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...or harm of Medic driven management?
- stephen black (31 July 2008)
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Target driven excuses
- Irving Cobden (6 August 2008)
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stephen black, management consultant london sw1w 9sr
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There are many examples of why badly thought through targets are bad for clinical care, but the 4hr A&E target is not one of them. It is depressing that there is still some much medical reistance to the management and operational lessons learned by the departments that responded intelligently to the target. Nigel Rawlinson's objections to the target are typical. I think they can be distilled down to these issues. Before the target, he argues, we devoted whatever time was necessary to every patient and were, as a consequence, often slow to treat them. Now, when the 4hr target looms we rush the treatment. And we force staff to work harder to meet the target. And we impose standardised processes that don't always work for patients with multiple morbidities. The first argument is an attempt to blame the target for failings of operational management in a particular department. The shift of blame arises, I think, because many doctors and not a few managers) simply can't envisage how changing the way an A&E department is organised can alter its overall performance. Yet good departments were often able to streamline the way they dealt with patients so that the average time to diacharge for many patients with minor injuries was more than halved to much less than two hours. These departments had no problems meeting the target and often reported increased level of patient and staff satisfaction as workloads actually dropped. Other departments didn't fix bad processes but chose to bolt on an "expediting" step of rushing to treat as the patients' stays came close to the target time. This is a poor way of dealing with the target and is bad for patients, but it is not the fault of the target but of an inadequate reponse to meeting it. Those managers and medics not familiar with the science of operational analysis seem to find this hard to grasp. Nigel Rawlinson may have inadvertently explained why when he stated "We had a philosophy in the department that was forward thinking, aiming to find solutions rather than identify problems." My experience of helping A&E departments improve suggested that a simple analysis of why patients were waiting would suggest the problems were often easy to fix with little effort, but that many departments had never gathered enough evidence to demonstrate clearly what the real problems were. You don't find good solutions if you don't understand the problem. One department had a problem with the turnaround time of blood samples which they ascribed to lack of resources in the lab. Analysis showed that the actual problem was a failure to distinguish urgent A&E samples from routine hospital samples, so A&E results would go to the back of the queue. Putting the urgent samples in a different coloured container enabled prioritisation and speedy turnaround (and with essentially no extra effort). Many A&E delays can be traced to similar root causes and are as easy to fix. One characteristic of the anti-target argument is a reliance on anecdote and a lack of reference to the actual statistics of A&E attendance. If you estimated the casemix of A&E patients from the stroies they tell you would assume that most patients require admission, long periods of observation and have multiple morbidities. But nothing could be further from the truth. between 60% and 75% of all attendances have simple, easy to treat problems. Any clinical time spent on unnecessary diagnostic tests or wasteful attempts at prioritisation is wasted clinical time. But that is exactly what poorly managed departments used to do. Processes were desiged to deal with the glamorous arrivals with serious multiple trauma and so on and minor injuries were regarded as a problem to be de-prioritised. The advent of see-and-treat (which is really a way to stream minor injuries into a streamlined and very efficient process) reduced the amount of time those patients spent in the department and actually freed up clinical time for the more needy patients. In fact when analysis is done of where clinicians time is spent is poorly managed departments it is not devoted to listening to patients with difficult problems or observing patients who have unstable conditions: most is wasted on activities which have no clinical benefit to any patient. Good management eliminates the wasted time, reducing clinical workloads and, at the same time, speeding the flow of patients. So we don't usually spend 4hrs because care of the patient demands it but because a badly designed process has many wasted activities for clinicians that don't contribute to the well being of patients. The target is not about making doctors work harder: its about challenging managers to design A&E processes to deal with patients in and effective and speedy manner. It is a pity that many people are still protesting that the target is clinically bad and passing the blame to the government instead of copying the experience of the successful departments who have reorganised processes to give a better experience for their patients and a better working environment for their staff. Competing interests: Has advised Department of Health on A&E target |
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Irving Cobden, Consultant Gastroenterologst Northumbria Healthcare Trust, Rake Lane, North Shields, NE29 8NH
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Nigel Rawlinson blames the 4 hour A&E target for mismanagement of emergency patients. However, the examples he gives of last-minute inappropriate moves are merely those of poor practice and gaming - what we in the Emergency Care Team used to call "hitting the target but missing the point". Whilst I have seen examples of similar behaviour, I have only rarely seen it as a result of poor resources these days: as he says, the target did lead to an increase in staffing and attention from Trust Management on the standards of emergency care. The implication that those patients have all been having active care or assessment that has added value to their care up to that time, and that would add even more if they could just be kept (waiting) in A&E even longer is facile: usually they are lying or sitting around because of poor systems. The very small number of patients who DO benefit are the reason the standard is 98% and not 100%. The proof is to be seen in those hospitals with superb emergency department services which work promptly, smoothly and effectively with, for example, early senior assessment, clear flows, pathways and accessible alternatives to admission, which don't necessarily correlate purely with workload and staffing. Incidentally, the 4-hour standard came from asking patients what THEY thought was a reasonable maximum time to wait- as is often the case they were relatively undemanding. Most good units strive to achieve shorter times than 4 hours because they consider it to be good patient care. It would be interesting to ask doctors attending A&E for themselves or with their relatives what they thought about long waits with nothing happening. Competing interests: I was a simple physician who worked for a while with a national team that tried to improve the lot of emergency patients |
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