Trust, an ingredient needed to innovate

Mònica Almiñana

"One, the citizenry will not forgive the president for hiding health information that can help save their lives. Two, in a crisis, people must feel like a soldier, not a victim. Three, telling the truth generates trust, silence generates fear. "

CJ Creck, The West Wing. Season 3, Episode 9 (2001-2002)

When Aaron Sorking wrote these sentences for his character, the White House press chief in the series The West Wing, in a chapter where a health problem was addressed, came up with some of the keys needed to manage the communication of this type of crisis. In a recent article in BMJ Leader, "Leadership during the COVID-19 pandemic: building and sustaining trust in times of uncertainty," Susannah Ahern and Erwin Loh also outline some of the keys to leadership in times of uncertainty. And one of those keys is trust. The authors themselves define it as "The expectation or belief of an individual, often in vulnerable circumstances, that another person's actions or motives will be honest, fair, and based on integrity (following sound ethical principles)." (1)

Clinical practice guidelines versus shared decisions

In the April post I was talking about the call for the end of clinical practice guidelines. This is an issue that is generating controversy and I think it’s worth revisiting, especially following the publication of “Making evidence based medicine work for individual patients” by Margaret McCartney and collaborators, where they say that there is concern because the guidelines, instead of reducing variations and improving the quality of assistance have managed to bureaucratize medicine, while at the same time reinforcing historical authoritarianism. This happens because, according to the authors, based on the evidence, the guides encourage doctors to ignore the real needs of the people they serve. In addition and to top it all, a review concluded that 62% of the guidelines were based on irrelevant evidence for health problems affecting people visiting the family doctor.

Health incentives: don’t shoot the behavioural economists!

Pedro Rey

The debate on the allocation of (economic) incentives associated with the performance of health professionals has been relevant for a long time. A few months ago, VOX has published an editorial with a very clear title: Paying Doctors Bonuses for Better Health Outcomes Makes Sense in Theory. But it doesn’t Work. The article cites numerous recent studies, such as this one on the United Kingdom or the United States, that show no effect of giving incentives to physicians either in their clinical practice patterns (inputs) or in health outcomes (outputs). A systematic review of studies on "pay for performance" (P4P) in the Annals of Internal Medicine reaches similar negative conclusions. However, a marked anti-economist tone of these articles emerges that I believe comes from a confusion. According to these articles, economists only know how to prescribe the use of incentives, without evaluating their effects, and also the incentives that we advise are only monetary and don’t appeal to the many different motivations, not only monetary, that can affect doctors decisions.

Right Care: focusing on the attitude

Continuing with the "Right Care" series of the Lancet magazine, in this third post (I recall that "Definition, gray areas and reversion" was the first, and "Between too much and too little", the second), I have taken into account the beliefs of patients who, according to Vikas Saini in "Drivers of poor medical care," encourage practices of little value, but I have also described the attitudes of doctors who don’t prioritise the value of clinical practices. Remember that, according to Donald Berwick, between 25% and 33% of health costs are wasted in medical actions that don’t contribute anything or do more harm than good.

Doctors strikes and medical congresses = less mortality

At a doctors' strike in Israel in 2000, the gravediggers noticed that their workload diminished in areas where the doctors’ strike was on, while it remained unchanged in areas where doctors did not adhere. Judy Siegel-Itzkovich, scientific editor of the Jerusalem Post, in a letter called “Doctors' strike in Israel may be good for health”  attributed the phenomenon to the shutdown of the scheduled surgery, which probably brings improvements of certain ailments, but which, by itself, can lead to complications and mortality. A few years later, in “Doctors' strikes and mortality: a review”, a systematic review of 156 papers analyzing the mortality impact of several doctors' strikes around the world, shows that during the doctors’ strikes, the population mortality either remains unchanged or lowers, but it never rises. The authors of the paper, like the Jewish publisher, also think that the phenomenon is an indirect measurement of the surgical over activity so common in clinical practice that, curiously, is shown when the programmed activity ceases drastically during a certain period.

Hospitals: 10 necessary structural reforms

Hospitals are structures that generate a powerful influence on the overall health system. Their effectiveness in the resolution of certain acute diseases, especially surgical, gives them a great social prestige. This fact should not, however, hide two structural problems that are burdening their perspective:

a) The first problem is internal. Bureaucracies themselves are showing signs of fatigue and this affects the quality of services, especially in the safety of admitted patients.

From the Triple Aim to the Quadruple Aim

Cristina Roure

Readers of the blog Advances in Clinical Management will be familiar with the term Triple Aim coined by Donald Berwick from the Institute for Healthcare Improvement of the United States(1) which recognizes those clinical projects that simultaneously achieve the triple objective to:

1. Improve the patient experience (satisfaction and quality)
2. Improve clinical outcomes in the population
3. Reduce health care per capita costs

Saving Plans: 5 Errors and 5 Proposals

Remember the games of the analogue times, precisely the moment when the player put the piece in the wrong place and there came a warning sound and the red light lit up the nose? Now it looks like a naff old thing, but I liked that Robert Kaplan and Derek Haas have chosen the image of one of these games, precisely one that is for operating a patient and that they have chosen it to illustrate their article published in the Harvard Business Review blog, "How not to cut health care costs".

