Ultimately though “transformation” is not something one can control.  It happens when the people we are accountable for start to act voluntarily and in concert.  So all we can do is create circumstances in which this order of change is more likely to happen and then serve and support what follows.

Below are two video lectures that deconstruct aspects of this process.  The first looks at communicating in a way that inspires motivation.  The second looks at the process by which a movement is formed.  Interstingly it identifies the crucial legitimising role of first follower. 

Both video lectures come from the internationally respected think tank TED.

Modes of Outpatient reform Cross References to Studies

This article describes the development and implementation of a nurse-led clinic which can perform pain assessment and evaluation. Patients can submit tests by post and nurse can coordinate the reissuing and filling of prescriptions delivered to the pharmacy for certified mailing. Face to face interviews with the nurse take place every six months and any change in condition triggers escalation referral.

The Assessment, Information, and Management (AIM) Higher Initiative, a quality improvement program undertaken at 15 community oncology practices, was initiated to improve the AIM of chemotherapy-related toxicities in patients with cancer.  Led by a nurse champion at each of the clinics, a variety of new procedures, processes and tools were implemented to improve quality of care. Nurses and practice administrators can use the quality improvement processes to generate changes in procedures and practices.

According to the authors, it is likely that greater satisfaction leads patients to become (1) more involved in their care, (2) increase adherence to recommended treatment protocols and follow-up, (3) which may contribute to improved health status. This Australia/Thailand HIV study found that there are four major factors underlying satisfaction:

•  Communication skills
•  Clinical effectiveness
•  Waiting time
•  Information

Study of a nurse practitioner-facilitated group medical appointment (GMA) intervention for COPD clients in a pulmonary practice. Receiving care in a group format, it was found that NP-facilitated GMAs are feasible and can help improve health outcomes. Both patients and provider response to the GMA were very positive. The GMA is described as an innovative solution for the management of chronic disease patient that is comprehensive, time efficient, reimbursable and well suited to NP practice which can be implemented in most practice settings.

Self management support programs aim to change patients’ behaviour by increasing patients’ self-efficacy and knowledge. Pearson et al suggested that improved behaviour is likely to lead to better disease control which would in turn, lead to better patient outcomes and reduced utilization of health care services, particularly preventable emergency room visits and hospitalizations, and ultimately to reduced costs.

www.fifefire.gov.uk/orgs/

Based on the philosophy that ‘children should not be admitted to hospital unless absolutely necessary’, Victoria Hospital provides home visit service that offers nursing care to children to support ambulatory care (following brief episodes of hospital care) and to facilitate early discharge for the child and family.

The report evaluated the role and feasibility of the one-stop clinic for management of postmenopausal bleeding, based on the use of transvaginal ultrasound and hysteroscopic examination under local anaesthesia. Based on analysis of 308 patients referred to the clinical between October 2000 and May 2002, the study concluded that the one-stop clinic is effective in reducing the number of hospital visits per patient as well as hospital admissions and the waiting list.

The Rapid Assess Chest Pain Clinics (RACPCs) are designed to provide prompt cardiological assessment of new onset chest pain in patients without known coronary disease. The service is aimed at ambulatory patients. This particular research has demonstrated that nurses can successfully run RACPCs without an increased risk of incorrect diagnosis. These clinics offer patients timely access to assessment of their chest pain and facilitate early diagnosis of cardiac disease. They are also well accepted by the patients attending the clinic.

This study evaluated whether patients treated in 12-step programs rely less on professionally provided services and more on self-help groups after discharge, thereby reducing long-term health care costs. Their finding shows that professional treatment programs which emphasize self-help approaches increase patients reliance on cost-free self-help groups and thereby lower subsequent health care costs.

See also follow up study: Humphreys, K. Moos, R.H. (2007). Encouraging Posttreatment Self-Help Group Involvement to Reduce Demand for Continuing Care Service: Two-Year Clinical and Utilization Outcomes. American Psychiatric Association, Vol. 5, 193-198.

This project sought to develop and pilot-test a peer-led community-based, self-help intervention for elders with diabetes – the Diabetes Club. The intervention targeted diabetes self-efficacy, seeking to empower elders then increase diabetes self-care behaviour targets, resulting in improved glycemic control. Club members and social workers collectively developed, implemented, tested intervention protocols. Findings showed significant improvements in diabetes self-efficacy, self-care behaviours and reduction of glycosolated haemoglobin. The results are promising, demonstrating the benefits of social-work involvement in diabetes and the potential of elders helping themselves and each other.

