It was 2:45am when I was woken to go on deck for the hardest watch of the day: 3am-6am. That brief moment between waking and dressing was important to know what gear to wear. Quiet, easy motion indicated warm clothes and wooly hat. The violent lurches of the boat and a loud rush of water overhead meant I’d be clambering into all the protective gear I could find: drysuit, harness, lifejacket and sea boots.
This was near the Grand Banks, an area of shallow water off Newfoundland that were rich fishing grounds but dangerous in a storm. It was during the last part of a transatlantic sailing race in September 2000. We had crossed the chilly Labrador current and were closing in on Boston having started in Southampton a couple of weeks earlier.
When had been tracking the weather forecasts showing a storm would pass as we planned to cross the Grand Banks. We evaluated the options and decided sailing South to remain in deeper waters was safest. We prepared the boat and ourselves for a difficult 24 hours and raced on. We were all tense, but we were ready.
These days the challenges I face are in the world of health IT. As I work in the Acute Delivery function of the Office of the CIO, I spend my time with managers and leaders in health figuring out how to travel the journey to more effective, efficient and safe services. These decisions are rarely straightforward, involve incomplete information, unforeseen consequences and significant uncertainties; much like the challenges I faced with my crew-mates crossing the Atlantic.
The Project Management Institute publication “Navigating Complexity” describes what constitutes a complex project:
These characteristics are present in many of the projects I’m involved in, day-in, day-out. Introducing technology to support patients and health professionals is usually broadly welcomed. But when the simplicity of pen and paper is replaced by the complications of structured data capture and formal workflows there are many challenges to overcome. Dr. Tony Shannon, a health informatics leader with Ripple, has shared many insights from complexity theory and how they help understand health systems.
As I work with hospitals and hospital groups to plan their IT investments into the future, there are many additional characteristics of complexity in play. Decision-making with imperfect information, ambiguity, and developments in the policy environment is decision-making under pressure. Nonetheless, decisions must be made.
The process we follow uses these approaches:
Nationally, a lot of effort has gone into developing a clear, coherent and costed view of an Irish Health system enabled by the Electronic Health Record. Part of being clear about where a hospital group intends to use IT, is to be clear how the EHR will enable their part of the health system.
Equally important is knowing the current infrastructure, systems and capacity of the hospital group. It’s more than just technology. It’s about understanding how the people involved in health IT can further contribute to health transformation.
The third part of the approach is to chart a course towards the desired future, identifying intermediate waypoints and milestones along the way. This involves making difficult choices about how to apply precious resources and skills to start and complete projects that will bring the organisation towards the vision. Small gains build to big wins for our health professionals, for our service users and for our communities.
The PMI guidance is valuable and describes the competencies required to manage complexity.
There is no one formula that assures success. Choices have to be made with incomplete information, with an uncertain landscape and unknown risks. Establishing the way forward requires collaboration between health IT experts, clinician leaders and service management.
When we skirted the Grand Banks in September 2000 we were making the best decisions possible with imperfect information. There was a storm we couldn’t avoid, but we planned ahead and we were ready for it; we battened down the hatches, we ate early, we shortened sail, we kept each other safe and we adapted to the conditions that came. With a mixture of exhaustion and relief we emerged out of that storm unscathed.
Thankfully there are few days in the office as dramatic as a storm on the Grand Banks. But the challenges we deal with on ordinary days are just as important. They require skill, perseverance, and good judgement. Patience, teamwork and communication are essential. And always with an eye on the forecast and horizon…
For as long as I can remember I’ve enjoyed fixing things. From a young age I had a wealth of opportunity bringing bikes in various stages of disrepair back into use. As I grew so did the scope and scale of my tinkering. I had more curiosity than capability and occasionally courted catastrophe. I ranged over most of the topics covered by books in the town library: engines, cars, electrics, construction, demolition, homemade gunpowder… I’d fix it or make it work better and at times break it entirely.
Kevin Kelly in his recent book Cool Tools (http://kk.org/cooltools/) describes a tool as ‘an opportunity with a handle’. Our household tool-bag back then was meagre and the tools were given many opportunities they never expected. At the time it was called ‘making do’; these days it would be called ‘innovation’.
It was no surprise to those close to me that I became an engineer. Engineering developed skills for making, fixing and improving things: science, maths, logic, problem solving, reliability, safety, project management, usability. I spent much of my career in the software industry where the tools I worked on captured, processed and analysed data to provide insights into customer problems which could be used to improve results. These tools brought together people, the way they work (processes) and technology to fulfil specific business needs.
A dozen years ago I started working in the health system. The clinical information system programmes I’m involved in focuses on enabling care professionals to reliably, effectively and safely support patients to get well, stay well or live a fulfilled life with illness.
The balance of concerns is different from the global software industry, but the essential issues are similar: enabling people to adapt the way they behave and work using updated or innovative tools to gain insights that improve decision making both at the point of care for the individual patient and for the long-term outcomes of communities. An engineering and systems training is useful in finding solutions to these complex real-world healthcare problems. But getting the right balance of people, process and technology in support of reliable, equitable, effective healthcare is challenging.
During a recent system implementation I supported a care team as they started on their first day using a new electronic patient records system. I was training a nurse manager late in her shift and a person she was caring for had a severe reaction to the treatment he was undergoing. The medical equipment provided alarms which helped her focus on the critical issues immediately. I watched her revive the older man and as she touched his cheek gently, I heard her speak calmly and tenderly until he was stable. I stood by as this nurse reacted promptly and effectively. My natural reaction is to step in and fix, but in this situation I could only contribute by getting out of the way and remaining silent. It was a key reminder that the tools my team brings forward need to make it possible for every care professional to work in that person-centred way without fluster and frustration. The tools need to provide the appropriate information at the right time to allow the professional and patient to make the best decision possible. Each of the tools my team deliver are not ‘an opportunity with a handle’ but are ‘an opportunity with a keyboard’.
Like the old days these tools aren’t always perfect, but innovative use of them can work wonders.
Delivering these tools requires an understanding of the unique challenges patients face and the challenges across diverse care settings. Many of our best days are when we meet patients, hear their stories and through that learn what is important for them. Working with nurses, doctors and support staff to address challenges in care delivery make up many other good days. Together we have to answer many substantive questions where answers are not obvious. A common thread in the successes is when the team recognise sectoral, institutional and personal biases then reach a shared answer to the essential question: “what is in the best interests of the patients?”
There are many opportunities for improving individual health outcomes and system-wide performance. The keys to unlocking improvements are in the hands of both patients that seek care and the professionals that organise and deliver care. My team works to provide the best possible tool-bag and the skills to use it for the patients and their care providers to make the best decision for the individual and their communities.