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25/11/14
From my personal experiences of working in and with the National Health Service the majority of Acute Trusts in England have an organisational management structure that is based on clinical units which are combined to make bigger clinical divisions.
 
Consider a 50-year old lady that presents to the Emergency Department (ED) with abdominal pain. After assessment by the Emergency Physician she was referred appropriately to the General Surgeons. The patient was transferred to the surgical ward. After assessment by a member of the surgical team a CT scan of the abdomen and pelvis is requested. The next day the CT is performed which identifies an ovarian swelling. The surgeon then refers to the Gynaecologist for further investigation which leads ultimately to an operation. In this not uncommon clinical scenario the patient moves between different departments and clinical divisions. The ED is part of the Division of Medicine, the General Surgery Department is part of the Division of Surgery, Radiology sits within the Diagnostics Division and Gynaecology part of the Women’s and Children’s Health Division.  The patient is blissfully unaware of these transitions across divisions, but they dictate the timeliness of her care.

 

Each department functions as an independent unit or silo. The staff working in each silo do a great job, but they only focus on their piece of the patient-based jigsaw. Their managers also work within the same silos. Everyone is working to the beat of their own series of targets and clinical indicators. No-one has ownership of the overall patient journey and nobody is driving the process forward thereby ensuring the patient’s transition between departments is smooth and timely. In reality the interfaces between silos are as real as brick walls. To inadvertently cross them can often be slow and sometimes even dangerous. Rarely are patients able to flow through the system, because the system is not designed to flow. Instead patients are moved along their journey by one department having to use a lot of effort as they metaphorically and physically push the patient into the next silo. In this ‘vertical’ divisional structure, power comes from the top, work becomes fragmented and it is easy for communication to be lost.
 
Due to the fact that the system relies on ‘Push’ rather than ‘Pull’ it causes friction between the various silos. This friction causes bad feeling, resentment and suspicion. Similarly budgets are also bound to these silos and this results in arguments about who is paying for a particular component of care. Sadly we often forget that there is a patient trapped in the middle of it.

This fragmented silo system causes us to try and manage an interdependent system as if it were compiled of independent entities. The irony of the word ‘Divisions’ should not be overlooked.
 
So I ask myself does it have to be like this? Is there an alternative
 
This may be an Utopian dream, but could we move away from rigid ‘vertical’ divisions towards a more ‘horizontal’ organisational structure which mimics the patient journey? Instead on having to force patients through metaphorical brick walls, we could have a system that has people and processes aligned to deliver the right care, on time, every time.
 
Vertical organisations are built upon the concept of hierarchical authority, where power and authority belongs to few and the majority of employees are subservient. Vertical organisations have steep authority gradients, and reducing levels of autonomy the further from the top you go. The vertical system encourages fragmentation, creating multiple silos that only have a narrow focus on their particular section of the care pathway, often at the expense of other silos.
 
In a horizontal system all hospital departments are integrated into the process so that they are aligned to deliver a common goal: safe, efficient and effective patient care from start to finish of the patient journey. The whole system is designed to be able to meet the patient’s needs and has the capacity to meet demand. Instead of a divisional management structure that runs a silo, the management structure in a horizontal organisation has managers that own the process from start to finish. So a manager has the responsibility, and is accountable, for ensuring all of the patients care is delivered to the right specification and in the correct timeframe.
  
Horizontal organisations have a much shallower authority gradient. This eliminates the hierarchical nature of vertical organisation promoting collaboration between departments (rather than fragmentation) with the common goal of more effective and more efficient patient care. So if the hospital management system adopted a more ‘horizontal’ approach so that managers were not responsible for a silo, but instead responsible for the entire patient journey it might knock down some of the invisible walls thereby reducing the inertia that exists within our hospitals. Management would move away from being primarily administrative and become more focussed on operational matters.
 
Horizontal systems are based upon a different hierarchy to vertical systems. Instead of the silo-based hierarchy of a vertical system, the horizontal system’s hierarchy is solely focussed on meeting the needs of our patients. This is dependent upon efficient connections between the patients (our customers) and those supplying the service (our departments, organisations, etc), with the needs of the patient being paramount. The patient is the ‘external’ customer, and the hospital service the patient requires is the supplier.
 
In addition, a hospital department such as the ED is an ‘internal’ customer of the organisation as it requires the other departments (suppliers) to deliver care to its patients. For example, the ED is dependent upon radiology and laboratory services to meet the needs of the patient. Likewise if the patient requires admission to the Surgical Admissions they also become a supplier to the ED.
 
The priority for the clinical staff in each clinical area is to focus on the patients trying to access their service and the patients currently under their care. As there is currently a struggle for patients to move on to the next department the clinical staff have to continue to look after patients long after their component of the patient’s care is complete. Consequently there has to be a clear and unambiguous signal that when one department’s work is complete and the patient requires the next part of their service. It is then the responsibility of that next department to ensure there is adequate capacity to take over responsibility for that patient seamlessly and commence their component of care immediately.
 
This paradigm shift in the way we consider delivering healthcare is vital if we are going to see a change in hospital performance. Patients do want to wait for services, consequently the whole organisation needs to be aligned so that there is no delay in moving between departments. Services need to be designed so that they can meet capacity and are able to meet variations in demand.
 
Due to their different skills there will always be some degree of ‘silo-ism’ amongst clinicians. Indeed this is a good way of concentrating expertise, but currently hospital managers tend to work in the same clinical silos as clinicians which further enhances this ‘tribalism.’ Consequently improvement initiatives are based to improve the performance of one department which tends to have limited impact on the overall patient journey.
 
What is necessary to make this happen?
Hierarchies, budgets, metrics and job plans must all be rotated through ninety degrees as part of a scientific organisational re-design. Horizontal reorganisation is not just necessary for the clinical areas, to achieve this there has to be change across an organisation as a whole. The factors within an organisation that confer power and legitimacy must be aligned to deliver on the whole patient journey, rather than each department focusing on delivering its own requirements. To ensure that the system is able to meet the needs our patients all executive board and managerial activity needs to be aligned to help the clinical teams deliver the care the patients need. Due to the fundamental nature of change, it is somewhat ironic that converting a vertical organisation into a horizontal one can only be undertaken through a top down approach initiated from within an organisation; but it needs to be done.
By Dr Paul Jarvis