My second paper: "Why are healthcare services fuzzy?"

My second paper just got published in AMJ, an open access journal. Below the abstract and the link to the journal. Very excited to see this finally happen.

Why are healthcare services fuzzy?

Abstract

Background
Healthcare organisations are an enigma to many people in- and outside the service. Organisational fuzziness is a common state, characterised by a lack of clarity, lack of awareness, lack of organisational knowledge, and the reliance on practice and custom instead of transparency.
Aims
The objective of this study was to obtain a better understanding of what causes this fuzziness and provide an actionable description of fuzzy organisations. Such a description is essential to managing and preventing organisational fuzziness.
Method 
We used a longitudinal case study in an integrated health- and social care organisation to obtain a thorough understanding of how the organisation functions. These in-depth insights allowed the identification of three generators of fuzziness.
Results
We found that the three main generators of organisational fuzziness are change, informal organisation and complexity. Organisational fuzziness is thus partly due to the inherent complexities of human systems. However, also continuous change and the inability of the system to adapt its formal structures resulted in structures deteriorating or no longer being appropriate.
Conclusion
Existing approaches to explain unclear or absent structures in healthcare organisations by describing these organisations as complex adaptive systems (CAS) are too simplistic. While aspects relating to people and their interactions are indeed complex, fuzziness of structural aspects are often the result of continuous change and insufficient organisational capacity to adapt to it.

http://www.amj.net.au/index.php?journal=AMJ&page=article&op=view&path[]=1857

Paper now open access

Just to let you know, my paper on the contributions of carers and staff in service design is now available as open access:

http://onlinelibrary.wiley.com/doi/10.1111/hex.12107/pdf

Thanks to the CLAHRC for making this happen :)

The final reckoning: how much should end of life care cost?

This is a repost from a blog article I was invited to write for the Gates Scholars Blog

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The big innovation in the 19th and 20th century was the acknowledgement that health is a systemic issue. If people do not seek medical advice for small problems due to economic reasons, these small problems can become big problems and cause further poverty. This realisation led, for example, to the establishment of the NHS in 1948.

Nowadays we are facing the sustainability challenge: will we be able to keep affording the systems set up as a result? One problem is the ageing populations of many developed nations – it is estimated that in the US on average between 25% and 56% of healthcare spending occurs in the final 12 months of life. A second problem is, ironically, continuing progress in the medical sciences which allows us to treat more diseases and prolong lives. But the associated costs are spiralling out of control. Also, scientific progress creates illusions regarding what it possible and feasible. Combined with the lack of a culture that discusses death as a part of life many doctors find themselves under pressure to do whatever is possible, regardless of quality of life – or costs.

The latter point – placing a monetary value on life – might sit very uncomfortably with some readers. However, when we look at health as a systemic issue the question of money is bound to arise in one form or another. Every dollar or pound can only be spent once. A cancer treatment that prolongs life for a couple of months (at often a pretty terrible quality of life) can cost £40,000, which could also pay the annual salary of a palliative nurse. In the United Kingdom the discussion is open. The National Institute for Clinical Excellence (NICE) makes decisions about which treatments are covered by the National Health Service (NHS) based on the calculation of quality-adjusted life years. But systems which do not have this transparency, such as the fragmented German system of different public and private payers and various associations representing healthcare providers, also have to make decisions regarding which treatments are considered effective and value for money in order to contain costs and kept health insurance affordable.

Another issue which affects the sustainability of our healthcare systems is the human side. Organisational structures are filled by people, both staff and patients. As the people in them change structures have to adapt and vice versa. A system in which structures and people are out of synch will not work in the long run. A popular contemporary line of argument is that because healthcare is fundamentally an interaction between people, it is complex and non deterministic. Other arguments for this complexity model are based on the enormous variety of issues faced by healthcare providers, although this is strictly speaking not a characteristic of complexity but rather indicates a complicated problem. Semantics aside, the focus on complexity are as one-sided as the earlier models of rational technocratic top-down blueprints which the complexity model seeks to supersede. It is not a question of one or the other, but rather ‘horses for courses’.

A climbing rose is a good simile for how organisational success depends on interactions between staff and structures. A climbing rose (staff) requires a scaffold (structures) to reach its full potential. The shape of the scaffold will have a key influence on the shape of the final rose bush, but it is not possible to completely determine the shape of the bush from the shape of the scaffold and sometimes it becomes necessary to change the shape of the scaffold. On the other hand, the best scaffold in the world is worthless without the right, good, healthy plants.

