Chris Bain on the Healthcare Environment

Nosokinetics

'Looking Around from the Inside...'

Dr Christopher Bain

MBBS, Master Info. Tech., MACS (Prov); PhD Candidate (Management Information Systems) - Edith Cowan University; Information Manager, Western and Central Melbourne Integrated Cancer Service, Melbourne.

(comments to rjtechne@iol.ie)

Background

As I have hit my 20th year of either being a clinician or working closely with them in the Victorian healthcare industry, I thought it might be useful to share some experiences from the front lines in response to Mark Mackay’s article "Looking in from the outside - time to get through the door". My last two posts, including my current one, have been in supporting change in healthcare management and service delivery......I must say it’s a grim picture.

I should contextualise my comments by saying that I remain committed to the cause!! I believe we need much better ways to assist healthcare managers in many dimensions, and I see computer applications based on scientifically proven techniques and methodologies as being a key part of that. In addition, I continue to work in the area of "nosokinetics", for example I am working currently on a web based simulation project with the Victorian Partnership for Advanced Computing VPAC in conjunction with Dr Gitesh Raikundalia of Victoria University here in Melbourne. Management information systems for healthcare of various kinds remain my key career interest.

I will focus my attention on hospitals in particular as they are the entities I have most experience with, and also where arguably, the biggest "bang for buck" is in relation to patient flow modelling activities.

The Environment - Is the Soil Culturally and Politically Barren?

In terms of the view from the "inside", I think we have a very difficult task ahead of us for a number of reasons, in addition to some of those that Mark has correctly identified from the "outside".

Tribes and sub-tribes certainly exist (Mackay 2007) (Fitzgerald and Teal 2003), but the problem goes deeper than that. I would argue that the number one problem is the effect of hospital culture and politics at all levels. In this tight funding environment which often sets up perverse competitive incentives (Drife and Johnston 1995) both in an operational and a research sense, managers (or even clinician-managers) can be driven towards personal survival and local performance optimization as key performance indicators (KPI’s). To complicate matters even further, various stakeholders (eg clinicians, clinician managers, managers and patients) can even have very different perspectives on what are important facets or measures of hospital performance (for example, see the work by Tregunno, Baker et al. 2004)

The pressure that managers or clinician managers are under (Caplan 1994) does not easily allow them to take on the kinds of thinking necessary to give these technologies a chance. In one respect, who can blame them, in what is an incredibly cut throat environment. This environment is, sadly in my opinion, quite at odds with the nature of the work the industry is meant to perform. Unfortunately, anyone who has worked in a hospital system at a senior level for any length of time will be able to provide countless tales of the poor professional behaviours and undermining of productive activities that go on.

By way of illustration consider the work by King and McInerney (2006) from South Africa. They described factors affecting the resignations of registered nurses in an urban institutional setting. They found that "The resignations of registered nurses related to their physical working conditions and environment and included the following: unsupportive management structures, autocratic and dehumanizing management styles, negative stereotypy of nurses and the nursing profession, lack of autonomy in the workplace, professional jealousies and fractures within the profession inaccurate systems of performance assessment compounded by favouritism and racism……".

It could be argued that this represents an extreme description of hospital culture, unique to that country. Work form around the world, however, paints a less than flattering, although perhaps not as dramatic, picture of hospital culture and politics.

For example, some of these findings are supported by a survey of 9638 nurses in Belgium by Milisen, Abraham et al. 2006. Norwegian research has identified (Skogsaas and Svendsen 2006) in interviews with hospital division leaders in relation to achieving change in a hospital setting - that "the most difficult challenge was to handle interactions dominated by suspicion, negative interpretation, assumptions and hidden agendas. Such interplays were the most limiting factor in the development of a common understanding of demands, goals and commitment to change processes across departments and units."

