If the NHS leadership really wants to follow through on its message for the future, they need to embrace transparency. Ric Whalley writes
There is a lot of talk amongst health leaders about harnessing transparency as the driver of change. But do enough people really know how this can be used in the best way to change behaviours right down to the front line?
This is an area of huge promise and opportunity if tackled in a rigorous, systematic way.
Power of transparency
I work to implement positive change across healthcare organisations and one of the things I witness most consistently is the power of transparency (and visibility) when it comes to improving both processes and performance. Examples include better supporting teams to progress inpatient next steps in a timely manner, reducing overall length of stay, and seeing medical consultants positively compete around a clearly displayed and understood theatre productivity system.
It’s early days, but I’m seeing a greater move towards embracing transparency, whether it be consultant performance or the recent changes to RTT (referral to treatment time) metrics.
Aligning metrics and performance information to patient groups supports a whole care pathway mentality
One area being developed by Chris Ham and the King’s Fund, which I’d like to explore here is the idea of clinical commissioning group system metrics. This initiative describes generating data and reporting CCG health system metrics aligned and grouped by patient type (ie: older people, or people with long term conditions).
Aligning metrics and performance information to patient groups supports a whole care pathway mentality and used well could help drive population-based decisions, supporting successful steps to integration.
There has been a lot of talk in healthcare recently about the what and the where, be it the Five Year Forward View, vanguards or seven day working. What we perhaps hear too little of is the how and that is the part that I’d like to focus on here.
How do we ensure the addition of these metrics, for example, don’t breed confusion and how do we learn lessons from the way things are currently done?
The following are three main issues with the way metrics are currently used in the NHS.
- Slow metric turnaround and inconsistent timings: If data and results gathered aren’t quickly measured in a timely way (which is so often the case) it means by the time metrics comes out, the world has moved on. People can’t remember well enough what happened at the time leading up to the metric performance, or feel paralysed to act because the lay of the land has already changed.
- A wide range of individual tactical metrics: This unstructured diversity of metrics leads to behaviours that often don’t support the best holistic solutions as well as organisations driving to simply meet the metric – rather than do the right thing (eg emergency department four-hour wait, and referral to treatment targets). This can result in a confused, scattered, difficult-to-manage framework.
- Lack of completeness and cascade of metrics from the top level through to the frontline.
Through my work with trusts, I know these issues can all be tackled, that step changes in productivity and reducing waste within the system can be made and sustained. The NHS is good at driving to metrics, but our responsibility is to ensure they’re right, clear and complete.
With this in mind, I believe there are two main ways to drive how the NHS meets its transparency goals for the future.
Ensure quick feedback loops: There is an appropriate frequency for each level of metric review; for example, the frontline has daily and weekly reviews, managers weekly and monthly, and the overall system monthly and quarterly. The quicker the feedback loop, the more recent and relevant the behaviour or event that drove the performance, so the easier it will be to test solutions and adjust behaviours.
I’ve seen how this can work from putting in place a daily and weekly improvement cycle to tackle theatre delays. This approach addressed issues such as patient bloods not being completed in time and different staff having different understandings of the actual theatre start time.
The result was productivity improvements of over 10 per cent in numerous theatre units, something worth millions to most trusts. One argument commonly made against this approach is that the data needs to be validated, but this is often an excuse for inaction.
Validating data is an inefficiency built into an untrustworthy system, but by driving a quick cycle you drive up the data quality due to its relevance.
Decongest and rationalise the metrics: If and when the new patient group based metrics are introduced for CCGs, we need to ensure they can supersede and encompass the current confusing, disjointed array of measures and priorities. It would be helpful to have a small set of clearly defined metrics at each level connected directly to the overall NHS strategy (the forward view).
These need to be metrics that are able to be managed within the area of work they impact in order to avoid a lack of accountability and responses like “we can’t do what we should be doing because of what the people over there are doing” (delayed transfers of care being a prime example). The best way to do this in a complete way, that doesn’t leave gaps is to build a hierarchy of metrics drawing a line from the strategy, right down every level to the frontline.
Outpatients metric split example
A simple example in a trust is outpatients, an area notorious for poor visibility of performance.
At the highest level outpatient performance is made up of quality (eg patient experience, waiting times, outcomes), staff (eg satisfaction, absence, retention) and financial (income vs cost). The example above expands one key element of the financial performance – the activity.
The activity is driven entirely by the number of sessions and the patients attending per session – this is the first place to look if the activity is not in line with expectations. This structure provides a way that the overall performance can be viewed and interrogated in a manageable yet comprehensive way, without needing to look at every metric at once.
Say that the number of sessions is in line with expectations, but not the patients attending per session, this then prompts us to step down the next level to patients booked and DNAs and so on. I have seen numerous examples where less than 50 per cent of clinic time is spent face to face time with patients, this approach highlights whether this is driven by the template design, booking efficiency, DNAs or a combination, allowing these issues to be addressed.
The metric structure can then be created in a hierarchy for each level to view and provide clear accountability for performance to the level below. For example you might have these metrics at a trust-wide level for the COO, at a specialty level for the manager and clinical director and even at an individual consultant level to empower them to own their own clinics.
This approach can be applied to numerous other areas as well, such as inappropriate referrals or test requests – currently many interactions with the service happen transactionally, in silos, it is far too common an occurrence for a patient to be “passed” from one part of the system to another in a non-joined up manner. Imagine a system where a GP, AHP or consultant gets quick feedback on the outcome and follow-up made to the pathways they have decided or action they have taken, joining together the patient journey for them, rather than them just seeing their part in isolation.
Just the visibility of this on a short timescale would drive huge improvement. Combine this with comparative, aggregated data and there becomes real incentive to change and improve.
A focused, transparent approach is the bread and butter of so many industry processes such as lean manufacturing, and the safety records in the airline industry. If the NHS leadership really wants to follow through on their message for the future, they need to embrace and distribute this best practice in the way they address the opportunities presented by transparency.
Ric Whalley is associate director for healthcare at Newton Europe
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