Bob's journey - A community health service design example
We first heard about Bob, when he was admitted to the hospital. We picked his case at random, to see if by doing things in a different way, we could improve his outcome. So we had permission to change the roles we had, and the barriers in the work flow. We used a systems thinking approach.
This is what the health system knew about Bob when we started:
He seems depressed, the hospital doctor prescribed anti-depressants.
He falls over alot, and he hurt himself falling over in the hospital when getting up to go to the toilet.
He cannot support himself, and it seems his wife cannot care for him at home.
He does not really have anything major wrong with him, he is old.
Relatives are around when we need to talk to them.
He drinks too much, and is a danger to himself.
We need to find supported housing for him, and keep him in hospital in the meantime.
At this point we talked to him, his wife, and his relatives. We asked them about Bob, and we asked Bob what he needed to live a good life.
This is what we found out about Bob.
He does not get on well with his wife, because she tries to hide his beer bottles.
He is very afraid that he is going to lose his guide dog, which is the only way he has of being independent. We then found out that he was visuall impared.
He gets annoyed at life, and he has little to occupy himself. However, he was a keen model engineer when he was younger.
And this is what we found out about Bobs pattern of events in the last few months:
He has been getting fed up with his bad eyesight, and he tries to keep moving around the house, and falls over.
He has taken to beer, to help him through the day. It is a recent trend.
He is very afraid of losing his guide dog - he was told it would be removed from him if he stays in the hospital.
He is very bored, and wonders if this is all life is about. He has no real friends.
He fell over at home, because he could not see much, and he had had a beer.
He has moved FOUR beds over eight days in the hospital, so when he got up at night and wanted the toilet, he had no idea where it was and fell over some equipment.
Those in the hospital never realised he was visually impared!
He thinks he will never go back home, but he really wants to.
We looked at his life and the time leading up to the hospital admission. We aimed to give him back what he wanted. This is what we did:
We told him that he could get his guide dog back, but he would have to stop drinking his beer. He readily agreed, and that cheered him up.
Especiallly when we said that we would help him go home. We spoke to his wife and helped to make things easier for her if he returned. We got his guide dog to visit him in hospital, and that was great for him. His relatives also visited him in hospital. His behaviour transformed, and he was not depressed anymore.
We also looked around the area. We found a local model engineering club and apporached them, and asked if they would welcome Bob as a member. Their answer was;
"We thought he was dead! It would be great to see him again"
We spoke to his relatives, and helped them understand his predicament. They got into gear and started to make things happen.
We arranged for Bob to be discharged, and his relatives set him up so that everything was ready at home. His wife was welcoming.
He stopped drinking, except for a bottle a day. And he started to go to the club once a week. On another day he would walk to the shops with his dog. We organised that he could attend activites that could keep him occupied at home. We said that his dog may be taken away of he started drinking again.
Bob stopped needing the health system in the same way, and felt in control of his life. He remained with a point of contact should he need the health service, and that contact knew Bob, and was his contact all the way through.
The effect on the health system was;
The recod keeping was slashed to only 20% of what was recorded before.
The financial savings from what the outcome would have been without intervening, was around £50,000. One stay in a community centre was not needed.
The impact on Bob, and his immediate family was that he got his dignity and control of his life back.
The effect on the health team was:
The staff got enthusiastic working with Bob closely, this is why they had joined the health service in the first place.
It helped them to realise the barriers that are ever present in the current system, that prevents them from doing the job they should be doing.
They realise that, by treating people as individuals and then designing the right actions, the service improves and the costs go down, The effect on the service users is that they gain some level of responsibility for their health.
This is what the health system knew about Bob when we started:
He seems depressed, the hospital doctor prescribed anti-depressants.
He falls over alot, and he hurt himself falling over in the hospital when getting up to go to the toilet.
He cannot support himself, and it seems his wife cannot care for him at home.
He does not really have anything major wrong with him, he is old.
Relatives are around when we need to talk to them.
He drinks too much, and is a danger to himself.
We need to find supported housing for him, and keep him in hospital in the meantime.
At this point we talked to him, his wife, and his relatives. We asked them about Bob, and we asked Bob what he needed to live a good life.
This is what we found out about Bob.
He does not get on well with his wife, because she tries to hide his beer bottles.
He is very afraid that he is going to lose his guide dog, which is the only way he has of being independent. We then found out that he was visuall impared.
He gets annoyed at life, and he has little to occupy himself. However, he was a keen model engineer when he was younger.
And this is what we found out about Bobs pattern of events in the last few months:
He has been getting fed up with his bad eyesight, and he tries to keep moving around the house, and falls over.
He has taken to beer, to help him through the day. It is a recent trend.
He is very afraid of losing his guide dog - he was told it would be removed from him if he stays in the hospital.
He is very bored, and wonders if this is all life is about. He has no real friends.
He fell over at home, because he could not see much, and he had had a beer.
He has moved FOUR beds over eight days in the hospital, so when he got up at night and wanted the toilet, he had no idea where it was and fell over some equipment.
