The Oxford Centre for Entrepreneurship and Innovation » Medical

Service Delivery Innovations in Healthcare: its not what you do, but how you do it that matters.

Matthew — Tue, 03 Mar 2009 09:53:52 +0000

On 25th February, as the 6th in the Medical Innovation lecture series, Steve Fairman and Prof Jon Meakins, spoke to the question of ‘Service Delivery Innovations in the NHS’. They drew on some interesting examples of how service innovations can be effective – the simple re-positioning of a fridge led to significant cost savings in one service, and enabled healthcare workers to meet stringent clinical care guidelines; empowering senior surgeons in another service reduced cancellations of routine surgical procedures and led to enormous cost savings.
Service innovations, as opposed to the more commonly considered technological innovations, are just as needed in health systems in developing countries. Of the 33 million people living with HIV globally1.5 million people are infected with HIV/AIDS each year and 1.6 million (73% of the total) people die from HIV/AIDS each year. The Millennium Development Goals (MDGs) have placed in the foreground the need to rollout out anti-retroviral treatment (ART) to those that need it – the second target of the 6th MDG calls for universal access to treatment by 2010. Many major donor organizations such as PEPFAR, Global Fund and the Gates Foundation provide resources to this aim and much is now being spent on the development of new and improved treatments. However, in these contexts, where health systems are often under-resourced at best, it can often be the most simple, and inexpensive interventions that can be the most effective at improving the rollout of treatment to those that most need it.
I draw on personal experience of a systems innovation in an HIV/AIDS referral centre in Central Mozambique, to show how inexpensive interventions can help to achieve this goal.
In HIV/AIDS treatment and care, eligibility for Anti-Retroviral Treatment (ART) is based on two important pieces of clinical information. Put very simply, if the CD4 count, a measure of the strength of a patient’s immune system is below 200, then he/she is eligible for ART. But also the patient needs to have a physical examination to determine the clinical ‘stage’. If a patient has any of the infections, or malignancies, that are characteristic of the Immune Deficiency syndrome (AIDS) then he/she is also eligible for ART. So to be put on ART, it is necessary to do a blood test, namely the CD4 count, and to be examined to determine the clinical ‘stage’.
At the time I arrived at the HIV referral centre in Central Mozambique, this system was extremely cumbersome. Firstly, the examination was done first by the doctor, then the patient would be sent to do the blood test, and then re-seen by the doctor to look at the result a couple of weeks later, which in combination with the clinical examination would determine appropriateness for ART treatment. The patient would be referred to the social worker to determine adherence issues, and social circumstances. The case, some days later, would be put before a clinical committee, and once agreed that ART is required, the patient would be referred back to the social worker and the pharmacist to begin treatment. All in all, this process could take well over two months.
But also, doctors’ time was not being utilized effectively. Looking at the profile of the patients being seen by the doctors, although all were HIV positive, most of them did not yet require ART. As a first-come-first-served service, all new patients would be seen by the doctors, but the triage nurse would also refer to the doctors any HIV positive patients requiring treatment of any sort, whether for malaria, for diarrheal illnesses or even for a headache, which would take up the doctors’ valuable ART prescription time.
Even though there were 8 doctors, each seeing on average 20 HIV positive patients every week, the majority of the patients were not requiring ART treatment. Only 18 new patients were being identified as needing ART and being successfully started on it each week. Many were being missed. In the context of ART expansion and rollout, with over 1 million inhabitants in the region, and approximately 20% HIV prevalence, the system was simply not geared up to meet the hidden and the growing demand for ART treatment.
Two important system changes were implemented. Firstly, representing a paradigm shift in patient flow, an appointment system was introduced so that doctors’ time could be better controlled. Secondly, a more targeted triage system was implemented, where ‘ART-nurses’ were trained and given more responsibility with regard clinical staging. Newly registered patients, that did not require urgent care, would be sent immediately by the receptionist to do the CD4 blood test, and then for a full clinical examination by the ART nurse to identify the patient’s clinical stage. They would receive an appointment for the triage nurse one week later where, with the CD4 blood test result in hand, the decision could be made if they fulfill the criteria for ART. If so, they would be referred to the doctor, to be seen immediately and to be put on treatment. If not then they would be referred to the social worker only, for counseling and follow-up.
As a result, many more patients requiring ART were identified and also much earlier in their care. Within about a month, doctors’ consultation times were taken up almost exclusively with patients requiring ART and it was not long before the numbers of patients getting on to ART had tripled from an average of 18 to 50 or more per week.

