THE MEANING OF “REDESIGN”

Healthcare redesign can be broadly defined as thinking through from scratch the best process to achieve speedy and effective care from a patient perspective, identifying where delays, unnecessary steps or potential for error are built into the process, and then redesigning the process to remove them and dramatically improve the quality of care.

In principle, healthcare organisations around the world have always aimed to serve patients. In practice, however, they do not always put patients’ needs and preferences first over the convenience of the organisation. Established ways of doing things often remain unquestioned; the daily struggle to keep existing processes going with limited resources—”hamster health care” as it has been aptly described—rarely allows space to step back and reflect critically. Redesign seeks to challenge this organisational treadmill and to question practices that are taken for granted.

This means not just doing more of the same, or doing it slightly differently, but rethinking the assumption that it needs to be done at all, and whether what is done at present adds any value to patients (or, indeed, to hard pressed staff). An important principle of redesign is that it should be led by frontline staff themselves, who are best placed to know what currently happens and develop creative ideas for improvement. Typical steps in a redesign initiative might include:

• Mapping the existing care process (sometimes described as the “as is” stage).

• Analysing where problems exist in that process and questioning why each step is done, by whom, where, in what sequence, and is there a better way?

• Imagining what an “ideal” process might look like (sometimes described in re-engineering as “visioning”).

• Identifying practical changes to the current process to make it closer to the ideal process.

• Testing these changes and evaluating whether they result in improvement.

In the initial process mapping stage frontline staff of all disciplines connected with a process pool their different perspectives to write down the different steps patients go through and what delays they encounter. Individual staff may feel their own “piece of the jigsaw” is straightforward and efficient, but may never have seen how it fits into the wider picture and how the whole system could be made more efficient. The process map can be represented as a simple text list or as a formal flow chart using different symbols or shapes to represent steps such as “transport”, “waiting”, or “decision making”. A simple illustration is given in fig 1.

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Figure 1

Process map.

Ideally, patients should also be directly involved in process mapping. However, patients may not feel sufficiently empowered and staff may feel reluctant to explore flaws in the process honestly with patients present. Indirect means of patient involvement such as confidential interviews, patient diaries, and observational tracking of patients through the system can help to overcome this.

THEORETICAL ORIGINS OF REDESIGN

Healthcare redesign draws on various quality improvement theories but seeks to incorporate learning from past experience of applying them to health care. These include, amongst others, the theory of constraints,⁹ lean thinking,¹⁰ and complexity theory.¹¹ However, two particularly important strands of influence will be examined here—total quality management (TQM)/continuous quality improvement (CQI)^12–14 and re-engineering.¹⁵ Both approaches have a primary focus on the needs of the customer or user, not the needs of the organisation, and examine whole processes rather than single departments or tasks. However, they recommend strongly contrasting methods: the guiding philosophy of TQM is continuous incremental improvement, while re-engineering is based on radical rapid transformation. The key characteristics are summarised in boxes 1 and 2.

In health care and beyond, both TQM/CQI and re-engineering have promised substantial change, but the reality has rarely matched expectations. Evidence on the extent of change and factors which have affected implementation are explored below. (It should be noted that much of the literature in both fields is either prescriptive in nature or presents the experience of individual stakeholders and enthusiasts; independent research evidence is relatively scarce).

In principle, continuous quality improvement led by frontline staff would seem an appropriate choice for health care, given all the evidence that “top down” imposition of change rarely succeeds in getting autonomous clinical professionals to change practice.¹⁶ An approach led by clinicians which allows for gradual negotiation and implementation seems more likely to be accepted. It has also been suggested that the emphasis of TQM on systematic measurement and evaluation appeals to doctors’ scientific training.

However, available evidence on TQM/CQI in health care suggests that improvements in quality have been slow to materialise and relatively small scale. CQI techniques may have some success within individual teams or departments, but changes made have tended to be limited in scope and impact. There is little evidence to support the claim that TQM programmes will act as a catalyst to achieve organisation-wide change.^17–19

There are clear messages from these studies that, where some progress has been made, the engagement of clinicians has been essential, as well as senior management commitment and persistence. However, professional resistance to what is seen as an imported business technique has been a common obstacle.

Pollitt²⁰ has argued that many business approaches to quality improvement, including both TQM and re-engineering, have failed to take account of the complexity of health care and the nature of professionalised knowledge. The language and values used are alien to health care and are rejected as management fads.

Re-engineering was a response to the perceived failures of TQM’s incrementalism and failure to achieve organisation-wide change but, as with TQM, research suggests that the gains made in health care (as in other organisations) have not been as great as predicted.^21–24 A particular problem has been its aggressive rhetoric and its failure to engage the staff on whom the organisation relies.²⁵ One situation where it seems to be more effective is where organisations are in such crisis that accepting the painful therapy of re-engineering is the only way to survive.

