Do we want to return to 'business as usual' in healthcare?

In response to Covid-19, many ‘business as usual’ activities were put on hold so that healthcare employees had time to focus their attention on rapid preparation. For many, pushing pause on routine meetings, reports and even some projects has been a welcome reprieve. Most of us are familiar with the feeling of completing reports of questionable value or taking part in meetings that were far from the best use of our time. For many, this is the daily experience of working in healthcare.

We are now entering a new phase of response to Covid-19, where healthcare organisations are both reflecting on the rapid and impressive changes that have been made, while also looking at how to recover from a backlog of deferred care and delayed projects. A lot of attention is already being given to how to sustain the positive changes that have been implemented over the last few months, but less is being said about whether there are also things that have been stopped that should never be started again. 

Now is the time to question the value of ‘business as usual’ activity. This isn’t just the responsibility of senior leaders but for anyone who draws on the time of others.

Before hitting the restart button, take some time to ask yourself and your team:

• How does this activity align with achieving our overall mission?

• Is the purpose clear?

• Is it delivering value? (over and above the opportunity cost of what we are not doing instead)

• Is there another way to achieve this purpose that makes better use of our time?

• Can this [task, report, meeting] be shortened, improved, or eliminated

• Could this output be created or delivered in a different way?

• Is there someone else who could complete this task?

The way we work is heavily influenced by our previous experiences, structures, processes and cultural norms so changing this is harder than it first appears. For example, when someone says the word ‘meeting’ we quickly form a visual image of what this means – so resisting the natural pull back to what is familiar requires intentionality…. and maybe even changing some of our language.

Now is the time to unleash the creativity of teams – to break apart the old, and design ways of working that value the precious time and skills of healthcare staff. If we don’t, we may look back a year from now and regret the missed opportunity to radically reinvent ‘business as usual’.

Stephanie Easthope
Manager

Unravelling the change. How patient and whānau experience can reveal new opportunities

Preface: Sophie is a registered pharmacist who draws on her experiences working clinically to describe some of the barriers patients can face in New Zealand’s health system.

Think about the last time you were sick. It is miserable and stressful and makes everything difficult. It can totally disrupt your intentions for the day, week, even month. You’re feeling so terrible you want to be seen by a doctor, so you pick up the phone and call your local practice, crossing your fingers that your usual doctor will be in and can actually see you that day. You manage to get an appointment and you drive to the doctor’s office and then the waiting starts. You turn up on time but are expecting to wait because your doctor seems to always be running late. Your GP provides excellent care but it can feel like it’s only a few minutes long before you are given a prescription of some sort and politely ushered out the door so the next unwell patient you sat next to in the waiting room can have their turn. Great staff and great medical advice wrapped in a poor user experience in a health system that relies heavily on you, the unwell patient, investing your own time.

Feeling sick and miserable, you might go to the pharmacy where you wait some more – luckily, they have a range of retail products you don’t need to kill the time. You’ll notice other sick people too, stressed parents with sick children, elderly getting their repeat medications, people dashing in and out asking “how long is it going to be?” or “the other two pharmacies don’t stock this, do you?” “I can only afford one this month, what medicine is most important?”. We’ve come to accept this is just how it has to be. It’s enough to avoid going in, delaying treatments, the onus of refilling prescriptions and navigating the health system relying on you – the sick patient managing this administrative and financial burden. In extreme cases, this whole process could take three hours of your day. For some this is just an inconvenience while for others it can cause significant social and financial hardship as a result of juggling family commitments, time off work and the cost of engaging with the sector. At its simplest level, our public healthcare system exists to look after people so why do we accept this sort of experience when we wouldn’t from other customer-focused industries?

This “chronic waiting” is exacerbated if you have a chronic health condition that requires ongoing follow-up, or need specialist advice from a hospital. That clinical consultation can be a valuable 10 minute appointment. So valuable that you take time off work, arrange childcare or recruit whanāu to drive you. For many, this trip from home to outpatient clinic could be well over an hour. You might arrange your day so you can catch a health shuttle, wait to be seen and then turn around to reverse the journey home again. Just in time for tea.

Valuing patients’ time

Fast-forward to present day adjusting to post-COVID-19 and think about if you were to get that sick now. You have far greater choice and preference in how you access healthcare. The technology that has been developed and adopted at snail’s pace over the last decade has finally been embraced by providers and patients’ alike. You might ring the practice and talk directly with the GP so that you are provided with a decision about your health needs as soon as possible. You might be given the option to have a virtual consult with your usual GP – who then asks you what pharmacy you would like to pick up your medication from – directly sending on the prescription. In this situation, you’d only have to leave the house to pick up your medication (or a family member might do that on your behalf). The rest of the day for you to recover without contacting others. 

You might now see your specialists for the same amount of time, but given the option to zoom in, only come for an in-person appointment when necessary. You could have joint consultations with your specialists and your GP. Either way, you still have access to care. Only now, you have saved on time, parking, transport costs and time away from work. Your time as a patient, who the health system is designed to serve, has been valued.

