JEFFREY BRAITHWAITE: How to improve the health system, part 1: support the staffSep 27, 2019
I hear many stories and over the years have conducted many studies about people’s experiences with doctors and hospitals. I access these in the course of my work as a health systems researcher and some simply come to me as a parent, husband, son, or friend. All can – at least potentially – be used to change the health system.
With around 11 million hospitalisations in Australia each year and more than 1 million people employed in the delivery of services, it is no wonder that everyone has a story to tell. Many tales are about good experiences; some not so good; and occasionally they are tragic.
There was a time when it was thought that every medical breakthrough would improve care for patients. That every change to the quality systems and practices in hospitals would make patients safer. That new guidelines and policies would be enough to make care better. We now know this is not always the case and it is the stories from and about the clinicians and patients at the coalface that illustrate this.
The recent media coverage of tragic events at Broken Hill Hospital where an otherwise fit and healthy 18-year-old, Alex Braes, died from sepsis drew attention to the problem of overcrowded emergency departments and the potential to miss things. He had an infected toenail, went to the emergency department four times, and the first three times was sent home. No-one listened to him or took his vital signs.
Other reported events have shown the unfair divide between services based on where people live – the postcode lottery. In the case of geographically dispersed Australia, this is starkly illustrated by the point that the further people are from a major city, the more likely they are to die from an adverse event. Many of these events could be prevented if patients in regional or remote centres received better care or were able to access existing health services.
This, despite Australia being one of the wealthiest countries in the world, with a staggering $170 billion spent on health each year. We have well trained and dedicated health professionals; access to quality care; subsidies for medications; cutting edge technology; and an enviable research culture contributing scientific innovation. We have clearly documented policies, well written clinical guidelines, extensive medical records and good IT and other systems in many parts of healthcare.
We are on the right track then, is a logical conclusion. We just need a little more effort, and to continue on an improvement gradient. We’ll get more effective care over time.
All of that’s important, but it’s not enough. What is missing is a deep understanding of how things really work on the clinical front lines of care. We need to move closer to where care is delivered and to see how those well thought out policies and practices and equipment actually work in supporting the staff who deliver services.
We need to learn how meaningful improvement occurs—or could occur when change is needed. To listen to how patient histories are taken and see how medication is administered. To observe busy emergency departments and learn from teams which perform well, with staff working together under pressure.
To appreciate how the next generation of emerging technologies, treatments and models of care, such as genomics, AI, decision support and precision medicine, are going to be taken up – and how this heady cocktail of cutting-edge solutions will interact with current care models, and influence decisions about patient care.
But if we go ahead and put all those new things on top of all the current system, we might make it worse, even while we intend to make things better.
In short, we need to understand profoundly what we are doing now, and how care will shape up in the future, in this complex adaptive system we call Australian healthcare. My research shows time and again that technology alone, even gee-whizz technology, is never enough in healthcare. People will always be the key determinant. They provide the compassion, the truly great care, the going-the-extra-mile services, and make the system deliver. Or not, as the case may be.
That’s the kind of research we do at the Australian Institute of Health Innovation at Macquarie University —to apprehend how the delivery system works now, and can change for the better. For instance, in the most far-reaching study of quality management practices in Australian hospitals, to be published soon, we looked at the 32 largest hospitals across the country, and examined, in-depth, how their quality management systems were performing.
Across this and other studies we have found that the best performing hospitals—those where measurements of the system show that patient care and satisfaction are highest—are those with excellent leaders, not necessarily in the executive suite, but opinion leaders and clinical contributors closest to the patient. These are the front-line leads who foster teamwork, work to continuously improve their care to patients, listen to the voices of their co-workers, and of course their patients and families.
The best teams – clinical microsystems, they are called these days – are agile and adaptive, coping with changing circumstances as required, focussed on what is best for the patients under their care. If the systems aren’t as good as they could be, they work around the problems to deliver good care anyway.
These unsung clinical heroes don’t want praise from the media, or to be in the spotlight. They want to have adequate resources, pride in their work, and a feeling that they will be backed when the inevitable happens, and something goes wrong. So mutual trust with higher management is a crucial factor feeding into an improvement culture.
This doesn’t happen everywhere. In fact, in some hospitals, perhaps too many, there is a perpetual divide between the clinicians on the ground and the managers and policymakers in the upper echelons of the hierarchy. It looked like that’s the way it was at Broken Hill Hospital where staff warned management about patient safety concerns, but repeatedly felt ignored.
So by all means search for technical or technological solutions to Broken Hill-type problems. But let’s not forget what is really needed. Unremitting support for the carers who battle every day for their patients. Even on the days they make the most tragic of mistakes. Because if they know they are supported, they’ll be less likely to make mistakes in the first place.
Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Macquarie University, and President Elect of the International Society for Quality in Health Care.