When faced with budget cuts, they say, health managers around the world apply the same recipe: reducing staff costs (both in numbers and in wages), optimize the use of space to save general services, stop investments and rationalize spending. The authors do not maintain that this package of measures is poorly done, but they question whether behind these policies there isn’t a strategic way of thinking that combines resources to achieve the best results in the most efficient manner possible and the efforts of the basic savings pack can become counterproductive for the health of people and also for the economy of organizations.

Therefore, we should appreciate that the article analyzes five errors of the basic savings pack, while proposing five alternatives focused on efficiency and effectiveness.

Family doctors: it’s time to strongly support

The number of places for family doctors at the last resident doctors (MIR) call from the Spanish government is of 1,671, only 25% of all specialties convened. The question is: Will this annual promotion of family doctors cover the future needs of an increasingly aging population? If we’d pay attention to a report from British experts, "Securing the future GP workforce" the answer would be clearly negative. This document ensures that to meet the challenges in chronic disease from primary care, half of medical students who now graduate would need to become family doctors. But how to make the profession more attractive if its disrepute is so big that each year, at the MIR call, there are many vacancies left and the dropouts during training reach 15%?

In a survey (“Why doctors flee and shun the family medicine?” by Gonzalez B, Barber P and Ortún V) undertaken with students from the sixth grade of the medical course, a surprising finding stands out: students prefer generalist specialties, including family medicine. The surprise, however, doesn’t last long, because after strenuous preparation for the MIR test, most of, by now graduated doctors, shift in preference and opt for more technical specialties. The same survey warns that, this in this shift, we can detect not only the influence of MIR but also other relevant issues such as working conditions, pay and prestige.

How to involve doctors in transforming the health system

All health systems need to streamline costs while solving a lot of complex problems and  improving health outcomes. We’re dealing then with difficult challenges that are almost impossible without the doctors’ involvement, and for this reason I found this article to be very relevant: "Engaging Doctors in the Health Care Revolution" by Thomas Lee and Toby Cosgrove, from Harvard Business Review, as they are seeking solutions from Max Weber and his 4 fundamental motivations for social actions.

Motivation 1. Look for noble targets

When managers and doctors meet up, they ought to discuss patients, quality and results, and if they really want to change the status quo, they should not wonder away from this script. The conversation, therefore, should never start with contracts and compensations, this topic ought to be reserved, if at all, for the end of the meeting, after the main topics. Managers ought to listen, assess the views and know how to create a process in which all parties should have the opportunity to add their personal touches to the final process. A basic script of 3 points that the authors extracted from Mayo Clinic should be kept in mind: a) at the time of sitting down for the discussion, everyone should be very clear that things can not continue as they are; change is needed, b) the transformative project that arises must be clearly focused on the patient, and c) this is a path on which all involved actors will walk together.

Leadership: difficulties and challenges

Managers from National Health Service consortiums now seem an endangered species, according to the King's Fund. Politicians have demanded cuts and they have fought greatly so that their centres can maintain the required levels of care. The result: the leakage of first level managers disappearing from the public system.

The first reference documents, which has as its subtitle "No More Heroes" (the green one), describes the new leadership style beyond the mandatory compliance to the objectives imposed from above. It said that Managers who have an inside perspective are essential if we want to get the doctors, nurses and other health professionals to do their work with quality. The new leadership should not only correspond to the manager, the heroism no longer makes sense. Therefore, now we need to have leaders throughout the organization, leaders who are present in every corner of all processes and, above all, know how to involve professionals in the management of resources, but also know how to facilitate the participation of patients in the decisions that affect them.

Differences between a leader and a manager

Las diferencias entre un líder y un gestor - John Sculley http://t.co/Y9U4xssKv6
— Julio Mayol (@juliomayol) February 22, 2014

The tweet edited by Julio Mayol lead to a video about an intervention of John Sculley, Chief Executive Officer (CEO) at the beginning of Apple. Those who have seen the movie about the life of Steve Jobs will recall that Sculley was the Pepsi Cola manager joining a young and sassy Apple, in order to turn it into a business. Those who have not seen it should know that this ended badly, especially because the leader, Steve, had a vision focused on innovation, while the businessman was focused on market and profits. Jobs was fired in 1985 and the company without him, continued fighting in an emerging market, with good results, as Sculley wanted, but without the punch of a leader. Jobs ended up buying Apple, thirteen years later, when the company, now without Sculley managing it, went into bankruptcy.

These two figures: the leader and the manager are essential for businesses, both public and private ones alike. The leader is associated with the vision, and thus with a project, while the manager is associated with a board of directors or the public administration directly. The success of institutions relies on the two figures finding a common work field where they can negotiate and share objectives. From Jobs-Sculley type confrontations, only resounding failures for both parties can arise.


Jordi Varela

Editor