Monday, 25 February 2013

The Pretence of Better Communication

This blog was first published at doc2doc It has been modified, extended and re-posted here.

Discharge Summaries in NHS
10 years ago in the NHS most consultants used to do discharge summary letters for their in-patients. Quite rightly so. The discharge summary was and is the only communication that the hospital provides to primary care on what happened to the patient in the hospital. It is one of the most important pieces communication that the specialist sends to the generalist. It was the knowledge of the expert given as an opinion. It was also an opportunity for the consultant to review and reflect on the care provided, identify errors and recognise the capability/limitations of the team members.

5 years ago the consultants mostly devolved this responsibility to some experienced staff working with them such as Staff Grades or Registrars. The discharge letter became a task that had to be done. Information was passed to the general practitioners.

Now, the discharge letters are electronic and are primarily if not exclusively done by FY1s or FY2s who are the least experienced doctors in the system. Discharge letters are a part of the contractual requirement to be sent within a set time. There is enormous data within those discharge letters which is sent to the GP more or less contemporaneously. The junior doctors do a very good job; of transmitting data; they cannot with their level or training, expertise and experience do anything more.

Anyone who knows a little about this things will recognise that to derive any meaning or learning from what we do on a day to day basis, data has to be processed and assembled to generate information; information has to be analysed and contextualised to create knowledge. In the case of the NHS discharge summaries, knowledge transmission has now deteriorated into data transmission. Transparency and detail which are important have taken the place of trust and succinct senior opinion which are equally important.

The most crucial and often the only piece of communication from hospitals to general practices is now generated by a combination of off the shelf software programmes filled in by the junior most medical staff and usually has no oversight from anyone senior. Of course there are reasons for this, the letters can be generated quicker, can reach general practitioners on time and the current economic climate a consultant who is an expensive human resource is better used doing actual clinical work. Fully understandable. But let us not make the mistake of assuming that this is superior communication.

A friend who works on analysing and reporting risks in financial industry wrote in to say 'in my area of work if I do not provide the final oversight on what gets published on the credit opinions..which can sway bond error means I can be banned from working in financial services...if related to sovereigns...maybe jailed as well'. Now that's how seriously communication should be taken.

The Abuse of Communication Skills

Now that this blog has a growing readership; friends and acquaintances are writing in with examples from their own places of work. There seems an increasing cultural tendency where people think its okay to abuse communication skills. Righting a wrong not by action but by words. Not fair but read on.....................

Car Parking Vs Patients

Clinician running late, found a parking place and noticed that the parking permit was missing. Dilemma. Go to work and ring security to inform - risk of clamping and £60 fine. Go to security first and late to work - patients waiting.

Decision. Go to security first. Cannot afford £60 fine.

Explanation: 'Oh we can apologise to patients, show them empathy, sympathy, tell them our story, sit by their side rather than opposite them, perhaps even hold their hand and build a better relationship. They will forget the waiting. But security will clamp and will fine £60; my work place will not be supportive'

'We can handle complaints'

Bed manager rings on-call doctor: 'Try and send patients home from A&E, there are no beds in the hospital and we don't want patients to breach in A & E'

On-call doc: 'Well, apart from clinical reasons, there is also patient expectation. We could have serious complaints'

Bed manager: 'Oh don't worry about that. Complaints come only later. We can handle that. We are really good at handling complaints. We can provide them a detailed explanation and an apology if necessary'

Those are classic examples of abuse of a good skill. I have a problem with people using great tools and doing wrong things with it.

Let us get real. Let us not delude ourselves in the NHS by harping on about the primacy of communication.

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Thursday, 14 February 2013

Servant Leaders in Healthcare - Stand up and make it count

Airline operational performance results for major carries in USA have come out and it shows that in general flying experience parameters are all getting better. The WSJ has a nice tabular column which explains it really well.

Southwest Airlines had the largest number of system wide emplanements (I take this to mean the highest number of passengers took Southwest flights) and they have the lowest rate of complaints per 100000 emplanements. Southwest had about 40% less complaints than the next best complained airline and the highest complained about airline had 14 times (1400%) more complaints than Southwest.

United had the highest complaints. The stats show that United had the highest rate of bumping (passengers denied boarding due to overbooking by airlines) and highest rate of lost baggage and understandably they had the highest complaints.

Then an interesting fact leaps out:

Out of 7 major USA airlines, Southwest had the second highest rate of bumping, third highest rate of late flights and was in the middle of the field for lost baggage but had the lowest rate of complaints. As I explained earlier it was not just lowest it was (at least for the month November 2011) had 14 times lower complaints than United.

