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President’s Address to the ASMS Annual Conference

My Dad recently passed away and one of my tasks was to tidy his study, back-up his still running computer, and shut it down.

A retired psychologist, he had thrown himself into writing a book about the impact of language on our lives; in particular, how it can affect our thoughts, actions and relationships. In one chapter he explores the fact that we quite often use terms that can mean different things to different people. Pretty vs Ugly. Success vs Failure. Integration vs Separation. One person’s success might be very different to another person’s idea of success. The meanings of words are subjective and open to many interpretations.

This made me think about the language and concepts being used here in New Zealand to describe, influence and change our health care system. The language and words are often vague and the interpretation subjective at best. Considerable time, effort and resources are then used in an attempt to bring that subjective interpretation to life.

One thing led to another and I thought it would be interesting to construct a meeting buzz word bingo. Many of you will be familiar with the concept and I’m sure you have words of your own that could also be used.

Buzz word bingo:

Integration	Live within our means	Continuum of Care	Closer to home	Overspend
Clinical Leadership	Advertisement - scroll to continue reading Target/s	Quality improvement	Big Data	Models of care
Better, sooner more convenient	Regionalisation	Bingo	Work differently	Moving up stream
Direction of travel	Social determinant of Health	Disruptive innovation	Change	Primary
Secondary	Break even budget	Clinical Governance	Network	Cost neutral

The big picture
There are many ways to put together a jigsaw puzzle – but the result should be the same. You have a reference picture to look at, to guide you and to confirm that you have completed it correctly.

Where is the picture for our health care system? Who has it? Can we have a better look at it?

Yoki Berra, a famous retired USA baseball player, said: “If you don’t know where you’re going, you might end up some place else”. I have this nagging feeling that parts of our health care system are heading someplace else at the moment. District health boards (DHBs) interpret concepts and implement them. Most of the time they appear to be doing so without a clear “reference picture”, which makes me wonder how they know if the jigsaw puzzle has been completed successfully.

As mentioned, these concepts have an impact on resources (money, staffing levels, etc.), time (working faster to achieve more in the same time frame) and they increase the scope of what we are expected to do in the public health care system. The relationship between time, scope, resource and quality are well known. In health care, we should add safety to quality.

The relationships are captured in the Triple Constraint or Iron Triangle. This is widely accepted and is self-explanatory.
If you need to complete a project in a shorter amount of time, you will need more resource or you will have to reduce the scope; otherwise quality and/or safety will be compromised. If you widen the scope, you need to increase time, resource or both, etc.

I want to take a closer look at the current drivers/targets and concepts and see how they relate to the triangle.

Time:
6 hours ED target
First Specialist Appointment wait times: 6 month, 5 month, 4 month
Reduce length of stay
Elective surgery target (numbers against time)

Scope:
Better, sooner more convenient
Move upstream (secondary care to primary care)
Influence social determinants of health
Reduce Ambulatory Sensitive Hospitalisation rates
Continuum of care

Resource:
Live within our means
Work differently
Cost neutral
Break even budget
Administration support FTE cap

Quality and safety:
Quality must be at the top of each agenda (Is it?? Really??). Or has taken a far distant second place to the dollar?

Currently pressure is being applied to all three aspects of the triangle in the hope this will increase efficiency and effectiveness. But will it? Up to a point the health care system can reduce waste and become more efficient but then something will have to give. Quality and safety (patient care) can begin to suffer or the system can try to cope by letting fewer patients into the system. If the hand basin is full, turn off the tap or it will overflow.

When do we reach the point where things start to come apart? That is difficult to determine. Health care systems and delivery are complex. The effect of change or pressure on the system often do not follow a “domino effect” where the fall of one domino leads to the predictable fall of the next. It is more akin to a “butterfly effect”, where you fiddle with something over here and something quite unpredictable and unforeseen happens way over there. In other words, it can lead to unintended consequences.