Systems changes such as these were not straightforward. Nurses had to be trained; senior clinicians had to understand that the changes were necessary; they had to ‘own’ the changes; even an appointment book had to be designed from scratch, and the semi-literate auxiliary staff trained with respect to its use; finally, the patients themselves had to re-learn what the referral centre was for – not a drop-in clinic for all ailments, but for the clinical staging, counseling, starting and maintaining of ART treatment.
However, this innovation required no investment, no research and development, no patenting, and no start-up costs and it had a considerable impact on the service and on patient care. It was the ‘pursuit of perfection’ in patient flow, as Steve Fairman put it, striving to do the best with what you have, that drove this change process. The experience left me wondering – why is it that when such simple changes can lead to such considerable impact, Medical Innovation is in general synonymous with Technological Innovation. Perhaps more time and money needs to be given to the small changes in patient flow, in work patterns, and in efficiency that can bring about, when aggregated together, huge benefits, whether financial or clinical to developing country health systems. Perhaps, instead of investing in lengthy and expensive drug and vaccine developments, might our resources be better used directed towards the identification of discrete improvements in the management of existing services that can lead to a greater overall impact in healthcare?

Why is innovation in the NHS often hard to achieve?

Matthew — Mon, 16 Feb 2009 13:41:45 +0000

Prof Sue Dopson’s presentation for the Medical Innovation lecture series (‘Why is Innovation in the NHS often hard to achieve?’ – 11th February 2009) effectively unpacked the shared, common conceptualisation of innovation in large healthcare organizations as a predominantly rational, linear and planned process. Presenting her research on Evidence-based change in the NHS several important issues emerge that help us to understand the role of innovation in complex healthcare organizations and the barriers therein involved.
Firstly, she noted that different professionals, such as managers, scientists, commissioners and physicians each belong to different communities of practice – or epistemic communities, that share certain ‘cultural’ characteristics. People therefore interpret ‘need’ and in the case of her research, ‘evidence’, differently. Different professional groups have different in-built responses to change, to innovation and to their work practices. This is due to social and cognitive professional boundaries that arise from the education and socialisation process that individuals have to go through to get into their profession. So complex conflicts can occur between the Department of Health, the University, healthcare commissioners, medical practitioners, scientists and technology transfer professionals as each of the groups’ differing socio-cultural perspectives – medicine, biology, social science, policy and management – clash around the shared goal of organizational change and how to achieve it.
Secondly, she noted that ‘context’ is important. We need to understand the history of prior relationships between key actors; the role of opinion leaders as accelerators and facilitators of change; and how professionals engage in networks translating innovations to the local level.
Without a sensitive understanding of the epistemic clashes between different actors in an innovation process and the context of prior historical relationships between these groups, then it is likely that an innovation will fail to be implemented.
Sharing of ideas, and best practices, she posited, will not just happen, you need some people to serve as a bridge between these different communities to recognise and overcome the power differences between communities. This is achievable by ‘getting on the balcony’ and managing conflict.
When the Chairman of the lecture, Trevor Campbell-Davies, asked the audience who are the leaders in the NHS that can achieve this, no-one was able to answer. Whilst curious and amusing that the UK’s largest organization has no identifiable leadership that can serve to facilitate this inter-professional boundary-spanning role, it does highlight a very important point. The people that work effectively across boundaries require an ability to communicate eloquently in several different socio-cultural domains. Their own personal trajectories will require grounding in policy, medicine, research and management. But importantly, they should avoid becoming institutionally affiliated to just one organization, whether the University, the Oxford Radcliffe Hospital or a technology transfer organization, and the socio-cultural baggage that this entails. Where individuals possess the potential to work effectively across boundaries, this should be built in to their job description, perhaps sharing employment between these key institutions. Boundary spanners could work more effectively if employed by, and sharing their time equally between, the Research Centres, the NHS and the technology transfer organizations. The leadership of organizational change and innovation in a complex healthcare setting such as the NHS need not be only from the top of one of these organizations, but also from between the (front) lines and interfaces of these different epistemic communities.

