As healthcare professionals our professional interactions with our users can result in a range of outcomes on which we are judged - “good enough” is simply not good enough!
The processes and procedures which determine outcomes are not directly visible so measurement has become “the lens” through which performance is judged. But measurement alone is not sufficient to give any assurance of safety and quality of care. The power of measurement lies in entrenching a culture of safety and quality, and, its capacity to trigger informed action if it is used constructively in the proper context.
Healthcare organisations are particularly complex and a sophisticated system of performance measurement is the golden thread which connects all the interdependent parts of care pathways so that they work together to achieve optimum outcomes for the users our services. Unfortunately, many healthcare organisations do not have one integrated performance measurement system.
When the measurement system is properly integrated and working well managers will focus on the right courses of action and minimise problems, such as:
The Functions of Performance Measurement
Over the last twenty years or so, we have seen performance measurements increase dramatically in healthcare organisations while simultaneously we appear to be experiencing increasing cases of abject poor care?
Are healthcare organisations measuring to ‘look good’ rather than measuring to ‘be good’?
When measurement is linked directly with big rewards or punishment (and fear) there is always a risk that the value of measurement will be undermined and rendered dysfunctional. “Measurement dysfunction” occurs when the measurement process itself contributes to behaviour which is not in the best interests of the organisation due to intentional and unintentional distortion and manipulations of data. When this occurs, specific numbers (Key Performance Indicators) might improve, but the performance that is really important will worsen.
Measuring to ‘be good’ is using measurements the right way, measuring to ‘look good’ is misusing the power of measurement.
Do the Right Test
For the Right Patient
At the Right Time
It is well documented that healthcare organisations across the world are looking to decrease their overall running costs while at the same improving the quality of the service they provide. Demand Management of requests for diagnostic tests is one of many strategies that have been deployed to achieve this.
Demand Management is not about doing fewer tests in order to save money. It is about improving quality and enhancing patient experience - doing the Right Test, for the Right Patient, at the Right Time. This may involve doing fewer tests and spending less in most cases. However, there may be circumstances when it may involve doing more tests and spending more if it adds value to the service by improving the standard of care provided. As healthcare professionals, our duty is to provide a consistently high standard of care first and foremost.
Multiple requests for the same tests within the course of a few hours or a day, may sometimes be necessary to deliver a high standard of care. However, there are occasions when the cause of such multiple requests is simply that the results of the initial test cannot be found, there are no records in the patient notes that the relevant tests have been requested, ineffective handover and communication between caregivers or some other avoidable reasons. This is over-testing and it amounts to a quality of care that needs to be improved. It is also wasteful because it adds no value to the care of the patient. Requests for inappropriate tests with doubtful diagnostic value also fall under the category of over-testing. Lean working is fundamentally about adding value by bearing down on waste and enhancing patient experience. By using Lean tools and Lean ways of working, waste will be minimised, if not eliminated, thereby increasing value and enhancing the experience of our patients.
There is no better opportunity for Pathology Departments to take a leadership role, with the support of all other stakeholders, in addressing the problem of over-testing. This will decrease the time wasted carrying out tasks that do not add value to the service, decrease the extra pressure placed on phlebotomists, Biomedical Scientists and other caregivers, provide a higher quality of care by removing the risk of potential iatrogenic anaemia and the sheer discomfort of unnecessarily bleeding patients who are already unwell. Furthermore, the greater the number of tests requested and performed, the greater the potential for error in patient identification, inadequate sampling due to volume, haemolysis, clotted samples and other possible sources of error. It follows that patient safety is one other important benefit of using Lean tools and Lean working to achieve a ‘Right Test, Right Patient, Right Time’ service.
