Systems not Structures: Changing HSC Professor Rafael Bengoa NIPE - - PowerPoint PPT Presentation

Maximising Outcomes, Embracing Challenges

NIPE PEC C Annual Confe ferenc rence

8 March 2017

Professor Rafael Bengoa

Systems not Structures: Changing HSC

Institute for Health & Strategy

• Bilbao. Spain

Rafael ael Bengoa engoa

NIPEC Conference Belfast . March 8 2017

“IMPLEMENTATION OF LARGE SCALE REFORM”

FRAGMENTATION…

Chroni ronic Budget dget !!

• GET

T BEYON YOND FRAGM RAGMENT NTAT ATIO ION N OF CARE. RE.

• MOVE

VE TO O SYST STEM EM MANA NAGE GEMEN MENT

• TARGET

ARGET BET ETTER TER CHR HRON ONIC IC CONDI NDITIO IONS NS MANA NAGEM EMENT NT

• IMPROV

ROVE E PATIE TIENT NT-CENT CENTEREDNE EREDNESS SS & EMPOW OWERME ERMENT

• MOVE

VE TOWARDS OWARDS POPULA PULATIO ION N HEALT ALTH H MANA NAGE GEMENT. ENT.

• EXPA

PAND ND USE E OF INFO FORMA MATIO ION N AND COMM MMUNIC UNICAT ATIO ION N TEC ECHNO HNOLO LOGY GY .

• EXPLO

PLORE E AND ADAP APT T OUT UTCOME COME BASED SED PAYME MENT NT MODEL DELS S TO O ENC NCOUR URAGE AGE VALUE LUE VERSUS RSUS ACTIVIT TIVITY

PROACTIVITY PATIENT EMPOWERMENT PERSONALIZATION PREVENTION POPULATION

WE HAVE “SYSTEM” FRAMEWORKS

STRUCTURES “COMMUNITY” SYSTEM

• Mental map Structures
• Fragmentation
• Reactive episodic care
• Paternalistis
• Vertical leadership
• Financing structures and activity
• Mental map : SYSTEM
• Continuity of care across a SYSTEM
• Proactive SYSTEM
• Patient empowerment
• Decentralized SYSTEM leadership
• Paying for value
• Health & social care “SYSTEM”

Vs .

PATIENT ENT

MANAGE “SYSTEMS” RATHER THAN MANAGING STRUCTURES

Management “Arsenal” for Transformation

• Electron

ectronic ic Medica dical l Record cord

• Electron

ectronic ic prescr script iptio ion

• Telem

lemedic icin ine, e, telec ecare are, te telem emonit itoring

• ring
• Risk

sk Strat atifica ificati tion n Popula pulatio ion

• Ne

New w fi finan nanci cing ng models

• dels
• Integ

tegrat ated ed care

• Coo
• ordin

dinatio tion Heal alth h & & Soc

• cia

ial l Care

• New

w profes fessio ional al roles les (nu nursin sing)

• Patient

ient Empo powe wermen rment (self lf- manag anagem ement) nt)

• Thir

hird d secto tor Strengthen engthenin ing

• Transf

ansforma

• rmatio

tion of f subacu bacute e facilitie cilities

• Metho

thods ds for a greater ater engagem ngagemen ent

• f

f heal ealth h professio essional als

• New

w forms rms of distri ributiv butive/fac e/facil ilit itat ator

• r

leadershi adership. .

WHAT ARE WE LEARNING ABOUT IMPLEMENTATION?

Minister

• f Health

• REINFORCES A “RESIST”

CULTURE

• DOES NOT CHANGE

MODEL OF CARE

• SOME LOW HANGING

FRUIT STILL AVAILABLE (WASTE )

• LAUNCHES A TRANSFORMATIVE

CULTURE

• REACH UP FOR THE HIGH

HANGING FRUIT

• TOUGH BUT DOES CHANGE THE

MODEL OF CARE

&

NEED TO MANAGE TWO AGENDAS SIMULTANEOUSLY

Bengoa/Arratibel . SI Health

• ENGAGE ALL RELEVANT ACTORS

TOUGHEST PART

NEW POLICY/STRATEGY (WHAT)

IMPLEMENTATION PROCESS (HOW)

Recipients of Change

SI-Health

• P. Arratibel/R. Bengoa

• Absence of buy-in from clinicians and other staff
• 'Big bang' momentum that is not sustained over time
• Cost-cutting so that investment in change is lacking or

insufficient

• The existence of weak capacity to make change work
• Burn out and 'reform fatigue' with constant churn and

change of focus

• Loss of interest
• Too much change, too fast
• Promotion or departure of person in charge
• The role of politics which can divert energy and derail

change

MOR ORE RE RESOU OURCE RCES & TR TRANSF SFORMATION ORMATION

MORE RE RESO SOURCES URCES & NO TRANSFORM RANSFORMATION ATION NO RESO SOUR URCES & TRAN ANSF SFORMATIO ORMATION NO RE RESOU SOURCES RCES NO NO TRAN ANSFO SFORM RMATION ATION

! THE RESPONSE !