There is nothing more that annoys passengers than bumping or flight delays or lost luggage. Why did Southwest have such a low rate of complaints? Why did Southwest customers not complain more? Looking at the data, one would expect many more complaints. How can we explain this?

Southwest Airlines practices Servant Leadership, which is pretty unusual at a whole organisation level. Servant Leadership seems to have led to employee empowerment which then leads to building ground level relationships with customers. All those lovely videos on youtube about Southwest are examples. Customers begin to see Southwest employees as 'friends' who are coping with difficulties that are common and typical of airlines; they do not want to add to the burden of their 'friends' by complaining.

Relationships trumps poor stats and bad stories. This is true of healthcare as well. Patients relationship with their doctors and their local hospitals are the ones that keep our NHS hospitals going; if that was not the case we would see a significant movement of patients away from high mortality hospitals every time the mortality results hit the press or a bad news story hit the press. That is not happening at a perceptible level.

However, some hospitals are finding an increase in complaints every time the mortality results are published and on the occasion when bad news stories are published. Complaints are a useful tool for feedback, problem detection and improvement but when an organisation is already on a well recognised path of validated development complaints on routine operational matters can also be a source of distraction, expense and negative publicity. Problems which were not or could not be prevented, as might happen in healthcare often, if identified, as soon as they happened and customer service methods were used to deal with them, could avoid complaints and its ill effects.

In an organisation that is clinically performing well, to ensure that the doctor-patient relationship and the hospital-patient relationship which clearly exists is translated into a low number of complaints would need empowered employees enabled by an organisation wide servant leadership approach.

Where are the servant leaders in healthcare? Which organisations follow servant leadership approach? I can recognise very few leaders but no organisation practising servant leadership.

The thoughts on servant leadership are quite old, ''Mark 9:35 Sitting down, Jesus called the Twelve and said, "If anyone wants to be first, he must be the very last, and the servant of all''; there are other religious and philosophical variations which are older and younger to that quote. However the management description of it was by Robert Greenleaf who wrote:

"The servant leader is servant first. It begins with the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to aspire to lead."
"The difference manifests itself in the care taken by the servant-first to make sure that other people’s highest priorities are being served. The best test, and difficult to administer is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servant? And what is the effect on the least privileged in society; will they benefit, or at least not be further deprived?"
Robert Greenleaf: The Servant as Leader 1970. (

One would have thought that the medical profession with its high altruistic calling of serving the ill would abound with servant leaders; it seems that may not be the case. The time has come for any true servant leaders in the NHS to stand up and be counted as this seems a good model for leadership development for our caring and noble profession.


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Wednesday, 6 February 2013

End of management (long version)

A shorter crisp version (about 600 words) is published in the FMLM (blog  for which this topic was originally written. This is the rambling 1500 word extended narcissistic version. You are welcome to it ...  

It is important to read Alan Murray’s ‘The End of Management’ Corporate bureaucracy is becoming obsolete. Why managers should act like venture capitalists; in the WSJ. Here is the link:

Once you have read this blog post gets its context and then you can read this either as a commentary of the WSJ article as relevant to NHS or on its own. This blog is deliberately off-key, the topic is such, bear with me. Compared to many healthcare systems we do quite well in the NHS. Could we do better? Of course yes but how we do that will define our future.

We are the management and we will tell you how to end management!?!?!

At a broader level, in the NHS there are no examples that I can think of where corporate structure or management has been ‘ended’. The previous government did good work with top down waiting times and so on; the present government is attempting top down radical change in organisational structures. The government is trying to get us do differently. When individuals try to do something creative, the organisations and the NHS as a whole tries to look at 'where and how it fits in with the overall plan'. But in the public sector there is the government not just wanting us to do different but also telling us how precisely to do it; with organisations 'encouraging innovation and creativity' only if it fits in with pre-defined policies. But that is what modern business is trying not to do; modern thinking in management is not telling people what to do but to let people to do things first and the management to amplify the good ideas.

Thinking of me vs thinking of you

At the narrower level, trainees (I am talking about all trainees in the clinical areas- not just doctors) are taught to think of how they are learning and improving themselves; never to explicitly think about their contribution to the organisation. In fact, often people think that their contribution to healthcare as such starts only when they stop becoming trainees. By that time the mind set becomes so fixed in thinking inwardly about the self and not outwardly about others that it becomes very difficult for the rest of their lives. Careerism becomes the mantra for many people in healthcare; we always thought this was the case in the private sector - true but that trend is changing in some areas. 