Recent Canadian research (Cooper, Joglekar et al. 2005) highlights that even in areas of core hospital functioning, such as in critical care, there can be less than ideal communication processes. In particular it highlights how the publicity and appeals elements of a recognized "fairness" or "reasonableness" framework around decision making, is prone to breakdown in relation to decisions about ICU bed access. (see Table 1)

Table 1: The four conditions of accountability for reasonableness:

Publicity: The decisions and reasons behind priority-setting decisions must be publicly available.
Relevance: These rationales must rest on evidence, reasons, and principles that fair-minded people can agree are relevant to deciding how to meet the diverse needs of patients in the context of limited resources.
Appeals: There is a process for revision and dispute resolution regarding priority-setting decisions.
Enforcement: There is a method of regulation in place to ensure that the first three criteria are met.

From Cooper et al. BMC Health Services Research 2005 5:67 doi:10.1186/1472-6963-5-67

The existence of potentially destructive effects of rumours in healthcare organizations is also acknowledged (Robertson 2005) - not surprisingly as rumours are part of human nature. McCallin (2005) even raises the worrying notion that healthcare professionals "may need to learn how to collaborate". Unfortunately this observation also ties with practical experience on the ground. Feedback from the field in the UK (Freeman and Walshe 2004) supports the contention of poor progress in encouraging collaboration within and across health services- in the area of clinical governance in this particular case.

Furthermore, there is evidence of the destructive effect of poor relationships between clinicians and managers (Patterson and Bishop 2003). Atun (2003) also commented about this issue in the NHS, referring to the "doctor-manager divide and an unhealthy ‘them and us’ culture." He also stated at that time "Unsystematic efforts to bridge this divide have had limited success." I do not believe things have radically altered in the Victorian context since that time.

The evidence described above points to some of the manifestations of a less than optimal culture, and politics in healthcare, and in hospitals in particular.

Change and Achieving it

Another key hurdle I can identify is resistance to change. Mark has touched on this in his article but it is an enormous problem of its own. Grol and Wensing (2004) have identified that there are barriers to change in healthcare, even when there are well evidenced practice improvements to be made. Cabana, Rand et al. (1999) identify "habit" and "routines" as reason why clinicians don’t follow clinical practice guidelines. Others have noted (Robinson and Turnbull 2004) that organizations need to foster practice change if recommendations are to be taken up and made sustainable - that is to say organizational culture (Skogsaas and Svendsen 2006; Seren and Baykal 2007) also has a role in aiding or obstructing change, even at the basic clinical care level, let alone with something potentially seen as much less immediate to day to day hospital functioning such as patient flow modelling.

There are also many reports in the medical IT/informatics literature that highlight clinician resistance as a reason for failure in IT projects in health (it's not a long bow to draw the analogy with the kind of work we are trying to foster under the banner of "nosokinetics"). From my on the ground experience, currently working in Cancer service reform across six hospitals, this phenomenon is alive and well.

My personal musings on this include an observation that medicine is a very traditional and conservative discipline by its' nature and people who remain, to their credit, clinicians for long periods of time (and who therefore often rise to management positions), are by their nature unlikely to welcome change (Roig JV, Rodríguez-Carrillo R et al. 2007). In addition, as I have alluded to previously, in some cases they are even politically motivated to shoot it down.

How to "get through the door"?

How we as a "community of practice" ("a group of people informally bound together by shared expertise and passion for a joint enterprise (Wenger and Snyder 2000)", can address these barriers is not an easy question to answer unfortunately. We’d all be bowled over in the rush to take up our various discoveries and innovations if it were.

Again, as Mark points out, the need is there (Green and Nguyen 2001) and has been for some time (Pasley, Lagoe et al. 1995). I think Mark is spot on with his point about answering the questions people are grappling with, and the potential benefits of so doing in his comments about leaving them (the "customers") with something (Mackay 2007).

In my opinion, the gap between academic endeavour and the hard nosed world I have briefly outlined above is too great for a traditional academic world view to penetrate on a consistent and useful basis. These "customers" need "simple", practical solutions. (for simple - read "where all the inevitable complexity is well hidden from them, but available for them to access if they wish to discuss it and understand it")

Small quick wins are also seen as a way to build trust and engender interest in relation to change in health care (Page 2003; Boxall and Flitcroft 2007) as Mark has also mentioned (Mackay 2007).

