Learning from others: lessons from cardiac surgery

When faced with a daunting challenge, one of the best places to start is often to look at how others have tackled the same challenge; to take forward what they did well and to learn from their mistakes. On 2nd November, the multiple sclerosis (MS) community who had gathered in the name of ending MS service variancelistened to the lessons that Professor Ben Bridgewater learned over the ten years that he led on national work to improve outcomes in cardiac surgery.

Lessons from cardiac surgery

Painting the picture of cardiothoracic services a decade ago, Professor Bridgewater outlined the challenges succinctly across three core areas: unacceptable variation in outcomes, failures in governance and an erosion of public confidence. Alongside this was a lack of transparency in the service, meaning that to find out what quality of care you might receive in any given facility was almost impossible.Through a national collaboration of cardiac surgeons with aligned goals, Ben and his team collected, collated and analysed data, presenting this back to clinicians across the country and affixing key performance indicators and governance systems into the mix. As a result, mortality following cardiac surgery is almost a third of what it was a decade ago – a wonderful result. However, Ben shared a great deal of learning and was confident that, if he were to do it all again, he might well do things differently. So what were the key learning points for us to draw on for MS services?

It’s all about people

Over the past year, the Neurology Academy has been listening and sharing learning from some of the Faculty on our Parkinson’s MasterClass as part of a retrospective for our sixteenth birthday. Something we have heard again and again is that service transformation ultimately comes down to people. Consultants specialising in Parkinson’s and other movement disorders reiterated again and again the importance of relationships. From to getting parity of service access across a patch, to enabling person-centred care, to thinking laterally to achieve optimal services, every story about delivering excellence relied on the strength of the professional relationships the clinical leader forged. We heard this same message in Dr David Rog’s presentation when looking at multi-disciplinary team meetings as a vehicle to end variance in MS services – and Professor Bridgewater shared this same experience.His work in ending cardiac surgery variation began with a collaboration of cardiac surgeons, noting that the success of their work was very much grounded in the personalities within the group. When he looks back on the main features of services going wrong for cardiothoracics, much of them were about people. ‘Mal-aligned culture, protecting organisations, unrestrained egos, dysfunctional relationships and a lack of organisational support or accountability at a Board level’ were reeled off in a list. ‘Poor systems’, also a key element found to be contributing to failing services, was the only thing in this top level list not centred around human interaction.Owing to this, it is unsurprising that one of Ben’s core recommendations to the MS community as it seeks to tackle variance is of clinical leadership.

‘You can’t just have individual leaders though’, he points out. ‘You need to scale it up.’

What that means in practical application is that there needs to be whole systems of clinical leaders all working to a shared agenda to affect change.[caption id="attachment_3681" align="alignnone" width="519"] Fig 1 – ‘what does good look like’ B. Bridgewater slides 2018[/caption]Figure 1 shows Ben’s suggested outline for what ‘good’ looks like in order to have equitable and optimal services for people – all human elements – highlighting just how essential allied health professionals and the professional healthcare workforce is to ending variation for MS.

Data makes all the difference

What do you do when you have established a national team of motivated clinical leaders?

‘What made the real difference was probably engaging with the data’, Ben told the conference,

and in cardiothoracics case, gathering and utilising the data to inform practice was mandated. It was more the transparency and unification that looking at the data caused than the information found itself, though. Statistically, Ben noted, the variation in cardiac surgery is exactly the same now as it was when his team began their work a decade ago, but the outcomes are much improved across the board: ‘we moved the pack from where it was to where it is now’, he noted.Ben helped the conference to understand what constitutes data by using a Microsoft model to present both his own work in cardiac surgery (fig 2), and the suggested ways of working for the MS community going forward. In summary, he described the four layers of data:

1. Systems of engagement: what you do with the information you have
2. Systems of insight: what happened in the past, what is happening now, and what might happen in the future
3. Systems of record: the information we are recording
4. Systems of infrastructure: increasingly the ‘cloud’ network

[caption id="attachment_3685" align="alignnone" width="500"] Fig 2 – ‘Microsoft model of understanding data’ from B. Bridgewater slides 2018[/caption]Working across these four levels will help to ensure all areas of data are being considered and that a full picture is being gathered and used.

Global technology – what can we learn?

In addition to the learning he shared from cardiothoracics, Ben presented on his current expertise: the role of global technology in delivering better services and care, and in improving patient experience. Having made this shift professionally to try and scale up the impact he could have on patient experience, he was able to give clear direction in how technology can improve services. He was very clear to focus on the transformation, not the technology, however.Rather than looking at how technology can augment existing services - something which some delegates from the floor felt is often hindering their practice rather than improving it - he felt that our focus needs to shift: ‘How can digital transformation change and improve the way we get to the outcomes we want to see?’ Essentially, how can we use technology to solve existing problems, rather than try to fix the current solution to that problem? (fig 3)Highlighting that there are three key models: product leadership, operational efficiency, and customer relationships, Ben suggested we could draw on elements of all, but that ultimately we need to understand what we are trying to do as each model has a different emphasis and creates different cultures.[caption id="attachment_3687" align="alignnone" width="500"] Fig 3 – ‘In a nutshell’ technology to drive service transformation: B Bridgewater slides 2018[/caption]In using technology, he urged us to consider a ‘digital vision’ to find, firstly, platforms to make things happen and secondly, a method to deliver it. However, the technology platforms can only work if they are designed to solve the actual problem, and if the people using the platform are on board.

‘You need to be clear about the problems so you can work out the solutions. But the people, the relationships and the culture are every bit as important as the technology.’

Neurological application

Ben shared a very acute insight as he reflected on his team’s work:

‘We weren’t quite clear about what we were trying to achieve and therefore it’s hard to know whether we achieved it.’

At the end of his presentation, Ben invited Professor Jeremy Hobart to share his thoughts on applying these findings to neurology – and to MS specifically. The take home messages were very much informed by this statement. ‘What do we want to do?’ asked Jeremy. ‘We need to clarify our problem statements – things like ‘improve outcomes’ and ‘engage patients’ are too ambiguous.’‘It is deeply challenging for us but we have to change radically what we do,’ summarised Jeremy. The importance of people and culture, a need to understand what we really want to achieve, and thought to how we can use digital thinking to shape tomorrow’s services – not augment today’s, were the three core thoughts to take forward.The only thing that remains is to start that radical change. But, as a delegates’ voiced from the floor,

‘Where do we start?’ Ben gave a clear, encouraging response. ‘Avoid rushing into anything until you’re clear about what the problems are. After that, any step in the right direction is a step in the right direction.’

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For more information:

• Read some of the stories around people-centred service change in Parkinson’s from our Parkinson’s MasterClass 16th birthday.
• Read Ben and his team’s academic article ‘Publishing cardiac surgery mortality rates: lessons for other specialties’ in the British Medical Journal.
• More spotlight articles for an in-depth look at some of the key issues raised at the Variance event
• Register for our follow-up meeting 2019: MS Service Provision in the UK 2019; Raising the Bar