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Implementing and sustaining transformational change in health care: lessons learnt about clinical process redesign

Katherine M McGrath, Denise M Bennett, David I Ben-Tovim, Steven C Boyages, Nigel J Lyons and Tony J O’Connell
Med J Aust 2008; 188 (6): S32. || doi: 10.5694/j.1326-5377.2008.tb01672.x
Published online: 17 March 2008
Leadership by the chief executive and senior management

Visible involvement of the chief executive and senior management is essential.3 Senior management needs to set the standards for service delivery and drive the change process. This requires management to engage and challenge staff with “stretch goals” (ambitious goals that stimulate staff beyond their current achievements), set the parameters for acceptable solutions, ensure strategies are implemented within set timeframes and budgets, monitor performance, and reward success. Staff members need to see that the program is a priority for their chief executive officer. To succeed in the face of obstacles and setbacks, resistance, or failure of certain elements of the project, senior managers need to be resilient and keep the momentum going.

The experience at FMC (→ Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”)4 has highlighted the significant benefits of having the executive team at hospital level directly involved in the redesign. FMC found it valuable to have senior clinicians and executives involved in tracking patient journeys and in clinical work. This has helped take redesign from being a project to being part of what staff do every day.

In New South Wales, regular visits to clinical redesign sites by the NSW Director-General of Health and the NSW Minister for Health have been found to be a powerful motivator for staff, as these visits indicate that clinical process redesign is a high priority.

Managing the process — internal versus external management

As outlined in other articles in this supplement, both NSW Health (→ Patient journeys: the process of clinical redesign)6 and FMC (→ Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”)4 created a central group to manage their overall redesign programs. In NSW, this involved many hospitals across the state, whereas FMC is a single medical centre. In both places, there was recognition that the redesign process was a method that had been widely and successfully applied in other industries5 and there was a need to learn from or directly involve experts in redesign. FMC staff attended an external course to learn the redesign principles, whereas NSW Health engaged external consultants. The NSW statewide project delivered a significant return on this investment for NSW Health by reducing length of stay for patients.

In both cases, strong program management, both centrally and at the level of individual projects, was essential. In NSW, the use of external facilitators (→ Patient journeys: the process of clinical redesign)6 was a powerful tool in breaking down the “silo” mentality and facilitating multidisciplinary teamwork. Their expertise in change management and in establishing data charts was exceptionally helpful in driving change. It was also essential to get the process up and running in multiple sites, where management and clinicians were often uncertain as to the benefits of the program.

Persistence and flexibility

It does not matter which improvement method or model (lean thinking,5 six sigma,8 or theory of constraints9) is used in the redesign process, as long as it is applied with rigour and persistence. We have found that there needs to be constancy of purpose by all those involved in clinical process redesign.

It is important to recognise that the redesign projects are not controlled trials, but are more akin to action research10 in that they are not designed to be perfect or dictated by strict protocols, but rather to be iterative and flexible as the need arises. In fact, it is crucial to their success that they are modifiable in response to data, as well as to staff and patient feedback. The plan-do-study-act11 method (testing a change by planning it, trying it, observing the results, and acting on what is discovered) is ideal for a flexible improvement model and allows reflective learning from one intervention to feed into the next.

Sustainability

Sustainability involves an ongoing improvement process. It should be a process of continuous review and improvement of health service delivery to meet a set of agreed standards. It needs to be embedded to become part of normal business for a health care organisation, not a series of one-off projects or crisis-driven reform programs.

Sustainability, in our experience, is the most challenging phase of clinical process redesign. It is best depicted as a staircase, which demonstrates the notion that redesign is, by nature, continuous (Box 2).

With this in mind, how should we approach sustainability? Our view is that it should be thought about as a dynamic process containing three main elements — standard work, maintenance and continuous improvement (Box 3).

Conclusion

Clinical process redesign holds much potential. It has already demonstrated that it is a powerful tool for improving the systems that underpin health care service delivery. It has provided benefits for patients and staff by enhancing access and patient flow, and increasing safety, as well as improving the experience and health outcomes for patients.

  • Katherine M McGrath1
  • Denise M Bennett2
  • David I Ben-Tovim2,3
  • Steven C Boyages4,5
  • Nigel J Lyons6
  • Tony J O’Connell1

  • 1 NSW Health, Sydney, NSW.
  • 2 Flinders Medical Centre, Adelaide, SA.
  • 3 Flinders University, Adelaide, SA.
  • 4 Sydney West Area Health Service, Sydney, NSW.
  • 5 University of Sydney, Sydney, NSW.
  • 6 Hunter New England Area Health Service, Newcastle, NSW.


Correspondence: kamcg@doh.health.nsw.gov.au

Acknowledgements: 

Thanks to Professor John Marley and Dr Deborah Lloyd for their editorial advice on this article, and to Dr Lloyd for her work in the preparation of this supplement.

Competing interests:

None identified.

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