Those in the hospital never realised he was visually impared!
He thinks he will never go back home, but he really wants to.
We looked at his life and the time leading up to the hospital admission. We aimed to give him back what he wanted. This is what we did:
We told him that he could get his guide dog back, but he would have to stop drinking his beer. He readily agreed, and that cheered him up.
Especiallly when we said that we would help him go home. We spoke to his wife and helped to make things easier for her if he returned. We got his guide dog to visit him in hospital, and that was great for him. His relatives also visited him in hospital. His behaviour transformed, and he was not depressed anymore.
We also looked around the area. We found a local model engineering club and apporached them, and asked if they would welcome Bob as a member. Their answer was;
"We thought he was dead! It would be great to see him again"
We spoke to his relatives, and helped them understand his predicament. They got into gear and started to make things happen.
We arranged for Bob to be discharged, and his relatives set him up so that everything was ready at home. His wife was welcoming.
He stopped drinking, except for a bottle a day. And he started to go to the club once a week. On another day he would walk to the shops with his dog. We organised that he could attend activites that could keep him occupied at home. We said that his dog may be taken away of he started drinking again.
Bob stopped needing the health system in the same way, and felt in control of his life. He remained with a point of contact should he need the health service, and that contact knew Bob, and was his contact all the way through.
The effect on the health system was;
The recod keeping was slashed to only 20% of what was recorded before.
The financial savings from what the outcome would have been without intervening, was around £50,000. One stay in a community centre was not needed.
The impact on Bob, and his immediate family was that he got his dignity and control of his life back.
The effect on the health team was:
The staff got enthusiastic working with Bob closely, this is why they had joined the health service in the first place.
It helped them to realise the barriers that are ever present in the current system, that prevents them from doing the job they should be doing.
They realise that, by treating people as individuals and then designing the right actions, the service improves and the costs go down, The effect on the service users is that they gain some level of responsibility for their health.
What did it take to make it work, a systems thinking viewpoint
Quite simple really, no extra training or skills. A got the team to work together - and share information amongst themselves. This is what they did:
None of actions above are difficult, none need extra funding. None were outside of the front lines team capabilities.
In every single item above, the current system made it difficult or impossible to do under normal circumstances. This demonstrated that it was the system itself that caused the poor outcomes and fragmented working.
- You have to find out what matters to the sevice user, and the root causes of the issues they have.
- Look at everything relevant in his life.
- You work on fixing those things that matter to him. If you need medical expertise that you don t have get it, and guide the expert to the service user.
- Do not do a referral, you keep reponsibility for the service user.
- If you need to handoff some of the work to someone else, talk to them verbally about the service user.
- Only do an assessment that you need to do.
- Only record those things you need to, and make the most important and relevant information prominent.
- If you need to do something unusual or spend some money, notify your manager.
- If you need help or support, we will give it to you. You need to ask for it.
None of actions above are difficult, none need extra funding. None were outside of the front lines team capabilities.
In every single item above, the current system made it difficult or impossible to do under normal circumstances. This demonstrated that it was the system itself that caused the poor outcomes and fragmented working.
Traditional thinkingMy front line working have spent more time with Bob than before, and they spent lots of unnecessary time asking lots of questions.
I cannot let my staff search about for clubs for people, they have much more important things to do. It will take them away from real needs people. We are saving money with less hospital beds, but the extra work comes out of my budget. I dont like that. I lose control of what is going on , because staff are not following strict procedures. |
Systems thinkingSo, by my staff getting Bobs need clear, and the root causes of the problems, we have a chance to turn Bob around.
My staff need to do what is necessary to get Bob sorted. I understand that our work will drop if we continue to work like this. How can I support my staff with this? I need to support my staff to get Bob back on his feet, as that will cost the public sector less in the long run. I need to give my staff flexibility in finding solutions, but I need to ensure my staff work effectively. I need to find out how to do that. |
The learning
It was actually not difficult for the team to do this - they had the required skills. What was difficult was doing something that was driven by their knowledge of what to do - rather than a prescription. Their motivation went sky high, as they saw the dramatic effect this had on Bob, and reduction on the work for the health system. Stress dropped even though work levels remained high.
it was difficult for the manager to think how to expand this for all service users, and was concerned that this would open the flood gates for the public to get what they wanted from the health service. The thinking was a transformation rather than an improvement of the current system.
Obviously, we did this with other service users, and the results had common learning. What surprised everyone is that not only do the measures improve, but a person undergoing this approach - they change. Their behaviour becomes positive, they become responsible, they become co-operative, their help the health worker do their job, and they try their best.
it was difficult for the manager to think how to expand this for all service users, and was concerned that this would open the flood gates for the public to get what they wanted from the health service. The thinking was a transformation rather than an improvement of the current system.
Obviously, we did this with other service users, and the results had common learning. What surprised everyone is that not only do the measures improve, but a person undergoing this approach - they change. Their behaviour becomes positive, they become responsible, they become co-operative, their help the health worker do their job, and they try their best.
