Closing the emergency care gap takes accountability and knowing what works

“And we don’t know why,” was a phrase used often during HSJ and McKinsey Hospital Institute’s Emergency Care Summit in February. 

Whether it was trying to explain step changes in demand, or deterioration in performance, or indeed why a “purple patch” of performance had not been maintained, there was a collective sense that we lack the data and the model of how this complex, dynamic system fits together.

‘It is often surges in demand that cause the pathway to fail’

We are not precise about the root causes of problems in the pathway, and therefore we lack confidence in deciding the action needed. 

So how can we be more accurate in capturing what’s happening within the system? To judge by feedback at the small summit – made up of 30 leading voices in the acute care sector – we need better numbers and a more sophisticated way to measure and manage the pathway.

One chief executive summarised by saying: “We are moving out of the dark ages in terms of measurement.” 

Another pointed out: “All of our reporting is based on daily figures, but it’s not about what happens on average. It is often surges in demand that cause the pathway to fail.”

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Words come before numbers

There is an important leadership task that comes before this, it was suggested by the group, to frame the issue in a way that engages staff, and gives them a vision worth aiming for.

This narrative needs to be rooted in patient safety and the consistency and quality of care, not the language of targets, breaches and performance. These are all connected, but worn out staff need a rallying cry which energises them. 

We heard of some strong examples, including Frimley Park and Homerton, which are the only two hospitals the Care Quality Commission has rated “outstanding” for A&E.

One version of the truth

In our work with numerous local systems, we have found it necessary and powerful to establish a shared view of the situation and root causes.

We have ended up calling this comprehensive diagnostic – which incorporates analysis, interviews and observations – “one version of the truth”, which is how a client described it. 

‘In multiple situations, we have found that the major cause of breaches is flow’

The power of getting this right is that all parties sign up to the findings, creating a shared evidence base that improves the quality of the discussion.

It also provides the basis for a “change story”, or narrative, which the whole system can contribute and commit to, and it helps to prioritise the key actions within a structured improvement programme.

In multiple situations so far, we have found that the major cause of breaches is flow – typically 60 per cent or so – rather than emergency department operations.

Chaos and variability

The forces we are fighting against are universal laws, such as the second law of thermodynamics, which states that “nature prefers chaos”.

The emergency pathway obeys that law. It wants to take up as much space as it can, and when it bursts its banks it can wreak havoc across the whole hospital and care system. 

We need to work to bring order out of chaos, which means daily disciplines, defined standards of care, daily board or ward rounds, planning for the weekend, and so on. 

This requires leadership attention, making this a daily and an ongoing priority. To commit to that as a basis for an improvement strategy, we need to believe that this beast can be tamed, and that the “natural limits” of this process can be tightened up, to meet a specification of care which is still largely undefined. 

‘You wouldn’t try and build a car without specifications. Should we try to deliver care without them?’

There happens to be a target of 95 per cent of patients being treated within four hours, but by and large the rest of the pathway – which is a complex, multi-stage process – lacks specifications.

You wouldn’t try and build a car without specifications. Should we try to deliver care without them?

As an engineer by background, I am comfortable with the language of ‘“specifications” but I recognise that others may not be, given connotations of products and mechanical assemblies, rather than flesh and blood.

We can call them standards of care, quality standards, or best practices, but whatever we choose to call them, we need them if we are going to tame this particular beast. 

The human factor

Specifications are necessary but not sufficient to deliver excellent care. In the end, it is about people and their attitudes, values, motivations, skills and behaviours.

This is why the CQC asks whether an organisation is “well led” or not when it inspects it.

So developing a reliable, high quality pathway is as much a challenge of behaviour and culture change as it is about process improvement.  This is part of what makes it difficult. 

‘Implementation is a skill, and we don’t have it’

Beyond “one version of the truth” – and analysis more broadly – the other major source of value which clients comment on when we work with them on improving the emergency pathway is getting their own teams to help them prioritise and structure the improvement initiatives, and strengthen their resolve and belief to see them through. 

We have the major advantage of being able to focus on just this, not trying to “fly the plane” at the same time as building it. But I think it goes beyond this. 

A hospital manager at one of London’s leading teaching hospitals put it bluntly during a recent working session: “Implementation is a skill, and we don’t have it.”

Ikea meets Toyota?

So the NHS’s improvement offer needs to bring together knowledge management and capability building, which ought to be structural sources of advantage in a national health system but at the moment feels more like structural weaknesses. 

This is very fixable, but it would mean investing in a different kind of capacity than the “winter money” has been spent on historically, and we heard at the summit that “historically” is the right word, as the expectation is that it won’t be available in future. 

So as the NHS regroups and rethinks the improvement offer, what does it need to look like?

In simple terms, I think it needs to combine the product design of Ikea with the management culture of Toyota.

‘The improvement offer the NHS needs now must deliver the best of Ikea and Toyota’

Ikea delivers products that are designed to be simple to assemble at home - OK, maybe that’s up for debate. 

What this would mean for the emergency pathway is that we would need to describe a modular “operating model” (standards of care) which integrates the Royal College of Physicians’ Future Hospital Commission, proven examples from the NHS and best practice service operations thinking from healthcare and beyond. 

It should be modular so that local teams can decide where to start based on the priorities they identify from “one version of the truth”, which in many cases will mean starting with the back door (supported discharges) rather than the front door, and extending beyond the acute setting.

And Toyota has perfected a way of managing that has as much to do with team-based problem solving, root cause analysis and continuous improvement as it has to do with “lean” process improvement tools. 

This is quite counter-cultural and, if the NHS took it on, would be a substantial shift in how hospitals are run. It tends to be learned from others – through “apprenticeship”, just like medicine as it happens – rather than from a manual or in a classroom.

So the improvement offer the NHS needs now must deliver the best of both: codified knowledge of what works – ideally, in a modular way so that it can be adapted to the local context and implemented in an order that makes sense – with experienced people who can get alongside hard pressed teams and help them make the behavioural shift which needs to underpin the process changes to bridge the gap we face.

Keep the bridge standing

And once this transition has been made, it needs to be embedded and sustained. There was a general acknowledgement that a key component of sustainability is solving the accountability problem. 

People were reluctant to use the word “performance” as it has unhelpful associations, but there was a way to describe this more positively. We need to:

• be clear on roles and what we expect of people;
• create transparency with trustworthy data, we need to support and empower people to take action; and
• keep ourselves honest against the expectations we have agreed.

In the best multidisciplinary care teams, this model works quite well and is considered not just a good thing, but necessary for safe care. 

It is also necessary for delivering a safe care pathway. 

‘A key component of sustainability is solving the accountability problem’

To pursue the bridge building analogy, it is like building a suspension bridge to cross a gap – which requires a lot of temporary scaffolding to put it in place – and ensuring that there is the right amount of tension in the cables to hold the bridge up and ensure safe passage.

I suspect that there will always be tension in the emergency care pathway, but this would be good tension, with a purpose.

John Drew is head of the McKinsey Hospital Institute