hamish dibley

Home » Posts tagged 'Gold-plating'

Tag Archives: Gold-plating

Why Conventional Change has to Change: A Better Way to Improve… Part 2

Albert EinsteinYesterday I outlined the problems inherent within conventional approaches and thinking about change management. All too often conventional approaches result in no or little positive change for either service users or taxpayers. Albert Einstein was right: to solve problems and improve our thinking has to change. Indeed, real improvement comes through learning by doing and reflecting on these results. It must also be rooted in research that provides data-driven evidence.

Essential to the acquisition of hard-data is knowledge of customer demand that illustrates patterns of need set against the deployment of resources. Good service (as experienced by the customer/patient/service user) always pays, it never costs. The inability to deliver service is paradoxically expensive and the real ‘gold-plating’: it means in the public sector patients or service users receive either too little and then either ‘represent’ to the service or (in the private sector) customers leave altogether.

Conversely, reviewing services from the customer/patient/service user perspective reveals the folly of conventional change management with its preoccupations on activity assumptions, arbitrary plans and make-believe monetary savings which rarely materialise. Improvement begins with adopting a customer mind-set, studying services and putting pre-configured assumptions of what works aside. Use innovative methods to understand how and why services perform the way they do and what it takes to get them better for those that need to use them.

A Better Way to Conceive Improvement

Intelligent change starts with turning convention on its side, researching performance of local NHS and care systems through the external lens of the patient. The way to realise better service and less cost begins with taking a different, horizontal view. Patients flow through healthcare systems.

Adopting a ‘Front-to-Back Thinking’™ mind-set is about recognising that activity and costs are a consequence of what you do not why you do something. Performance improvement comes from studying patient-level demand; analysing the nature of activity that this demand generates and achieving sustainable cost savings through the elimination of activity waste. How well an organisational system meets patient needs should inform both strategy and costs.

Studying patient demand allows for intelligent system and service redesign solutions around cohorts of patients, not pathways. The principal work is two-fold: research and redesign. The former is evidence-informed problem identification through data analysis.

Research is undertaken to understand patient-demand by looking at the ‘what, where, who, why and when’ of their healthcare usage. It is important to recognise here that the requirement is to utilise both quantitative and qualitative research techniques. A common error with many analytical models is to draw linkages between correlation and causation or indeed assert causality as a consequence of data analysis. Data analysis asks ‘what’ questions which need to be linked to demand analysis’s pursuit of ‘why’ to authenticate findings.

This phase entails analysis of time-series consumption and case-mix data; encounter data to understand customer activity and patterns of usage as well as the type, frequency, volumes and predictability of customer demand together with an understanding as the balance in value versus non-value activity. The work provides patient segmentation into meaningful typology groups which forms the foundation for subsequent improvement work.

Redesign implies a set of sequential steps to undertake intelligent improvement activity. Such Improvement must focus on redesigning the care models and systems around patient cohorts, beginning with the ‘vital few’ patients who, although small in number, consume disproportionately large amounts and activity and costs.

It involves using knowledge gleaned in the research phase to undertake prototype service redesign activity. Clarity of the patient purpose is paramount; as is patient-centred performance metrics; redesigned systems, processes and roles; experimentation with operating models and continuous feedback loops to ‘learn to improve and improve to learn’.

Teams of interdisciplinary professionals are assembled and given autonomy to work together first understand and then meet the holistic (medical and non-medical) needs of these patients, who themselves set the boundary. Flexible services and systems are harmonised according to patient need. The role of leaders also changes, from mandatory monitoring in board-level meetings to problem-solving issues that beyond the control and scope of local interdisciplinary teams.

Key skills that are required include medical and technical but extend more importantly to interpersonal, organisational and problem-solving abilities. The focus is on decreasing end-to-end service times, ensuring more work is done right-first-time; reducing or removing activity that adds no value to the patient thereby preventing such patients from boomeranging around the system.

Here the work involves alterations to budgets, roles, measures and, where necessary, technology. Importantly, the purpose is to develop the redesign and determine its anticipated economies through internal base-lining of current performance via patient-level not service-line reporting.

