How should regulators in health work with hospitals?
05 December 2020
By Nicola Burgess
Healthcare regulatory organisations are currently at the top of the National Health Service (NHS) hierarchy in England, issuing commands to the service providers (NHS Trusts, hospitals) below them in the pecking order.
But this top-down regulation can lead to providers focusing on implementing new processes or meeting targets, and not on whether the new regulation has any value to patients. Since the merging of NHS England and NHS Improvement in 2019 there has been debate about how this new major regulatory organisation can best foster a culture of continuous improvement across the healthcare system as a whole.
A comprehensive evaluation of a five-year partnership between NHS England and the Virginia Mason Institute, of the US, finds a less formal, more relational approach to governance produces a reciprocal learning environment for both regulators and service providers. Along with colleagues at Warwick Business School we suggest a relational approach to governance is vital for the development of a sustainable continuous improvement culture in healthcare.
Since 2018, we have been analysing the progress of NHS England's collaboration with the Virginia Mason Institute where the goal of was to transfer learning from an adaption of the Toyota Production System (also known as 'lean') by Virginia Mason Medical Center (VMMC) – a hospital in Seattle – to five English hospitals to foster a sustainable culture of continuous improvement capability.
The Toyota Production System evolved from the late 1940s to compete with US car manufacturers like Ford. At the time, Toyota had a very poor reputation for quality and very little money to invest in the machinery required to produce cars at the same volume and unit cost as US manufacturers.
Furthermore, in the aftermath of the Second World War, Japanese industry faced severe capacity constraints due to a reduced workforce and a scarcity of raw materials. So Toyota had to find a way to compete, using less of everything. Their goal was achieved through adopting an uncompromising focus on ‘value’ from the perspective of the customer, and to make value-adding activities flow seamlessly without any 'waste'.
Implemented as a production system, lean requires everybody’s involvement in the pursuit of continuous improvement through the elimination of activities and processes that don’t add value and remove these wasteful non-value adding activities.
Applied to healthcare, the goal of a production system is to constantly eliminate waste so that the quality and speed of care delivery is continuously improved, benefitting both patient and payer since less resource is spent on activities that deliver no value to the patient.
Improving the quality of patient care while simultaneously reducing the cost of care delivery is an attractive proposition for healthcare leaders. Many healthcare organisations around the world have attempted to integrate lean production principles into their operation, but very few have had success long-term or on a large scale.
Difficulties come in many forms, from lack of internal improvement capability, professional resistance towards improvement methods, and pressure from outside sources to achieve specified targets or goals. In summary, challenges common to the highly-regulated professional environment suppress the opportunity for creativity in developing solutions to thorny problems and thereby improving the performance of complex systems.
Where lean does work in the NHS
The VMMC is a notable exception to the widespread failure to effectively implement lean principles; in fact, it has been successfully enacting the system since 2002. The Virginia Mason Production System (VMPS) puts patients and continuous improvement in the quality of care at the centre of its operating values, and this approach has led to the VMMC gaining a reputation as one of the safest hospitals in the world.
In 2015 five English NHS hospitals were selected to form a partnership with the Virginia Mason Institute and implement localised versions of the VMPS. The goal of the partnership is for each of the hospitals to develop localised versions of the production system and foster a sustainable culture of continuous improvement capability in their organisations.
We are due to produce a full report in 2021 on how the five hospitals have done in adapting the VMPS to their context, but so far we have found positive results. One unexpected, but promising, finding illustrates a shift in the relationships between senior members of NHS England and NHS Improvement, and the CEOs of each of the five NHS hospitals. This shift can be credited to the partnership with the Virginia Mason Institute and a commitment to the implementation of the VMPS.
During the evaluation, we discovered a significant shift in the inter-organisational relationships as a result of the partnership. One particular aspect of the implementation of the VMPS was found to be particularly beneficial: the monthly meeting of a Transformation Guidance Board (TGB).
Through this regular meeting, a partnership ‘spirit’ has emerged between senior members of NHS England, NHS Improvement, the Virginia Mason Institute and the five CEOs. The meeting requires each CEO to present their progress with implementing their localised production systems, the results of improvement work and reflections on challenges experienced.
While the meeting is clearly structured for governance and accountability, conversations are frank and fluid between the peer group of CEOs and senior members of NHS England and NHS Improvement. The monthly meeting bears the hallmark of a learning network, where new knowledge is co-created and all members are learning together.
So what are the key factors for making this partnership successful? We have identified two interrelated components of the partnership: protected relational space and an informal behavioural contract, known as a ‘compact’.
1 Protected relational space
This refers to a safe and supportive atmosphere rather than a specific place, where collaborators should feel free to discuss both their successes and failures without judgement. This should also be a space where processes can be discussed that would challenge current institutional practises.
The monthly face-to-face meeting of the TGB provides an example of a protected relational space. It would last around six hours and did not feature any phones, laptops or other managerial distractions. Contrary to what might be expected, several representatives described these meetings as “the best day of the month”. The CEOs from the five NHS hospitals would rarely miss a meeting.
We attribute this to the friendly, informal atmosphere that characterises these meetings, and allows for the frank discussion of any and all issues experienced by the collaborators. Over time, the relationship between regulator and service provider shifted from one characterised by positional authority, where one party exercised power over the other, to a more informal relational authority, meaning both parties saw themselves as equal partners working towards a shared goal. This fostered honest discussions and built trusting relationships between senior partnership members.
A compact is an informal, non-binding agreement between the groups involved in the partnership, akin to an explicit (mutually agreed) psychological contract. This might be considered a first step towards building relational authority, as the representatives must work together to agree on the terms of the compact.
The members of the NHS partnership took nearly 12 months to negotiate the expected behaviours and responsibilities outlined in the compact.
An important behavioural aspect of the compact was an agreement to open and transparent communication, with related responsibilities such as listening and giving and receiving constructive criticism with good intent (or the assumption of good intent on the part of the collaborator giving the criticism). Another behavioural factor considered in the compact was the focus on continuous quality improvement from the perspective of the patient.
The associated responsibilities for NHS Improvement included maintaining the positive atmosphere of the collaboration and being empathetic with issues encountered by service providers as they try to foster localised versions of the VMPS, even when both parties were experiencing external pressure to demonstrate immediate change.
There were many factors considered in the development of the compact, all of which form the guidelines for how the collaboration should proceed. If one group does not meet the terms of the compact, a meeting can be held to discuss what all members of the collaboration could do differently to improve progress towards their shared vision.
We believe this relational approach to regulation could and should be extended to the wider NHS system. The positive attitudes of parties involved in the partnership, the shift to open and honest discussion and learning between the groups, suggest this could be a valuable approach for moving the NHS forward in terms of quality improvement.
But this can only be done if regulatory organisations and service providers adjust their processes to put patients first and develop trusting and respectful cross-organisational relationships.
This article is adapted from the original at Research Outreach.
Follow Nicola Burgess on Twitter @DrNicolaBurgess
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