I think the challenges we face are so big that a more open discussion regarding end of life care will be inevitable. On the other hand, a new direction in the policy debate that seeks to reconcile technocratic approaches to structures with insights about the complexity of human interaction should help to ensure a system that can adapt to changing environments and new challenges.

Paper: What can carers contribute to service design?

My paper is finally out - I submitted it last year in June and it was published as early view this July. I carried out a study with three groups of stakeholders and assessed to which degree they agree on priorities for service design.

Of course I am biased, but I think this is really important and interesting research as it is the first time that we can quantify the contribution of different stakeholder groups which historically had different amount of influence on the service design process. For example, experts and policy makers usually have a lot of influence, carers (and patients, but unfortunatly I was not able to include them) usually have much less. One of the reason why they have so much less influence is because those with the power over the process doubt how useful their contribution can be (I guess you can call this a certain degree of professional arrogance) and this is exactly where my work chimes in. I can actually show that they can contribute new idea which established stakeholders recognize as valuable.

The article is available as open access:
http://onlinelibrary.wiley.com/doi/10.1111/hex.12107/abstract

Exploring the boundary of a specialist service for adults with intellectual disabilities using a Delphi study: a quantification of stakeholder participation

Eva-Maria Hempe, Cecily Morrison, Anthony Holland

 

Background

There are arguments that a specialist service for adults with intellectual disabilities is needed to address the health inequalities that this group experiences. The boundary of such a specialist service however is unclear, and definition is difficult, given the varying experiences of the multiple stakeholder groups.

Objectives

The study reported here quantitatively investigates divergence in stakeholders’ views of what constitutes a good specialist service for people with intellectual disabilities. It is the first step of a larger project that aims to investigate the purpose, function and design of such a specialist service. The results are intended to support policy and service development.

Study design

A Delphi study was carried out to elicit the requirements of this new specialist service from stakeholder groups. It consisted of three panels (carers, frontline health professionals, researchers and policymakers) and had three rounds. The quantification of stakeholder participation covers the number of unique ideas per panel, the value of these ideas as determined by the other panels and the level of agreement within and between panels.

Findings

There is some overlap of ideas about of what should constitute this specialist service, but both carers and frontline health professionals contributed unique ideas. Many of these were valued by the researchers and policymakers. Interestingly, carers generated more ideas regarding how to deliver services than what services to deliver. Regarding whether ideas are considered appropriate, the variation both within and between groups is small. On the other hand, the feasibility of solutions is much more contested, with large variations among carers.

Conclusions

This study provides a quantified representation of the diversity of ideas among stakeholder groups regarding where the boundary of a specialist service for adults with learning disabilities should sit. The results can be used as a starting point for the design process. The study also offers one way to measure the impact of participation for those interested in participation as a mechanism for service improvement.

Applicability of Engineering Design Processes in the Design of Integrated Intellectual Disabilities Services in England

I have been quiet for an aweful long time - and a lot has happened since. Most importantly: my thesis is all done, approved and on the shelves of the Cambridge libary, so I am now a doctor (yeah). I since moved back to Germany and for the last 14 month I have been working as a consultant in Munich, with a focus on health care projects.

In case you are interested, I pasted the abstract of my thesis below. If you want to read the full thing, drop me a message (ideally with a bit of beackground on what you do and why you are interested in my work) and I can send you the pdf.

Applicability of Engineering Design Processes in the Design of Integrated Intellectual Disabilities Services in England

This dissertation investigates the applicability of engineering design processes for the design of integrated intellectual disabilities (ID) services in England. It aspires to contribute to the development of an engineering-design-style (ED) design process for a particular integrated health and social care organisation. Healthcare services in the developed world are faced with challenges arising from a growing burden of chronic disease and aging populations. In order to address these challenges, a more holistic understanding of health that also considers social factors is needed. A local integrated care service for people with intellectual disabilities constitutes an interesting case study as these intellectual disabilities services have several decades of experience in integrating health- and social care.

This study contributes to knowledge by elicitating the need to combine the engineering tradition of design as problem-solving with the tradition of design as enquiry. The applicability of engineering design processes in an indisputably complex domain, such as integrated ID services, also helps clarify of the concept of complexity within engineering design. Methodological contributions are made by developing and applying a research framework for exploratory design research and by demonstrating the utility of engineering design tools outside engineering. Furthermore, this study also provides important insights for the healthcare management literature by suggesting an approach to distinguishing complicateness from complexity, demonstrating the value of contributions of currently marginalised stakeholders and showing the applicability of a mathematical technique for pre-structuring service user involvement.