Following the prototype period, leaders make an informed choice about the benefits from adopting the new (systems) design including further roll-out opportunities. This approach is encapsulated in the Consumption Demand Method™ which enables the emergence of better services that act as testing grounds for continuous improvement set against a better understanding of patient demand.

Why Conventional Change has to Change: A Better Way to Improve… Part 1

The No Change ParadoxAchieving great service is straightforward if unconventional: give customers/patients/service users what they need. However, convention dictates that to adopt this approach will lead to expensive ‘gold-plating’ of services (quality service but at higher costs).

Instead leaders and organisations seek to follow convention and manage their activities by protecting budgets, imposing access restrictions via criteria or eligibility introducing service level agreements and focusing on efficiency through reducing transactional or unit costs.

Yet, the real paradox is that an explicit focus on managing activities paradoxically increases the very thing organisations seek to reduce – cost. Convention decrees that the answers to problems are already known and pre-prescribed solutions can be delivered through meticulous plans and reports. As a consequence these change approaches fail to deliver in practice.

Take conventional healthcare commissioning in the NHS – a person as a health and/or social care need; their need is assesses and then sooner or (most often) later a service is first commissioned then provided by different professionals.  Service level agreement met, project milestone ‘green-lighted’ and ticked.

What happens is because services are not designed around the need(s) of the person/patient/service user, they represent to the service in the vain hope that their need(s) maybe better met. Professionally, the response to this problem is to repeat the process of assess, commission and provide. The outcome experience of the person/patient/service user is that they continue to represent and costs rise. Why does this happen? It is because the mind-set is misguided.

Conventional business change needs to change

Conventional change or improvement relies on a wrong-headed ‘back-to-front’ perspective. What is meant by this phrase is a rear-guard focus on removing cost by reducing activity and expecting patients to change their behaviour. It results in an obsession with activity volumes and ‘bottom-line’ costs. The one problem with this approach is that it doesn’t work. Back-to-front thinking always leads to distortion of organisational performance and higher costs.

The mechanics of conventional change follow a typical path. Invalidated hunches, opinions and/or data consisting of worthless aggregated activity, arbitrary benchmarking and/or cost volumes are used to identify problems.

Understanding the patient or service user (as opposed to non-user public) perspective in this process is rarely, if ever sought. Agreeing appropriate governance arrangements typically loom large at this point and take-up not inconsiderable internal discussion, effort and time.

Much time is consumed completing a litany of project management induced paper-chasing reports such as project initiation documents or PIDs. Once signed-off this document helps formulate a project plan which is established to solve the preconceived problem. A business case is then written which outlines time, costs and predetermined outcomes.

These outcomes are then ‘monitored’ through office-based completion of reporting documents such as highlight reports full with activity and cost volumes with ‘traffic light’ systems – green for good, amber for somewhere in between and red for bad. None of this involves spending time in the work and empirically understanding ‘why’ things are the way they are.

Improvement activity is often relegated to time-limited projects and people who sit outside of the actually work. Disproportionate time and effort is then spent on conducting public consultations (‘the blind leading the blind’) which replace the opportunity to generate empirical knowledge of what is actually happening and causing problems at the sharp-end, in the work.

Performance metrics derived at the business case stage tend only to measure activity on whether a project is completed ‘on time’ and ‘to cost’. Little regard is made of how much operational improvement is achieved in resolving the real problem(s).

‘Off-the-shelf’, standardised solutions are mandated that usually involve automation or greater use of technology (sometimes referred to as ‘channel shift’ or ‘digital-by-default’); sharing or outsourcing services; restructuring to establish new ‘target operating models’; rationing buildings and service provision; charging and trading services and/or reducing staff numbers. Here abstract cost-benefit equations are the order of the day.

Unless consultants are engaged, ‘delivery’, ‘execution’ or ‘implementation’ is then solely contracted out to frontline staff who are left to try and make the problem fit the predetermined standardised solution(s). Benefits realisation plans are written remotely and focus on the completion of activity tasks not performance improvement.

Consequently, ‘change’ seeks to solve symptoms not address root-causes. The predictable result of this way of approaching improvement are failing projects, higher costs and poorer service as experienced by patients.

Tomorrow I will outline the more intelligent way to conceive of how to change for better and undertake meaningful performance improvement.