Evaluations of two re-engineering pilots within the NHS suggest that personal commitment from the Chief Executive and other senior managers was an important factor in making the improvements which were achieved, but clinical resistance to what was seen as a brutal and inappropriate technique proved to be a major obstacle.^21,24 In both sites re-engineering had to be adapted to a more incremental and negotiated style to secure the involvement of clinicians. While this reflects the reality of managing change in health care, it implies a withdrawal from the grander ambition of transformational change; in practice, re-engineering has come much closer to TQM/CQI than the clear theoretical differences between these approaches would suggest:“Second order change rhetoric gave way to first order impact.”²¹ (page 272)“If BPR has to be applied incrementally and selectively, it doesn’t look so very different from other quality initiatives such as TQM.”²⁴ (pp 413–4)

REDESIGN: BLENDING QUALITY IMPROVEMENT APPROACHES

A direct link exists between the re-engineering pilots and current redesign initiatives in the UK; a number of key players from the re-engineering pilot sites now occupy senior roles in the Modernisation Agency and the NHS Executive and their thinking has influenced the NHS Plan.⁷ In the US the Institute for Healthcare Improvement is grounded more in the TQM/CQI tradition, which has consistently been advocated by its director, Don Berwick.^13,26 However, both agencies—and others around the world—are conscious that the evidence suggests both approaches have major limitations and have not been as successful as was hoped.

Their thinking is converging on redesign as an attempt to retain and combine the best elements of re-engineering and TQM/CQI but avoiding the pitfalls. In particular, these agencies are experimenting with ways to retain the benefits of gradual negotiated improvement without losing the organisation-wide lateral vision of re-engineering and the opportunity to make discontinuous revolutionary changes as well as continuous improvement. Although redesign is often presented by its advocates as a single new entity, it is in fact more of an umbrella term covering a range of approaches with varying degrees of emphasis and eclectic use of tools and frameworks. This range can be seen in the practical examples given in boxes 3, 4, and 5. The first example shows all the hallmarks of a classic CQI process, but with some more substantial changes in role with the introduction of a pharmacy technician. The second example has more in common with the radical questioning of traditional assumptions and simultaneous removal of several steps in the process associated with re-engineering. In the third example the use of continuous “Plan-Do-Study-Act” (PDSA) cycles is combined with the ambitious transformational aim of rapid improvement across organisational boundaries beyond the usual reach of individual work teams.

THE CHALLENGE FOR REDESIGN

Deciding how to combine apparently opposing philosophies is a difficult task; if redesign is to fare better than its predecessors it has to manage a number of balancing acts between apparent “dualities”.²⁷ A number of tensions can be identified:

1. Change will not work unless it is owned and led by clinical teams. This requires a gradual negotiated approach as advocated by TQM/CQI, which will be enhanced by support from clinical opinion leaders. Although TQM/CQI has had more success in gaining clinical ownership than re-engineering, clinicians have been sceptical about the sweeping claims of many quality improvement techniques imported from the private sector and have used their professional autonomy to resist. Equally, the evidence suggests that strong senior leadership (clinical and managerial) is needed to support front line teams, remove obstacles, and negotiate horizontal cross-boundary relationships if quality improvement is to have any deep and lasting effect.

2. Change has to be manageable: testing incremental improvements is a safe way to learn about redesign and foster a more receptive culture. But redesign also needs lateral thinking which looks beyond existing processes and addresses whole systems, otherwise incremental improvements are likely to remain small scale with little impact on the wider organisation. Here, the “blank sheet” approach of re-engineering which challenges traditional assumptions has much to offer. Again, senior leadership is likely to be key to keeping an eye on the big picture and ensuring smaller improvements are consistent with the overall direction, but it is important that this is top level vision and navigation rather than top down imposition. Trying to retain this radical vision is perhaps one of the most serious challenges for redesign; at present, many initiatives described as redesign do not in fact look very different from simple CQI projects.

3. Early successes help gain interest and acceptance—innovations are more likely to succeed when people can see demonstrable benefits.²⁸ However, policy makers need to recognise that ambitions for radical overnight transformation are unrealistic and that change takes time:

• Clinical and managerial staff need dedicated time set aside.

• Individuals and organisations need time to learn, to reflect, and to implement.

• Cultural change—to a new way of thinking—is a long evolutionary process.

(4) Redesign must be demystified: much of it is common sense, accessible to all, and not the preserve of a few initiates. The tendency for each new quality improvement theory to generate its own jargon and esoteric knowledge must be resisted if clinicians are to become involved effectively. But the change in thinking and the facilitation skills needed require a major investment in training and development. Developing enough people of the right calibre at all levels will be a major task. If redesign is to be a primary vehicle for change, development needs to encompass top level leaders, not just isolated change teams working against the current. A particular challenge will be to ensure that training stresses the need to engage and learn from patients themselves at all stages of redesign.

Perhaps one of the most difficult challenges facing redesign is managing the weight of political expectation. As Walshe and Freeman²⁹ have recently argued, the evidence suggests that most quality improvement interventions work some of the time, but rarely live up to the dramatic claims made for them in their early stages. Success is contingent upon multiple factors, including the manner of implementation in each setting and specific local contextual factors. Redesign faces the same issues of achieving change in a highly complex professionalised organisation as other quality improvement techniques. Although it seeks to learn from past evidence, there can be no guarantee that it will fare dramatically better. Indeed, emerging findings on the first wave of some UK redesign initiatives suggest a similar pattern of quality improvements being achieved but not being as extensive as hoped.^30–32

Walshe and Freeman²⁹ argue for careful research into quality improvement initiatives, but suggest that research which looks only at whether they work will probably just reiterate the findings that their impact is very variable and their effectiveness mixed. Research which examines how and why they work in some cases is likely to be more productive, and it is important that such research should influence the further development of redesign initiatives. However, redesign faces the very real danger that its success in convincing politicians it can turn health care around will be followed by disappointment and rejection when the gains prove to be more modest than expected.