• A focus on the how not what

what

• f change
• Identifying ways to create

and sustain a receptive context for successful change

• There can be no guarantees – there is ‘no

simple recipe or quick fix in managing complex change’ (Pettigrew et al 1992)

Quality of policy developed nationally and locally is

important in terms of both its analytical and process

• elements. Policy informed by evidence and data is important

in presenting a sound case for change and persuading sceptical practitioners. Successful polices demonstrate coherence and alignment between goals, feasibility and implementation.

Quality and Coherence of Policy

POSITIVE RESULTS FROM REFORMS… Evidence : Benefits in :

• Improved outcomes
• Patient satisfaction
• Patient safety
• Increased use of care plans
• New roles for staff
• Ambiguous results at reducing costs

19

COMMUNITIES THAT BUILD DENSE MULTISECTOR NETWORKS = LESS MORTALITY !

Critical in creating the conditions for transformational

change and in ensuring they remain in place long enough to become embedded. Importance of political context and impact of politics in shaping the environment governing large-scale change. Structural change or change involving regulation and/or inspection can occur rapidly. Cultural change takes longer.

Environmental Pressure

Kingdon Policy Streams

 The three streams have

lives of their own

 The probability of

rising on the agenda is increased if all 3 streams are joined

 Partial couplings

between 2 streams are less likely to result in policy changes

Northern Ireland

• POLITICAL SUMMIT
• PARLAMENTIARY HEALTH

COMMITTEE

• GOVERNMENT ……

People in key posts leading change is critical. Not heroic

leaders of a traditional command and control type but those who exercise leadership in a more adaptive, distributed style. Quiet or servant leaders are often more effective than those who lead from the front. Building teams across whole systems is essential in health system transformation.

Key People Leading Change

• Nursi

sing ng experti rtise se is cr criti tica cal to health th system ems reform rm.

• NURS

RSES ES SHOU HOULD LD BE FULL LL PARTN RTNERS ERS WITH TH OTH THER ER HEALT ALTHCA HCARE E PROF OFESS SSION IONALS ALS IN REDES DESIGNIN IGNING G HEAL ALTH TH CARE ARE

• As the Institute of Medicine’s (IOM) Future of Nursing: Leading Change,

Advancing Health report states:

• Recommen

enda dati tion

• n 7: P

Prepa pare re and enable e nurses es to lead change e to advance e health. Nurses, nursing education programs, and nursing associations should prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses. (IOM, Future of Nursing, Leading Change, Advancing Health: Report Recommendations, National Academies of Science, Washington, DC, p. 5).

Culture involving deep-seated assumptions and values

leading to particular patterns of behaviour can serve as a barrier to change and create inertia. Health systems comprise a complex set of multiple cultures. A supportive culture can challenge and change beliefs. Leaders can be agents for cultural change.

Supportive Organisation al Culture

Supportive Organizational culture BALANCE PUSH & PULL STRATEGIES…..

• Some level of “orquestration” from above but seeking to identify

commitment rather than compliance

• Key element of the “orquestration” is from the payment reforms

(value) rather than from micromanagement of providers.

1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10

20th CENTURY 21 st CENTURY

SOURCE: Muir Gray

STRENGTH OF PROVIDERS STRENGTH OF PROVIDERS STRENGTH OF PAYERS STRENGTH OF PAYERS

PAYMENT REFORMS COMMISSIONING VALUE ; NOT ONLY ACTIVITY

• Results seem to support new payment models:
• Improvements in quality

The Alternative Quality Contract (AQC)

PAYING FOR VALUE: THE PLAN

The managerial-clinical interface is critically important in

health systems especially at a time of rapid change which can seem threatening to notions of clinical autonomy. The disconnect between managers and clinicians is a feature of all health systems. Those opposed to change can block or sabotage it. Managers and clinicians need to understand each other’s worlds.

Managerial- clinical Relations

31

NHS Staff Management and Health Service Quality West and Dawson Staff Engagement

Change From the Inside Out: Health Care Leaders Taking the Helm

Donald M. Berwick, MD, MPP1; Derek Feeley, DBA1; Saranya Loehrer, MD, MPH1

• JAMA. 2015;313(17):1707-1708.

doi:10.1001/jama.2015.2830

The Institute for Health & Strategy