This study aimed to determine whether group prenatal care improves pregnancy outcomes, psychosocial function, and patient satisfaction and to examine potential cost differences. Results suggested that women in group sessions were less likely to have suboptimal prenatal care, had significantly better prenatal knowledge, felt more ready for labor and delivery, and had greater satisfaction with care. Breastfeeding initiation was higher in group care. There were no differences in birth weight nor in costs associated with prenatal care of delivery.

http://www.gloshospitals.org.uk/ppi/leaflets/pdf/GHPI0563.pdf

A nurse-led clinic aims to monitor treatment and adjust the dose of anticoagulant. Clinics are held twice a week where blood test will take place. Patients will be discharged from the clinic once the correct dose of anticoagulant is found. Home visits can be arranged for those who are unable to attend their blood test at the clinic.

http://www.nhsbenchmarking.nhs.uk/docs/HICpresentation11.pdf
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ImprovementStories/PursuingPerfectionAViewfromAcrossthePond.htm

At Bradford Health and Social Care Community, patients are not passive recipients of care but more like collaborators for change, for example, patients are invited to multidisciplinary team meeting and their viewpoints are taken into account. As a result, patients who are tested negatively for pathology would receive a letter rather than waiting for a follow up outpatient appointment.  They still have the choice of meeting their consultant if they wish, but most people prefer to receive a letter. This is a saving of 300 clinic slots a year that can be reallocated.

http://www.nodelaysscotland.scot.nhs.uk/CaseStudies/CaseStudyItems/Pages/GoldenJubileeNationalHospitalIntroducingPatientFocussedBookingtoreduceDNArates.aspx

In order to improve the average DNA rate (7.7%) within the outpatient department, the hospital adopted the Patient Focussed Booking (PFB) approach to arrange appointment. PFB clinic held in October 2007 for minor procedures has seen DNA rates drop to 1.7%; while dermatology PFB clinic’s DNA rates have dropped to 1.8%. PFB clinics can better utilise clinical sessions, improve patient satisfaction and improve quality of care.

For more information on PFB, please visit: http://www.scotland.gov.uk/Resource/Doc/89501/0021443.pdf

http://www.natpact.nhs.uk/demand_management/downloads/BigWizard_1.2_step3.pdf

Radiology departments produce X-rays for emergency patients, inpatients and outpatients through the same facility. Staff manages the workload by prioritising patients according to clinical need. This often means that emergency patients are seen first and outpatients typically face long waits. Some units have redesigned their service into three separate processes for the three patient groups.

http://www.skillsforhealth.org.uk/workforce-design-development/workforce-design-and-planning/competence-based-workforce-design/New-and-innovative-ways-of-working/Virtual-outpatient-clinics-in-sleep-services.aspx

Virtual clinics in outpatient setting to improve outpatient capacity and improve patient care. A consultant respiratory physician undertakes virtual clinics from his computer by reviewing all the referrals and arranging for any relevant sleep studies to be done prior to the first clinic appointment. Treatment for sleep problems can be initiated even before the patient is seen in clinic. This includes life style changes such as losing weight and reducing alcohol and caffeine intake. Specially trained clinical physiologists can interpret sleep studies and instruct patients in the use of domestic CPAP (Continuous Airways Pressure) treatment for sleep apnoea even before attending the outpatient clinics.

http://www.allbusiness.com/health-care/medical-practice-family/14560393-1.html

In the 1980s, outpatient and ambulatory care made up about 20 percent of hospital revenue in America, but now, it’s more like 45 percent.  At Ohio State, outpatient services make up 36 percent of the system’s $1.5 billion in annual revenue, and in response over the past five years, the system has added 10 outpatient centres to deal with this demand in a more cost effective community setting away for acute hospitals.

http://www.kingsfund.org.uk/document.rm?id=8621&lt

Introduced with the aim of replicating the multi-disciplinary approach of the hospital ward, but in a community setting. Uses predictive risk modelling that was developed by the King’s Fund to target patients with a 70% chance of admission to hospital in the next 12 months. But this model could be adapted to encompass patients who have a history of high outpatient usage e.g. patients with long-term conditions. Weekly multi-disciplinary team meetings; daily activity rounds with GP; community matrons and ward clerks; information entered directly into GP’s computers via direct access. All necessary outpatient investigations, visiting schedules, and information flow between all services co-ordinated by ward clerk.

http://www.southwarkpct.nhs.uk/documents/5281.pdf

In Southwark PCT and Acute Trusts, the whole health economy has been responsible for implementing a range of initiatives for long term conditions in order to help reduce outpatient activities, these include:

• a managed care model, with patients stratified according to their risk and then managed on a self care, disease or case management basis with each patient receiving a personal care plan.
• community based service alternative where appropriate, including specialist community nurse led services, chronic illness clinics in primary/community settings with supporting diagnostic services.
• self-care programmes for patients, including the Expert Patient Programme

http://www.redbridge.nhs.uk/loxford/1-1polysystems.asp

Polysystems include GP surgeries, pharmacies, dental services, community and voluntary services and more. What these services have in common is a local focus on healthcare provision, with a drive to promoting well-being and keeping people healthy.  Polysystems are a collaborative approach to joined-up services will enable patients to experience a seamless service without delays as they move through and around the system, independent of where they access it.