The research is guided by a framework developed specifically for exploratory design research into the care service domain. An initial exploratory study investigates design-related issues faced by the local service and to which degree engineering design is applicable. The predominantly qualitative data is analysed in diagrammatic form. It emerges that the formal, structural aspects of the organisation are complicated and suited to an engineering design approach. However, complex informal aspects, such as customs or personal relationships, surround the formal structure and are beyond the current scope of ED design processes but can be addressed by approaches in the design as enquiry tradition. Four issues are identified which will require amendments to the ED design process: organisational settings, knowledge management, the lack of a clear role, and neglected stakeholders.

The exploratory study is followed up by a detailed study which uses a Delphi approach to investigate whether the confusion about the role of specialist services is a general problem in the ID field. It further characterises key stakeholder groups in ID services in terms of their expertise and level of agreement or disagreement. The findings outline requirements for new design approaches that bridge the traditions of design as enquiry and design as problem-solving.

Building Change on Local Knowledge - Catalyst for Change: Investment in Girls’ Education

Together with fellow Gates Scholar Julia Fan Li, I interviewed the very charismatic Ann Cotton, founder of CAMFED. CAMFED is a Cambridge-based charity that champions women's education. We produced a five-minute-long video clip and wrote an article. The latter was published in the Winter 2010 edition of Gates Scholars magazine - you can find the magazine here, our article is on page 10 and 11.

Nigel Crisp - Turning the World Upside Down

(This review will be published in "The Eagle 2011", the annual year book of St John's College Cambridge)

What happens if you turn the world upside down? Well, things are starting to look very different. And a different perspective is needed as the world is changing, and so are the demands placed on health services all over the world. Firstly, the world has become more interdependent. Disease travels faster - SARS for example, which had started in rural Asia, reached over 30 countries within just a few months and caused severe disruptions in the economy, travel and trade. Borders between rich and poor countries are blurring; health has gone global.

Secondly, patterns of disease are changing, partly due to demographics, and costs are rising. This is particularly a problem in the developed world. The 19^th and 20^th century, when our health systems were developed, were characterized by a fight against acute disease. But, the challenge of the 21^st century is an epidemic of non-communicable chronic disease. Thus, a shift is needed – from focusing on treating disease to allowing people to lead lives which are as healthy as possible. While the developing world is still largely plagued by acute and communicable diseases, it has a pragmatic and more holistic view on health which could hold the key for the problems of the developed world.

Lord Crisp uses his wide-ranging experiences to provide an insight into these challenges for health care and ways to solve them. Having read philosophy at St John’s, he went on to become the only person so far to simultaneously hold the posts of Chief Executive of the NHS, the largest health organization in the world, and Permanent Secretary of the UK Department of Health. Lord Crisp left these posts in 2006 and is now an independent cross-bench member of the House of Lords. His particular area of interest is international development and global health. He authored the report “Scaling Up, Saving Lives” which set out practical ways to increase the training of health workers in developing countries. Among other projects, in 2007 Lord Crisp co-chaired an international task force on increasing education and training of health workers globally; and in 2009 he co-founded the Zambia UK Health Workforce Alliance to increase number of health workers trained in the country.

“Turning the World Upside Down” sets the stage by discussing the links between health, wealth and social change. Lord Crisp does so by first looking at the developing world and then contrasting and comparing its challenges with the developed world. He shows how health cannot be seen in isolation, but is rather a deeply contextual issue – a key insight that leaders should keep in mind when designing interventions and programmes. Lord Crisp goes on to examining the status quo of links between rich and poor countries, and concludes that there is an unfair trade occurring in both directions. Poor countries are exporting the scarce resource of health workers to rich countries and in exchange importing ideas and ideologies which might not fit their societal context. Health workers are critical to any health system and understaffing is a global problem. Better remuneration, living conditions and facilities as well as safer environments draw health workers from poorer countries to richer ones. Several countries have enacted policies of ethical recruitment, but Lord Crisp argues that the extent of the problem also warrants more fundamental questions. Understaffing means a smaller supply than demand. Yet what is meant by demand? Does it mean workers needed to achieve a medically desirable level of care, or the level of care which a society can afford? If the latter definition is employed, the landscape of over- and undersupply changes dramatically.