Best with limits

This leads to people taking very defensive attitudes. Most people in healthcare management are either numerically shy or numerically illiterate. They are unwilling to make a personal numerical prediction on their or their department/division/directorate’s improvement based on a measurable internal parameter due to the fear that they may be unable to stand by it. In any case most of the numbers are geared towards predefined reporting parameters. People who work in the NHS also seem to think that they are somehow very altruistic and have a high sense of entitlement. That attitude is even more profound in the clinicians with clinicians tending to believe that they express their altruism by their very individualistic approaches to healthcare. It is also possible that there are certain kind of people who are drawn to public services (possibly risk averse, change shy, rule-bound, authority loving, service minded and so on) and it would be difficult to use the same methods as for instance in Google to achieve a new management approach.

At both the above levels, healthcare and NHS is thought to be too important and too costly to be creative or innovative; the phrase used is 'risk'. Healthcare especially in Europe and even more so in UK has innumerable external controllers and bodies telling people what to do and how to do it that it simply chokes off creativity even before it begins. In other industries there is an obligation to do some degree of statutory reporting with no real controls on how they do their business.

So, it seems like what the above WSJ article is saying is not possible in UK healthcare at all. There seems no space that is available or can be created for those concepts to happen without falling foul of something or someone. But there lies the opportunity as well to ‘end management’ and create self-sustaining systems.

Blue skies

Hence, I can now boldly enter the imaginary world to explore how the 'wisdom of the crowds' can be harnessed. I think the way to do it is to disengage from current conventions and demonstrate its success. That does not mean rebelling, non-cooperating, behaving illegally, not concentrating, becoming disenchanted or any such thing. It is using our own methods to satisfy our requirements and our clients’ requirement rather than using a method or doing a thing to satisfy an external definition. 

For instance when the roads around Birmingham were choking instead of building a new road, they opened the hard shoulder to traffic which in other roads is actually illegal; peak time traffic situation has improved since in that area. Compare that with an example of the situation in some hospitals where they buy yet another business intelligence interface/data-mining tool to provide information at service line specialty level when the managers and clinicians often feel that human connectivity was the issue that needed resolving to enable their older software to be used effectively. Often the tool is not really the problem, our thinking is.

Let us assume for example that one of our services is not accredited by some specialty society because we did not meet one or more of their requirements in the way they wanted. Normally the tendency would be either to stop that service or to work very hard to meet that accreditation standard. However, if our results in that particular specialty or aspect is better than anywhere else, would we as an organisation, anyone in the specialty society or the general society as a whole be unhappy? Certainly not. In this scenario the badge of not being accredited becomes a badge of honour. The problem is we do not think like that in the NHS. We probably should.

Like the Birmingham roads, what 'illegal' things could we do to make ourselves better?

Obviously we should disengage and develop only if it is beneficial to our hospital and patients and we are able to track it and prove it contemporaneously.

Is this an example of wisdom of the crowds in the real world of healthcare?

     Finally let me try a hypothetical yet hopefully practical proposition to disengage and demonstrate. There is a focus on Unplanned emergency re-admissions and we may not get paid for such re-admissions. I am aware of some of the things that we have started doing to tackle this issue. Let me put to you a potentially disruptive solution in the 'end of management' mode 
      a) not offering routine follow-ups for any patient who is discharged from the ward (medical, surgical, post-operative) 

and instead

b) Guaranteeing a clinic slot within a defined time (48 hours to one week as agreed) should the patient choose to contact us.

My hypothesis is, this approach will reduce unplanned emergency readmissions as the issue is often/mostly to with patient concerns on access (rather than real life-threatening matters); the 'routine' follow up itself is mostly to satisfy clinicians habit rather than a scientific finding that all complications in all patients happens precisely 3 months after seeing the doctor and hence patients need a 3 months appointment. This will also clear up the 'congestion' we have in our clinics. 

Okay, where is the 'wisdom of the crowd' here? The crowd in our example is the patient; and the wisdom is the patients’ knowledge about their own health on what is wrong with them and they should be able to access us when they find something wrong with them. This is of course one step further than the current thinking on 'crowd' which is usually the employees in a large organisation. We even need to change the definition of crowd to suit our requirement. 

Rambling ambiguity and the threads of new systems

We can predict that the conventional management methods will not work in the 21st century. End of management as we know it is not chaos as many would like us to believe. New models are not apparent or clear yet. Perhaps there may not be one new model; possibly there may not be a well defined model at all. There are emerging themes; democratisation of data, data mining, crowd sourcing, coping with anti-knowledge, cloud care and dumb-terminals, many more............ It is not these themes that are important; it is how we implement these themes that are relevant. We can be told how to do it thus not ‘ending management’ or we can show how we do it.

Thank you for getting to this sentence of the blog. If you thought this was rambling ambiguity, I am grateful for your attention and will do better next time. If there are some threads that we can build on then I have achieved my aim.


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