Delivering high quality of care also means investigating the incidences of under-testing. This will be considerably more difficult than identifying and resolving the incidence of over-testing. For example, it is well documented that the incidence of obesity and diabetes is increasing worldwide, and the treatment and management of these patients is costing healthcare organisations vast sums of money. The glycosylated haemoglobin test (HbA1c) for the treatment and management of diabetes will help control HbA1c levels and lower cholesterol levels. Yet there is ample evidence of under-testing in relation to HbA1c in recognised at risk groups. Glucose molecules in the blood normally become attached to haemoglobin molecules. The haemoglobin becomes glycosylated (also referred to as HbA1c) – as the blood sugar becomes higher, more of the haemoglobin becomes glycosylated. The glucose remains attached to the haemoglobin for the life of the red blood cell: approximately about 2 to 3 months. The glycosylated haemoglobin test shows the average blood glucose level for the 2 to 3 months before the test. This can help determine how well a person's diabetes is being controlled over time.
Keys to Success
Using Lean tools and Lean working to establish a ‘Right Test, Right Patient, Right Time’ service is a challenge – but one that can be overcome by taking the following series of steps:
· An Optimum Test Utilisation Group (OTUG) is created. This is a multi-disciplinary team in which the relevant stakeholders are represented, and take an active part, from throughout the organization – supported by the Executive Team. Through an open and transparent process the evidence, in the form of relevant data, complaints, staff experience, patient experience and any other relevant information is examined by the OTUG and best practice agreed. There must be a readiness to learn from one another and a willingness to change if necessary. It must be clear to everyone in, or associated with, the OTUG that the quality of care will never be compromised for decreasing cost.
· Invest in an IT software which warns the clinician generating a request that the same test was requested in the last number of minutes, hours or days, and offering the option to abort or proceed with the request.
· Generating a sense of urgency is critical for any change programme to succeed. This is more so in the case of using Lean tools and Lean working to establish ‘Right Test, Right Patient, Right Time’ service because of the length of time it may take to gather all the relevant data - a sense of urgency must be maintained.
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‘Do No Harm’ standard of care applies to every employee in every healthcare setting and it is a legitimate expectation of every user of healthcare services. The overwhelming majority who access healthcare do not expect to be caused any harm – not by failure to follow manufacturers’ instructions or any other conceivable inadequacy or complacency!
Yet it is not uncommon to hear some serious and even fatal errors explained away by the phrases ‘the manufactures’ Instructions were followed – unfortunately it was just one of those things!’ or ‘It’s been done like this for years and there have been no problems – this is a one-off; something else must have caused the problem’. Worse still, seek to conceal errors.
When it comes to patient safety and standard of care there can be no hiding place behind the validation of regulatory agencies and accreditation bodies either! Inspections and audits by these bodies have an important role to play but they are too infrequent to provide adequate assurance of safety and high enough standards of care across the board in our fast evolving healthcare settings. They are no more than a snapshot of a limited range of activities upon which a clean bill of health is issued to healthcare organisations.
Besides, it is common knowledge that before such visits there is often frantic activity in the host organisation to ensure that any lapses in documentation or procedure are carefully managed in order to avoid the embarrassment of serious noncompliance, thereby compromising the effectiveness of the visit. In recent years, we have all been shocked to the core by hospitals that had been given a clean bill of health by regulatory or accrediting bodies when, in reality, they were cauldrons bubbling underneath with practices that did the ultimate harm to their patients – kill them!
Systems and technology can fail. Caregivers will make mistakes. Regulatory and accreditation guidelines and recommendations alone will not ensure patient safety. They give an indication of minimum standards of care patients should receive. Their audits, reports and recommendations should complement an internal framework of higher standards which must include an overarching continuous improvement programme through audits, training, competency assessments and risk assessments. Strong leadership is a requirement and there is no place for complacency in this framework.
It is worth remembering that as organisations in the healthcare business we deserve what we tolerate!
Gus Lusack is an experienced HCPC registered Biomedical Scientist who has worked in both the NHS and private sector. He has a keen interest in the subject of value creation in healthcare through improving quality and decreasing waste within restricted budgets. Gus has a Master of Business Administration (MBA) degree, Lean Six Sigma Black Belt certification and is an APMG – International PRINCE2 Registered Practitioner.