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Hospitals have a finite number of clinicians and managers who must not only meet the needs of every patient but also the need to improve the performance of the hospital on many fronts simultaneously. In many hospitals, management and clinical attention is itself a bottleneck, where the demands on time are exceeding capacity. It is therefore vital that measurements help focus management attention and improvement efforts.

They should guide managers and clinicians to stop working on the things that are not actually improving the performance of the hospital as a whole and focus attention on those few areas that will make a big difference quickly.

And yet it is not unusual to find a plethora of local measures. This is certainly the case in healthcare. In fact, at the last count there were over 100 measures a hospital in the UK could be asked to report on at any moment in time. We are driven to develop measures that focus on the finer resolution only when we are unclear what to change. This can lead to an explosion of measures and paradoxically divert management attention to the parts rather than the whole. These local measurements can also distort behaviour and a measurement applied in one part of the system can have a devastating effect on another part of the system and the performance of the whole. As Mike Williams alludes to in the Foreword of Pride and Joy, a financial decision in a seemingly non-critical area damages the performance of a critical area: theatres.

Local optima does not add up to global optimum.

If we are to improve patient flow we need to identify the multitude of local measures that try to optimise each part of the system rather than improving patient flow through the whole system and eliminate them. These measures need to be replaced with a few, simpler, system-wide measures. Systems will flounder if these local measures are not abolished and improving patient flow is not the primary objective.

A good set of measures will help us directly find the answer to the following questions:

  1. Why change? Unless there is agreement on the size of the current problem it is difficult to gain consensus on the need to address the situation.
  2. What to change? Answering this question is vital if we are to focus improvement efforts. Identifying which resource is most often causing the most disruption/delay across the most patients is a good starting point.
  3. What to change to? Identifying the core problem without proposing a solution that does not lead to unintended negative outcomes can be devastating. Any solution must simultaneously deliver a breakthrough against the prime measures of improving the quality and timeliness of care and the financial performance without exhausting staff or taking imprudent risks. Anything else is an intolerable compromise.
  4. How to achieve and measure the success of the change? If we are confident in our analysis of what to change and what to change to then we should be able to establish the expected size of the improvement. It is vital that we compare the actual outcome with the expected outcome. This does not only entail measuring the gap if the improvement is less than expected but it is equally important to measure any gap that is greater than expected. Understanding the unintended outcomes of success is equally important when focusing improvement efforts.