I am not saying we should not try to improve the system (quite the opposite, in fact). We need to tread carefully, however, and be alert for unintended consequences. These can potentially have a significant negative impact and are more likely to occur if changes are further encouraged with ‘carrots and sticks’, especially if the carrot or stick is big. This can lead to gaming of the system or perhaps ignoring or not reporting the true situation, thereby avoiding the stick or alternatively being awarded the carrot. This can contribute to the creation of an environment where a “Mid-Staffordshire” type event is more likely to occur or repeat itself.

Are there early warning signs or red flags to indicate we are reaching a point where things might start to unravel? Yes, indeed – as I have mentioned, quality and safety might start to suffer and/or the system might try to cope by letting fewer patients into the system (eg, to meet the maximum waiting time target for electives).

The recently released report by the Health Quality & Safety Commission shows the number of serious adverse events reported in the year to June has again risen, more than doubling since the first report in 2007. This has been attributed to increased and better reporting by the health sector and, while this might be the case (in part at least), I think we should watch this space very carefully.

A recent article in the New Zealand Medical Journal shows that 36% of patients needing hip and knee replacements (in the two DHBs where the audit was done) are not getting them because of budget restrictions. Meeting the waiting time targets further impacts on these figures. http://www.radionz.co.nz/national/programmes/morningreport/audio/20156313/shorter-wait-times-squeezing-patients-off-waiting-list.

This adds further weight to the increasing concern and evidence of a growing unmet health need in New Zealand. This seems to have gone past the point of ‘watch this space’. There is increasing evidence that things are starting to unravel.

We must be careful what we measure. Measuring number of units performed against time (the expectation is to do more in less time) and simultaneously putting significant pressure on resource (break even budget or else…) can lead to unintended consequences. The six hour ED target is a good example. We measure time (six hours) but not quality or safety or the compassion of service delivery. Because we are not measuring it, is it less important? As long as everybody is out the door within six hours, the target has been met.

Is putting pressure on all three aspects of the iron triangle a method of driving “disruptive innovation”? I don’t think Harvard Business School professor Clayton Christensen, who invented the term and concept, would approve.
Time to change the triangle
I am proud to be working in the New Zealand public health system, one of the best in the world. The New Zealand public seems to support that view. In a recent article in the New Zealand Herald, Brian Gaynor explored the differences in private health insurance coverage between New Zealand and Australia. http://www.nzherald.co.nz/brian-gaynor/news/article.cfm?a_id=14&objectid=11351424. In it he states: “But the most frightening statistic is that only 12.5 per cent of New Zealanders aged 65 and over are covered by health insurance compared with 52 per cent across the Tasman”.

I do not find that frightening at all. I find it reassuring that most people over 65 years of age in New Zealand entrust their health care to the public health system. That does not mean we can pat ourselves on the back and sit back and relax. We have an obligation to make sure their trust is not misplaced. We must continue to innovate, improve and modernise our health care system. Surely there are alternate ways of achieving this, other than trying a top-down “squeeze” on the iron triangle (it is called that for a reason) and running the risk of compromising quality and safety and increasing the unmet health need?

I recently attended the APAC 2014 meeting (highly recommended) in Melbourne. In Maureen Bisognano’s (CEO of the Institute of Healthcare Improvement in the USA) keynote address (http://vimeo.com/105695300) she pointed out the importance and positive impact that the joy of the health workforce has on the delivery of health care. At the entrance of the Institute for Healthcare Improvement in the USA people encounter the following sign:

We will improve the lives of patients,
the health of communities,
and the joy of the health care workforce.

A new triangle started to take shape in my mind:

Joyful Workforce:

Maureen asked a few show-of-hands questions.
In the past week have you:
Skipped a meal due to work?
Eaten on the run?
Worked a full shift without a break?
Arrived home late from work?
Changed family or private plans due to work?
Drank too much coffee, tea, etc. to keep going?
Slept less than five hours a night?

I would like to add to that:
In the past week did:
HR make your life easier?
You leave work feeling positive about your day?

