (eg surgery, finance, radiology, facilities, HR, cardiology, etc) but it is very well known that in healthcare many of us are unaware of core generic technical skills (evidence, shared baselines, operational data analysis and data tracking, data based decision making).

The NHS is and has been focused for a while on 'leadership', 'social movements', 'change' and such similar things.

My problem with this is profound. I believe that core generic technical development should precede personal development. Personal development methodology is very profound and is designed to promote self-awareness and self-belief. The risk is when the personal development comes before the technical development, people become so convinced about themselves and what they are doing that they feel that technical development is a non-essential trivial distraction.

What is also interesting is the technical skills are easier to teach/learn, assess and practice though most people would think it is difficult and personal development is far more difficult to achieve and demonstrate though most people would think that they have 'got it' after a few sessions.

I have huge concerns that at a local level the deaneries and SHAs do not do this and at a national level personal development happens at a fantastic level to NHS persons who mostly do not have the technical development. 

The fundamental message here is, one must know what/how to do it before they begin to believe they can do it.

Thursday, 27 January 2011

Clinical Leadership

One of the weirdest ideas of leadership and leaders is about being a 'senior', board member, top management, etc. Please let me explain. Leaders by default definition have followers; no followers - no leaders. Leaders become and remain leaders because followers allow them to do so. This does two things - the leaders begin to believe that they belong where they are (in leadership positions) due their 'own' and followers become passive because they put the leaders in there in the first place and do not want to admit wrong judgement. Further factors are mathematical politics, allowing time and running on reputation. There are glaring examples in politics that many of us would be aware of.

Once this happens, leaders begin to believe a bit too much in their own credentials. They forget that the fundamental source of all leaders and leadership is followers. The leaders who are by this time out of touch, deluded and completely in their own world begin to substitute the power of followers by the power of rules, law, agenda, reward, punishment and so on. Interestingly and correctly these are the tools of managers/administrators. The tension starts building, leaders become ineffective, leaders and followers become frustrated, external pressures build on what is perceived as 'failing' leaders, leaders use even more top down management methods because this is seen as going 'forwards' rather than stopping and getting back in touch with what put them there.

So the perpetual confusion between the roles of leaders and senior managers results in the unwillingness to recognise that all managers are NOT leaders and not all leaders will have good managerial skills (try telling that to any of your board members, medical directors, clinical directors or similar, that they are a 'director' or 'senior management' but not a leader). Some are blessed with both, both need some of the other's skills; what is crucial to understand is that leadership and management are fundamentally different. The sources of power of the managers are authority, position and mandates; the drivers are policy, guidelines, targets and the deliverables are the successful completion of what they are required to do. For managers failure is something to avoid.

The sources of power of leaders are first and foremost their followers; the background is usually due to knowledge, expertise, passion, and deliverable for leaders is their ability to bring people together for a cause if possible with success. Failure of a task is a learning experience for leaders and a true leader will rejoice the coming together of their followers irrespective of the eventual outcome.

In this context I would suggest that doctors are in a unique position. Doctors would and should quite simply be able to differentiate between managerial role and leadership role. Doctors due to their power of knowledge and skills in their chosen field need to aim to deliver the best care in the pursuit of clinical excellence that will actually be their 'management' role. Doctors as managers as currently taught in deanery 'management' courses completely miss this point. Doctors need to manage their time and resources to provide clinically superior care, that is the success of a doctors real management role; the management of their own clinical care delivery. That is the role of every doctor including the clinical director and the medical director. I could argue that for doctors good clinical management is the only management that is relevant.
We have to understand that most of us will not be leaders and we have to develop good followership traits along with management skills. Even those who are leaders must support other leaders whole-heartedly. Some doctors would demonstrate leadership. In my view the leadership is not really linked to any title or position in their place or work. These leaders should be recognised and supported. This would usually but not all the time be based on good clinical management but not necessarily related to it.
One of the first things to do therefore is to de-link managerial hierarchy from leadership situations. That does not mean that some managers would be good leaders or some leaders would be good managers; it simply means that there is no formal link or requirement for managers to be leaders or vice versa. The next step is to recognise that leaders could be anywhere in the hierarchy and create an obligation on managers to recognise and enable these persons to be effective.
These would result in Successful Healthcare.