This new service started in 2009 as a pilot study led by Saigei and funded by NHS London. Although Government policy advocated the transfer of patients from hospital to their homes, research into clinical and financial efficacy of this model of care was ambivalent. Pilots were operated in two London localities to establish whether and if so what models of home based care were viable. The pilots were rigorously evaluated using a scorecard designed by Saigei expressly for healthcare. It includes six dimensions, namely:

• staff confidence
• clinical outcomes
• patient experience
• stakeholder support
• operational efficiency
• financial efficacy

One year on, clinical outcomes are still measured using validated instruments such as the Modified Barthel Index and the EUROQol EQ5d patient reported outcome measure (PROM).

Longer term monitoring of quality shows that readmission rates are very low and primarily relate to patients who are already recognised as high intensity users of acute services.

Patient satisfaction is measured using a Kings Fund validated questionnaire, and the results are extraordinarily positive.

The evidence is so compelling that the service was established permanently and saw more than 520 patients in its first twelve months. It is funded jointly by the acute trust, adult social care, and the PCT commissioner.

The PACE Service delivers value both by shortening in-patient care episodes and avoiding admissions altogether. This has allowed the locality to manage winter pressures smoothly and has supported the acute and primary care Trusts in delivering the acute Trust’s cost improvement programme.

Saigei is now partnering three more localities who are adopting similar models of provider collaboration. In each case building strong evidence for both the clinical and the economic efficacy of this form of collaboration between acute, community and social care providers.

Fig 1. Summary of Research Into Hospital at Home

Since 2000 UK governments have advocated home based care as a reform that can shrink expensive hospital capacity.  

The National Beds Enquiry (2000) recognised ambulatory and intermediate care facilities as a feature of systems which relied less on hospital beds.  This led to the incorporation into the NHS plan (DoH 2000) of a £900 million investment by 2003/4 in Health and Social Care ‘to promote independence and improve quality of care for older people’. 

Whilst the Government recognised that ‘intermediate care cannot be the responsibility of only one professional group or agency’ (DoH, 2001) the programme was positioned as an alternative to hospital care ie to ‘avoid admissions’ rather than as a synergistic collaboration between hospital and community providers along a single pathway.

Proponents of integrated models of care assert that “integration of care components in newer health systems will maximize patient benefits and organisational efficiency” (Boult and Pacala, 1999).  Indeed, a review of thirteen integrated care programmes from the US, UK, Sweden and the Netherlands (Ouwens et al, 2005 cited by Ramsey and Fulop 2008) reported several beneficial themes:

1. reduced hospitalisation
   (reported in 6 programmes, 3 with significant trends)
2. increased process capability
   (reported in 5 programmes, one of them with a significant trend)
3. Increase in functional status and health outcomes
   (reported in 9 programmes, one of them with a significant trend)
4. Increase in patient satisfaction
   (reported in 3 programmes)
5. Increase in quality outcomes
   (reported in 6 programmes)
6. Decrease in costs
   (reported in 4 programmes)

The leading US Health Management Organisation (Kaiser Permanente) was highlighted as using far fewer hospital beds per head of population than the NHS (Feacham et al 2002). This triggered a series of UK pilots testing the prevention and case management elements of the Kaiser model. 

Whilst some success was reported in terms of fewer admissions and shorter stays, the results were in line with national patterns so could not be attributed to the new models of care.  Nor was there any explicit evaluation of cost efficiency (Ham 2005).

Whilst the rhetoric of integration was used, the pilots were commissioner-led and focussed on reducing hospital admissions by providing accessible alternatives ie they sought to circumvent rather than integrate with an essential step in the care pathway. 

There is evidence to suggest that community supported models can provide equivalent care for the right patients.

A UK study comparing outcomes for in-patient versus home-based care at three months concluded that there were no significant differences between the two methods of care except where patients had complex health needs (Shepperd, et al 1998) in which case the in-patient model was superior.

A US study of 455 patients provided with acute-level care at home (including treatment of cellulitis, pneumonia and exacerbation of COPD) also concluded that outcomes for appropriately selected patients matched those of a hospital care model (Leff et al 2005). 