 Lord Crisp continues to turn the world upside down in the following chapter and looks at what rich countries can learn from low and middle-income countries. These lessons fall into three broad categories: different ideas, attitudes and approaches to health; specific innovations in policy or treatment; and working together. He argues that pragmatism, creativity and vision, often born out of the lack of resources, can complement Western thinking. For example, many developing countries address their shortages of health professionals by basing their health system on workers who are not as extensively trained. Instead, these community health and mid-level workers receive specific training which is determined by local need instead of oriented along professional lines. Lord Crisp goes on to look at the practical implications of the health challenges of the 21^st century – what role do science and systems play? And who is really in charge: the professionals or the patients? In the final two chapters he summarizes the need for a paradigm shift to global health and what action is needed to confront the challenges of health in the 21^st century. Lord Crisp argues that transition will inevitably occur due to the burden of cost, which will become unbearable. Amongst others, it will be necessary to move clinical and public health closer together in order to shift from a focus on curing disease to one on keeping people healthy. This will have to be linked to new business models and financial incentives, as well as a need to rethink training and deployment of staff according to tasks instead of professions.

Lord Crisp provides a fascinating insight into the links between health in the developed and the developing world. He challenges a one-size fits all approach and argues for the need of a systemic view. He also challenges ideological preconceptions to developmental work. Lord Crisp argues that it is about economic growth, not aid, and that as aid builds dependency, the true goal should be empowerment. His experiences of working both in the developed and developing world allow a first-hand insight and lead to a pragmatic look at issues. Lord Crisp argues convincingly that both sides can learn from each other – let us hope that they are listening.

Making Health Care Safer - Summary

I only summarized the main plenary sessions so far but the conference had so much more to offer - lots of interesting posters and several very interesting talks in the parallel sessions. A big well done to the organizers for assembling such an interesting program.

I think what I take away from the conference are a couple of main themes:

• context-dependency - this was raised over and over again, one size fits all just don't work but more importantly what works in one place might not necessarily work in another. Is decentralization key to addressing this? But how can we then ensure quality and uniform standards?
• emotion - Justin Waring mentioned this and I also came across it in my reseach. Health care services are dealing with people and people are not (always) rational. Surprise, optimism, fear or anger are all strong emotions which will influence how people react in certain situations. So far this has not been addressed at all.
• complexity
• knowledge
• organisational hurdles

The amazing thing is that these are themes which also surfaced in my own work - thus I seem to be on the right track. Makes me a bit more optimistic (speaking of emotions) about my viva :)

Making Health Care Safer – More Plenary Talks

I really liked Denis Fischbacher-Smith’s talk. He talked about the report Organisation with a Memory which he worked on. This was based on the premise that organisations should learn from adverse effects in order to prevent future systems failures. 

He identified three main obstacles to learning 

1. organisations driven by short term imperatives
2. high management turnover and
3. involvement of politicians.

He stressed the difference between passive (lessons are identified but not put in practice) and active learning (lessons become embedded in organisational culture and practices) but also pointed out the communication problems across disciplines and between medical and management functions. Other points he touched upon where the importance of culture and the problem that organisations tend to manage what they can measure. All in all his talk was fairly pessimistic (some might say realistic) about organisational learning. But perhaps this is just another example that we really need new ideas and approaches in health care which are compatible with the existing culture and hopefully can shift it towards being more receptive to learning in the long run.

The first talk on day two brought the focus back on patient safety. Teun Zuiderent-Jerak who looked argued that while safety is a system property, there are several ways a problem can be framed and approaches. He used medication safety as an example, where the classical approach is to control medication behaviour and report errors, while an alternative approach is to see errors and safety as synonyms. The first approach would seek to standardize dispensation while the second one focuses on fostering resilience. Such a shift from control to delegation would have impacts on multiple levels – and would raise very different questions when it comes to spreading and sustaining change than the first approach of standardization.

The last plenary talk was by Justin Waring who first summarized where he sees the field of patient safety. He felt that the scale of the problem, its sources and potential solutions have been well researched in the past years. But there are still gaps that future research will have to address. To do so, he identified three critical perspectives: knowledge (which seems to be sticky when it would need to be slippery and vice versa), cultures (how ideas are lives and breathed) and power and organization (resistance to change and unintended consequences). 

He went on to identify four concrete gaps: 

1. Sources of safety
2. Roles of professional practice networks
3. Role of emotion and
4. Spaces between care processes.

Slides for many of the plenary (and parallel sessions) can be found here:

http://www.sdhi.ac.uk/pastconferences.htm