Thoughts or questions that are not asked at all or often enough:
Are you happy in your job?
Are you okay?
You look tired. Take a break.
Thank you.
Is there something I can do to help?
Great job. Well done.
And in some DHBs: Isn’t it time for you to take your sabbatical?

Who takes or has responsibility to encourage and promote a joyful workforce? Do we have a measure or performance target for this important aspect of our health care system?

Compassionate care
I touched on this topic at last year’s Annual Conference and the dangers of compassion fatigue and burnout. This year we have some excellent speakers on the topic. Have the public’s perception of compassion in health care delivery changed? This is obviously difficult to determine or make a call on. I recently came across two paintings depicting doctors in their work environment. The first is the well-known and much written about painting “The Doctor” by Sir Luke Fildes (1887, The Tate, Britain, London). In 1887 the doctor could offer not much more than compassion to the dying child but in doing so inspired the painting. http://www.tate.org.uk/art/artworks/fildes-the-doctor-n01522.

The second is a painting commissioned in 2002. The artist is Ken Currie (National Gallery, Scotland). It depicts professors in the Department of Surgery and Molecular Oncology at Ninewells Hospital and Medical School in Dundee. https://www.nationalgalleries.org/collection/artists-a-z/c/artist/ken-currie/object/three-oncologists-professor-rj-steele-professor-sir-alfred-cuschieri-and-professor-sir-david-p-lane-of-the-department-of-surgery-and-molecular-oncology-ninewells-hospital-dundee-pg-3296.

The artist spent a significant amount of time with the clinicians in their work environment to get insight into their daily working lives and pressures. Their facial expressions are quite gaunt and they look tired. There is no patient depicted but all three seem to have been interrupted in their clinical duties. Their clinical skill and knowledge make it possible for patients to receive individualised clinical care. It is difficult to judge from the painting if compassion is one of those things. It is difficult to offer compassion if you yourself are constantly tired, rushed and under pressure.

Doctors need time to spend with their patients and to ask “what matters to you?” instead of “what is the matter?”
Distributive Clinical Leadership
The importance of distributive clinical leadership is the one aspect of our health care system where there is wide spread agreement, including the Minister of Health (current and previous) and clinicians. We do have a reference document, In Good Hands (picture of the jigsaw), and yet after five years the implementation across the country is still variable. The health care system cannot innovate, improve and modernise without distributive clinical leadership. We need to urgently review this. It is very encouraging to hear Health Minister Jonathan Coleman emphasising the importance of clinical leadership.
Effective, Efficient, Appropriate
Our public health care system already compares favourably with other systems as far as efficiency and effectivity goes. Are we starting to fall behind when it comes to the appropriateness of health care delivery? Countries like Canada and the USA are currently rolling out and promoting the ‘Choose wisely’ programme, making best use of resources in an evidence-based way, engaging and empowering patients to make the right decisions: http://www.choosingwiselycanada.org.

There are also difficult conversations to be had around frailty care and towards end-of-life care. These conversations can only be had by a clinician who has time to spend with his/her patient and their family to reach a compassionate and well informed decision.

Conclusion
Do not get me wrong, we have a very good public health care system but we should continue to improve and modernise it further. I have obviously generalised and made some broad statements. The truth and saddest part is that there are good examples where DHBs, managers, clinicians, clinical networks, departments etc. have made significant improvements and implemented successful change but their success is not shared or transferred to the more troubled DHBs or areas. We do need to actively seek out the positive deviants and duplicate their successes across the country.

Our jobs are intellectually challenging and physically demanding. We are faced with constant change and the pressure to stay within budget and to do more with relatively less. This can lead to fatigue, compassion fatigue, burnout and a less effective, more prone to mistakes, workforce. This is not an environment that promotes joy in the workforce.

We need to look after our health care workforce, optimise the work environment and make sure we achieve and maintain joy in our workforce. Clinical leadership has a major part to play in achieving this. Investing money in health care and the health of the New Zealand population is not money wasted. Our patients and we should expect a safe and high quality health service delivered by compassionate staff in a friendly environment.

Let us change the triangle.

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