Whilst, this form of care is not right for all patients (Shepperd, et al 1998, Burns & Pauly, 2002) it can benefit “segments of the patient population such as the elderly, the frail elderly” (Burns & Pauly 2002) although other research warns that readmissions from home-care are higher in elderly patients needing complex medical care (Leff et al 2005). 

Balancing hospital care for elderly patients is not easy.  Their admitting complaint is typically an exacerbation of one aspect of a more complex condition and they often need social support as well.  These patients can dwell in hospital beds beyond their need for acute care because of poor coordination and collaboration between hospital and community/social infrastructure (Kao & Walter 2009). 

Extended hospital stays also can adversely affect the function and health of patients, particularly older patients (Kao & Walter 2009) implying a greater need for ongoing care.   Such delays have been attributed to “efforts on the part of individuals, departments and services to make themselves efficient without regard for the resulting organisational consequences.” (Scott and Hawkins, 2008). 

This lends credence to The National Service Framework for Older People (DoH, 2001) which emphasises the need to integrate health and social care services and specifically envisages a coordinated team including general practitioners, hospital doctors, nurses, physio therapists, occupational therapists and allied health professionals.

UK evidence (Shepperd, Doll and Broad 2009) shows home-based care is popular with patients; and US evidence (Burton 1998) shows home-based care is more comfortable and puts less burden on families. 

Further, patients’ carers appear to prefer domiciliary care with perceptions being reinforced by experience (Ojoo, Moon & McGlone 2002).  This view is qualified however by the See-saw Report (Harvey et al 2008) that care delivered closer to home whilst preferable to patients may result in the “burden [falling] on informal carers”.

One UK study found that hospital-at-home can deliver care at similar or lower costs than an equivalent admission to an acute hospital (Jones, Wilson, Parker 1999). 

Another UK meta-study reviewed evidence for the transfer of specialists to primary care and joint working with acute care delivered equivalent outcomes however hospital capacity was not reduced and so overall demand increased. (Sibbald, McDonald and Roland, 2007)

In a meta-study, Ramsey and Fulop (2008) reviewed three modes for achieving integration.

1. Organisational: citing King et al (2001) and their review of children’s services during the 1990s - concluding that integrated working does not require organisational integration, and that organisational integration can result in an imbalance of power between hospital and community interests.
2. Integrated Multidisciplinary Teams: citing the work of Goodwin et al (2004) and Hamilton et al (2005) as recording improvements in working practices and even care outcomes but no cost advantages.
3. Contractual Coordination of Care Delivery: citing Ahgren (2003) as reporting no significant change to systems or services and resistance from front-line staff; and Ahgren and Axelsson (2007) which reports better outcomes where the focus is on outcomes rather than structure and led by local respected staff delivering the care.

On balance then, available evidence of reduction in cost of care resulting from home-based models is at best it is contingent, if not conflicting.

Ramsey and Fulop (2008) report that integrated care can “break down barriers between primary and secondary health care, as well as health and social care” setting a platform for trust and closer collaboration.  There is also evidence that “more integrated care could have a number of benefits, including: responding more effectively to the needs of people…, improving the effectiveness and safety of care…” (Ham et all 2008)

Enthoven and Tollen (2004) record reduced management overhead in Health Management Organisations (HMOs) where payer and provider are integrated and monitor demand and plan care together.  This view is supported by Shih et al (2009) who point to information systems saving “operating expenses in managing health care supply chains.”

However, Burns and Pauly (2002) are not so supportive of this opportunity, arguing that where HMOs work properly they do so because of special not easily replicable circumstances including few competitors, an established multidisciplinary team and an already strong patient service culture. 

Again, the evidence suggests potential but the results appear ambivalent or contingent on local circumstances.

Little practical guidance is offered.

Six layers of healthcare integration have been suggested, namely: organisational, service, clinical, functional, normative and systematic.  (Fulop et al, 2005 adapting Cantandriopoulos et al, 2001).  And where integration has achieved some success, academics have credited both foundational work and enabling facilities.  This includes:

1. The development of common, standardised activities and new organisational structures (Burns and Pauly 2002) and
2. Clinicians being able to “…effectively access and share information in a timely manner” (Shih et al 2009).  This assertion is invariably linked to the use of information technology (Shih et al, 2009; Ham, 2005).
3. “Voluntary collaboration” of partners is “vital to achieving sizable supply chain transformation.” (Shih et al 2009 citing Schneller 2006; Ahgren and Axelsson, 2007)
4. The “pivotal role” of case managers in linking health and social care (Johri et al 2003 as cited by Ramsay and Fulop 2008)

One of the biggest challenges to sustained collaboration is the differing priorities of health and social care.  Health is free at the point of need while ASC has to means test and recover funding from patients and their families.