We have proven that we can move away from one-size-fits-most service provision.

As we design or improve services, the value of patient journeys and experiences through our complex processes and systems can be an incredibly insightful way of understanding that what might work for the system, is not working equitably for our populations. Now that we have had a taste of a flexible, adaptable and digital health system, we can see that blending both in-person and virtual options to empower patient’s with choice and determine how they would like to access care. We have proven that we can move away from one-size-fits-most service provision.

Healthcare globally is an astonishingly fragmented industry; with many stakeholders (with differing priorities), third party funding and an extensive network of regulations. The soil we have laid in healthcare often barricades our best attempts for transformational change and innovation. But what we do have is passionate health providers that can be empowered to disrupt how we work to better deliver to our patients. With the richness of patient experiences and journeys to help unravel the changes that have occurred during the pandemic, we can begin to understand what should be invested in, be sustained and what has not worked well for different populations and patients.

COVID-19 has tested the health system and those that work in it at all levels to really ask ourselves– why didn’t we give each other the permission to test new ways of working sooner?

Sophie Oliff
Senior Consultant

A simple tool for prioritising delivery of the backlog of planned care

An estimated 30, 000 New Zealanders missed out on their elective surgery over the Covid-19 lockdown period and many more had their first specialist appointment or diagnostics delayed.

Now, with case numbers declining, hospitals have been able to shift their attention to how they can increase delivery of planned care. Herein lie some big challenges. How do we ensure, that as elective surgeries and outpatient clinics resume, patients are seen according to their clinical priority? Not just within specialties but across specialties. How do we fairly allocate theatre time or clinic space? And how do we ensure that our response does not increase the health inequities that already exist?

On every list of patients waiting for an appointment, a diagnostic or treatment there are multiple levels of unknown increasing clinical risk. The longer a patient waits, beyond their maximum clinically acceptable wait time, the greater the level of unknown risk. We can ask clinicians to review their lists and re-prioritise patients, but we balance that with time not spent in clinic or in theatre seeing patients. What’s more, this approach leaves clinicians to ‘go into battle’ for their patients risking increased mistrust between clinicians and managers and the potential for unconscious biases to influence decision making.

The answer lies in a simple ratio.

The ratio between the time the patient has waited and the length of the clinically accepted wait. Known as the acuity index, the ratio was first mooted circa 2013 by the Ministry of Health. It enables patient priority to be objectively compared across lists, specialties and ethnic groups based on the clinical priority assigned on referral to the waiting list. A ratio less than 1 indicates the patient has waited less than the maximum acceptable time, a ratio of greater than 1 indicates they have exceeded the maximum acceptable time, a score of 2 indicates they have waited double the maximum acceptable time and so on. The ratio is grounded in clinical decision making – the clinician determines the clinical priority and therefore the maximum acceptable wait – yet provides a simple, common language for administrators, managers and executives working to coordinate delivery of the backlog of planned care. The acuity index for a patient with a shorter acceptable wait time will grow more quickly than the acuity index of a patient with a longer acceptable wait time but at some point the risk for the patient that’s been waiting two years for their next annual review overtakes that of the patient that’s been classified as urgent (unless the follow up wasn’t actually necessary but that’s a whole other topic). The acuity index enables us to objectively compare those patients and determine who should be booked next on the list or where we should target our interventions to mitigate the risk of delayed treatment.

Figure 1. The acuity index enables us to objectively compare patients with different clinical priorities

It doesn’t stop there though. The acuity index enables us to view and compare waitlists visually and to understand whether we are making gains towards addressing the backlog or not. For example, in figure 2 there is a large group of patients that have waited more than twice their clinically accepted wait. This information could be used to target interventions to mitigate the risk for these patients. The two charts in figure 3 illustrate how we can track how different specialties are performing. Here, we have a problem in general surgery where on average patients are waiting 2.5 times their clinically accepted wait, but the situation is improving. Whereas orthopaedics was tracking quite well but something has changed, and the acuity index is now increasing. This information might prompt conversations about whether theatre or clinic resource is allocated where it is needed most throughout the Covid-19 recovery. Again, the acuity index provides a common language for communication between clinicians and managers and helps to build trust and foster collaboration between specialty groups. 

Figure 2. The acuity index can be used to understand the backlog of patients waiting.

Figure 3. The acuity index can be used to understand whether we’re improving or getting worse.

Once we have a common language, to understand the multiple levels of unknown clinical risk posed by patients waiting, then we can target our interventions to manage the risk of deterioration or harm. We can use the data to inform decision making around using our allied health and nursing workforces to provide alternate methods of advice and treatment, we can appropriately communicate with referrers and patients and we can make the best use of our theatre and clinic resources, both public and private.

Bridget Thompson
Senior Consultant