Health Service Integration Project - a lesson in project governance

Health service integration means different things to different people.  In this article I am referring to the integration of health services between two different healthcare organisations following the commercial acquisition of one business by another.  

This is slightly different idea from the traditional concept of health service integration, which is a commonly defined as bringing about "the management and delivery of health services so that clients receive a continuum of preventative and curative services, according to their needs over time and across different levels of the health system."

I am using a bit of literary license here and have been vague on purpose to highlight the issue of good governance.  Any integration project, whether its integrating newly acquired business entities or integrating the delivery of health services, requires the foundation of good governance and seemless integration between strategy and operational activity for success.  

Project Governance is simply 'the mechanisms, processes and relations by which organisations are controlled and directed'.  A project can have a really great strategy, but if the project management mechanisms, processes and relations are not set up properly and inhibit people from actively carrying out the taking required actions then the integration of the services is blocked before its even started.

A  while ago in my career, I was involved with a health organisation that purchased another business (a commercial acquisition).  Within the new business was a unit that provided health assessment services directly related to those performed by the department that I managed.  This business unit had around $1 million revenue per annum which was not huge but still significant in relation to our department.  We were not directly involved in the commercial acquisition process, instead the integration strategy was devised by senior executives who were responsible solely for sealing the deal.  It was assumed that once the purchase went through, that my team would be able to take over the services carried out by this other team.  The strategy looked good in theory and the responsible executive had created a 90 day plan onboarding plan.

As I previously mentioned, my department which included the primary operational team were not involved in the purchasing decision or strategic planning and were only told about the purchase and planned integration two days prior to the purchase.  In addition, once it did go ahead, it seemed that nobody was responsible for the project.  The service revenues and expenses were moved onto my P&L statement, but there was nobody or no governance group ultimately responsible for signing off on major decisions.  This was pretty messy for an organisation of over 200 people. 

It was assumed that the two services were similar and one could just be plugged into the other.  This was a big mistake!  Of course there were a host of relationships, systems and processes that were unique to each department and could not simply be 'plugged in' and if the operational workers has been asked about this up front they could have informed the decision makers early.  There is an interesting article from Harvard Business Review, titled When Emotional Reasoning Trumps IQ that outlines the neuro-psychology behind integrating project strategy and operations.

I did what I could to manage and lead the project from here.  I was not and still am not an accredited Project Manager but I did have a reasonable amount of experience managing small to medium sized projects.  My primary experience was in PMI project management methodology with some understanding of agile/lean working environments so I was able to prepare a framework and drive things forward to a point,  but we were playing catch up and at the time I did not have the seniority in the orgnisation or the required influence to be able to make the important decisions.  The way the organisation operated I was unable to directly influence project governance.

Here is what I did:

1. IDENTIFIED AND ENGAGED with key stakeholders in the other team and throughout key business departments, primarily our IT and Finance departments. 
2. DRAFTED A PROJECT PLAN with key requirements, road blocks and contingencies and created a detailed Gannt chart highlighting key dates and relationships to other major projects. 
3. Having engaged the key stakeholders, we DEFINED THE PROJECT PHASES and required steps:

1. Planning phase
2. Urgent transition phase -  identifying capability required to maintain BAU Requirements
3. Migration planning phase - preparing for overall service integration
4. Migration of relationships, resources and materials
5. Synchronised infrastructure switch
6. Service integration/handover

Unfortunately though, even with a solid project plan the project was fundamentally flawed because there was nobody with clear and defined accountability.   I had taken a certain amount of responsibility but when it came time to make the major decisions there was no owner.

My manager at the time could have taken this role, but it had not been given to her and she had other reasons not to pro-actively campaign to take ownership herself.  The original project manager was leaving the company partway through the project so did not have any vested interest and had effectively signed off.

In my opinion the poor project governance derailed the project before it had even started and as a result it floundered affecting the performance of the department and the company.  The integration blew out from three months to almost one year and in that time client relationships were damaged and a lot of the value of the newly acquired business was lost.  Some entrepreneurs might argue that models of governance inhibit entrepreneurial freedom, but good governance should not be onerous and mechanisms can be built in for handing responsibility down where possible. 

So what can we learn from this?  What could we have done differently to make the project more successful? 