The boundary between hospital and social care is recognised as particularly challenging.  The complex mix of different funding models, reporting lines, and priorities is seen as underpinning failures of ‘inter-professional’ collaboration (Glasby 2003).

The NHS Plan 2000 and the Health & Social Care Act (2001) introduced the idea of Care Trusts as a means of Health and Social Care collaborating by pooling budgets and commissioning health and social care jointly.  However, whilst these organisations have made it easier for front line teams to coordinate care, they have not proved transformational and there remain concerns about their financial efficiency (Glasby and Peck, 2005) and the extent to which social workers can retain the scope and values underpinning their profession (Limbrey 2006).

Pressure to reduce the cost of national health provision is undeniable and policy frames the solution to that challenge as reducing hospital capacity by relocating care to a community setting.  However, evaluation of the performance of home-based models of care has been inconsistent and the results whilst suggesting potential are ambivalent on the questions of safety and value for money. 

Where home-based models of care have been explored, patients appear to prefer the non-hospital setting but evidence of clinical efficacy is qualified with cautions that this form of care is not always appropriate or safe.

Older people emerge as a group that may benefit from a home-based care but this same cohort, improperly managed, experience readmission.  It is also clear that any model serving elderly patients requires support from social care which presents difficult relationship challenges particularly at the boundary between hospital and home. 

The evidence of financial savings resulting from home based care is at best contingent if not conflicting.  Overseas work provides better support that UK-based research which is limited and inconclusive, not least because these attempts have seen commissioners seek to buy from ‘elsewhere’ ie to substitute rather than integrate with hospital provision; and to specify activity rather than care outcomes. 

Successful operations management depends upon an understanding of the interdependent components of the system and how they interact together to fulfil the purpose of the operation.  Each component of the system is charged with contributing its best to the system, not to maximizing its own performance against local competitive measures like productivity, profit or sales.  Systems thinking is fundamental to operational performance.  Non-systemic changes simply shift issues to other areas of the system.  As Deming observed “a hack can do great damage”.  This precept is most effectively undermined by traditional Western management techniques and short-term performance horizons.

An appreciation for people and how they interact with each other, with circumstances and with the system.  This idea underpins the insight that performance is dictated primarily by the system rather than individuals and so managers should act on the system to foster effective group behaviours.

Variation data gives insight into the system.  It indicates whether it is in control and its stability.  It also highlights the results of constraining thought and the affects of any action to change the system. This idea underpins the insight that systemic performance should be measured over time (not as snapshots), across the entire system (not single components) and from the point of view of the customer (not against internally focussed criteria).

Knowledge in terms of how it is perceived, classified, interpreted and developed; specifically, the idea that as individuals we apply interpretive rules (resulting from our own experiences) to sort and select data and to predict outcomes.  The value of these rules is defined only by their usefulness for action.  This idea underpins the theories of organisational learning and dialogue which aim to share data and develop group theories and group solutions that take into account all of the insight available within an organisation and not just the strongly argued ideas of dominant individuals.

Systemics: silo working and local optimisation creates problems for overall performance.  This is a sophisticated way of saying there is no “I” in TEAM.  We succeed or fail as an organisation, not as a form or a department.

Psychology: so we need the components of the system to behave as and work as a team.  This has a great deal to do with clarification and alignment of purpose; with defining individual roles clearly so everyone can see how their activity adds up to a team success; alignment of incentives so everyone benefits from working as a team - unwind anything that incentivises opposing behaviours; and with developing and encouraging behaviours underpinning enthusiastic collaboration instead of unilateralism and competition.  Part of this work is about actively managing out behaviours that do not fit the culture your need in order to succeed.  This work is routinely side-stepped and yet it is crucial to securing performance.

Variation: choose ‘measures that matter’, that help you make choices about how to proceed; focus on the consistency of your service and how this changes over time.  Performance ‘today’ does not tell you anything decision-worthy (every system has good and bad days).  A focus over time lets you know whether things are getting better or worse; whether your latest change is for the better or the detriment of the system; whether you have enough or too much resource to meet your commitments.

Knowledge: encourage your teams to use facts rather than personal assertion; and to harness collective expertise and insight.  Start by getting your management teams to include their front-line staff in raising and solving operational challenges.  Not only will this result in more complete solutions and better choices but the process of working together improves communication and secures support.  One expert issuing directives rarely beats a purposeful consensus.

Further reading:

14 Management Principles: W. Edwards Deming