How to turn a good idea into a successful innovation

Matthew — Thu, 05 Feb 2009 16:11:24 +0000

Oliver Bernath’s lecture ‘How do you make a good idea successful?’ (4^th February) was a candid look at the entrepreneurial spirit and how to capture it. Based on his own experiences, some positive and some negative, Oliver showed that being a successful innovator has much less to do with the idea, and more to do with not falling into some pretty simple traps. Firstly, you need to be confident in the Unique Selling Point of your product. It needs to be sustainable and you need to be able to describe it in one sentence. Secondly, you need to make sure you have identified your market. Will the product reach an audience? Who is that audience? How is that audience changing? Thirdly, you need to make sure that the product will make you money. This means creating an efficient team around you, keeping cash available during funding shortfalls and staying lean.

But what struck me the most was how making a good idea successful seems to depend a lot on you as a person. Key to the process is whether you can take risks. Can you put your own weight behind the idea, take a gamble on it and commit to seeing it through? Are you the sort of person that knows when to quit on an idea that is failing? Are you humble enough to not bluff your way through a funding pitch? Are you able to motivate the people around you, nudging them in a certain direction?

These are not simple things, they cannot really be learnt nor taught, and they are likely to be innate in some people more than others. Talking with some medical students after the lecture, they were, rightly, in awe of Oliver’s personal trajectory – consultant neurologist, entrepreneur, management consultant. ‘At Medical School, we are taught to just think in a linear fashion – stay on a straight and narrow path.’

It seems to me then, that any discussion of how to turn a good idea into a successful innovation cannot be separate from a discussion of how to turn a good idea person, into a successful innovator. If our education system is limited in this way, then it needs to be addressed so that in addition to producing good innovations we are producing good innovators.

Medical Innovation

Matthew — Thu, 05 Feb 2009 16:07:01 +0000

What makes a good Medical Innovation?

In his lecture, “what makes a good medical innovation?’ (28^th January 2008) Prof Lionel Tarassenko noted that several important ingredients are required. The organization developing the new technology must remain nimble, and it must find the right partners in the early stages. But also, drawing on fascinating examples of signal processing techniques applied to the continuous monitoring of the vital signs of patients in Intensive Care Units and in patients with long-term conditions, he illustrated that good ideas should come about through interdisciplinary collaboration between different areas of expertise.

In the cases that he used, the disciplines of medicine and electrical engineering were combined in perfect harmony. Continuous monitoring allows for a greater predictive capacity in identifying those patients with imminent and worsening clinical conditions. But also it overcomes the strangely adaptive behaviour of nursing staff to the many repeated false alarms that the existing monitoring devices were known for, namely to ignore them.

It seems that the future holds exciting innovations in many areas that combine medicine with other disciplines. In the area of telemedicine, technologies such as teleSurgery can enable access to needed expertise in developed countries and help avoid a brain drain. In the area of nanotechnology, new nanomedicines could completely displace certain classes of drugs and change the ways diseases like HIV, malaria and TB are treated. In the area of eLearning technologies, capacity building and collaboration with international institutions can occur in real-time. In the area of social networking, Web 2.0 and wiki will mean that health professionals and patients in developing countries can effectively network with each other and with the industrialized world, participating in knowledge development. Finally, open access technologies are revolutionizing and democratizing medical publishing resulting in a paradigm shift in why and how we publish scientific research.

When researchers from different backgrounds talk to each other and cross-fertilize their work, creative and applied ideas emerge. I wonder which will be the next inter-disciplinary collaboration to emerge as the front-runner in medicine. Quantum physics? Artificial intelligence? Complex Adaptive systems?

It may or may not be apparent, but the Medical Innovation lecture series was devised to serve this function. By bringing together students, researchers, academics, practitioners and managers to debate the cross-cutting issue of innovation, it is hoped that some cross-fertilization will emerge, and with that new ideas for future collaboration and indeed innovation.