Conclusion

In conclusion - I write this outline of the current state of the barriers we face as a spotlight on some very real issues that may be more apparent from the "inside" than the "outside", as we all try to advance the cause of "evidence based management" for want of a better term. In order to succeed we will all need to continue to collaborate on solutions in a fashion cognoscente of these harsh realities.

References

Atun, R. (2003). "Education and debate: Doctors and managers need to speak a common language." BMJ 326: 655.
Boxall, A. and K. Flitcroft (2007). "From little things, big things grow: a local approach to system-wide maternity services reform in the absence of definitive evidence." Aust New Zealand Health Policy 4.
Cabana, M., C. Rand, et al. (1999). "Why Don't Physicians Follow Clinical Practice Guidelines? A Framework for Improvement." JAMA 282: 1458-1465.
Caplan, R. (1994). "Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers." BMJ 309(6964): 1261-3.
Cooper, A., A. Joglekar, et al. (2005). "Communication of bed allocation decisions in a critical care unit and accountability for reasonableness." BMC Health Serv Res. 5(67).
Drife, J. and I. Johnston (1995). "Education and debate: Management for Doctors: Handling the conflicting cultures in the NHS." BMJ 310: 1054-6.
Fitzgerald, A. and G. Teal (2003). "Health reform, professional identity and occupational sub-cultures: the changing interprofessional relations between doctors and nurses." Contemp Nurse 16(1-2): 9-19.
Freeman, T. and K. Walshe (2004). "Achieving progress through clinical governance? A national study of health care managers' perceptions in the NHS in England." Qual Saf Health Care 13(5): 335-43.
Green, L. and V. Nguyen (2001). "Strategies for cutting hospital beds: the impact on patient service." Health Serv Res 36(2): 421-42.
Grol, R. and M. Wensing (2004). "What drives change? Barriers to and incentives for achieving evidence-based practice." MJA 180((6 Suppl):): S57-S60.
King, L. and P. McInerney (2006). "Hospital workplace experiences of registered nurses that have contributed to their resignation in the Durban metropolitan area." Curationis 29(4): 70-81.
Mackay, M. (2007). Looking in form the outside-time to get through the door. Nosokinetic News. 4.5: 2-3.
McCallin, A. (2005). "Interprofessional practice: learning how to collaborate." Contemp Nurse 20(1): 28-37.
Milisen, K., I. Abraham, et al. (2006). "Work environment and workforce problems: a cross-sectional questionnaire survey of hospital nurses in Belgium." Int J Nurs Stud 43(6): 745-54.
Page, S. (2003). ""Virtual" Health Care Organizations and the Challenges of Improving Quality." Health Care Manage Rev 28(1): 79-92.
Pasley, B., R. Lagoe, et al. (1995). "Excess acute care bed capacity and its causes: the experience of New York State." Health Serv Res 30(1): 115-31.
Patterson, L. and N. Bishop (2003). "Doctors and managers - Commission for Health Improvement gives its perspective." BMJ 326: 1217.
Robertson, R. (2005). "Rumours: constructive or corrosive." Journal of Medical Ethics 31: 540-1.
Robinson, J. and D. Turnbull (2004). "Changing healthcare organisations to change clinical performance." MJA 180((6 Suppl)): S61-S62.
Roig JV, Rodríguez-Carrillo R, et al. (2007). "Multimodal rehabilitation in colorectal surgery. On resistance to change in surgery and the demands of society." Cir Esp. 81(6): 307-15.
Seren, S. and U. Baykal (2007). "Relationships between change and organizational culture in hospitals." J Nurs Scholarsh 39(2): 181-7.
Skogsaas, B. and M. Svendsen (2006). "Leadership and change processes in hospitals." Tidsskr Nor Laegeforen 126(23): 3084-7.
Tregunno, D., G. Baker, et al. (2004). "Competing Values of Emergency Department Performance: Balancing Multiple Stakeholder Perspectives." Health Serv Res 39((4 Pt 1)): 771-792.
Wenger, E. and W. Snyder (2000). Communities of Practice: The Organizational Frontier. HBS - Working Knowledge for Business Leaders.

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