1. ACCOUNTABILITY - Firstly, I believe that there should have been clear single point of accountability for the project.  By the time this finally happened, it was already 5-6 months after the acquisition
2. STRATEGIC INTEGRATION - Operational people should have been actively consulted and included in the up front strategic planning so that strategy and operations could have been woven together more seemlessly.
3. ALLIANCING - Finally, as a bit of a left field idea, I wonder if an 'Alliance governance model' could have been employed to carry out the project. 

What is alliancing?

Alliancing is a method of managing projects where parties work collaboratively to deliver the project.  It is a model with a defined working framework and associated agreements that is generally employed for large complex construction/infrastructure projects where risks are not well known, but interestingly has become increasingly used in the delivery of healthcare in New Zealand.  This model of project management is not generally employed for small scale projects such as this yet, but I believe it has value and should be explored as an evolution idea into the future.

Alliance contracting is characterised by a number of key features, which generally require the parties to work together in good faith, act with integrity and make best-for-project decisions. The alliance participants work as an integrated, collaborative team to deal with key project delivery matters.
Under alliance contracts, risks of project delivery are often jointly managed by the parties.

In a project such as the one I described above, stakeholders from both the departments, the one doing the acquiring and the one being acquired could form the alliance team.  In addition team members from the finance and IT departments could also be involved.  If a team like this was able to collaborate right at the beginning of the project with clear guidelines on accountability, responsibility and reporting, it might have completely changed the dynamics of the project.


  

Chronic Musculoskeletal Condition Self-Management Resource

Its great to see organisations like Arthritis Victoria creating resources that encourage and support people to self-manage chronic conditions.

I'm excited to be able to tell people about this instructional video that I worked with Arthritis Victoria on in 2013.  It is an instructional video promoting how people with chronic musculoskeletal conditions can use of Warm Water Exercise (or Hydrotherapy) to manage their conditions.

My involvement included designing and drafting the script, and auditing the exercise science content.  I also co-presented with my colleague Renee De Silva, who was the program coordinator for the Waves program, which was a large volunteer led program involving around 120 volunteers and 1000 participants attending classes each week.  The volunteers themselves were inspirational, often having led classes every week for over 10 years and sometimes up to 30 years!

For community based health and wellness professionals working with people with Chronic Musculoskeletal conditions I highly recommend looking at this great resource.  Have a look at this short trailer for an introduction.

 

If you Want to purchase a copy for yourself or others, visit the Arthritis Victoria online store here: https://www.arthritisvic.org.au/Shop

Reaching more people, more effectively through health technology

In a previous post from September 2014 I summarised the key innovation hotspots identified in a Price Waterhouse Coopers health industry report HealthCast: Global Best Practices in Bending the Cost Curve.  Hotspot 4, was:

1. Care anywhere through technology development 

As an example, in 2009-10 I was involved as a provider and course facilitator with 'The Life Program' a diabetes prevention program established and operated by Diabetes Australia Victoria for people diagnosed with 'pre-diabetes' that made use of technology to enhance program reach and effectiveness.  The program was established to be run through a network of statewide providers in Victoria, with a population of over 5 million people spread throughout lots of cities, towns and regions.

The program is still running and has evolved from when I was involved, but at that time innovative solutions were employed to support program management.  An online portal was built and utilized to provide value in a number of ways.

• The program was actively promoted through the portal.
• Program administration was centralised through the portal with client details and medical records were securely stored, accessed and updated through it, both by a centrally located administration team and course facilitators located throughout the state.
• The portal was also linked to a database management tool which provided ability to analyse records, compare results and identify trends which was a powerful tool for evaluating program effectiveness.

 The program also employed tele-health innovation with an telephone coaching service.  This element was in its infancy at the time I was involved with the program, but it has developed into a significant offering in its own right.  This program provides a real life example of the use of technology to provide better access to healthcare.

Having worked in occupational health over the last few years I have had the opportunity to be involved in a number of different programs that have utilized technology solutions to administer programs remotely or via networks of providers, manage cases with multiple providers and more effectively manage data and reporting.

A recent Pilot study conducted by Partners Connected Health and published in the April issue of Journal of Medical Internet Research, shows another example of technology innovation improving healthcare for cardiac patients by facilitating better remote care (Thank you to Jennifer Priester for the link).  They names their system iGetBetter, and explained how their system included: 

• a web platform
• interactive voice response (IVR) telephone system 
• wireless personal connected health devices that measure and collect key vital signs. 

They further explained how patients received a Bluetooth weight scale and self-inflating blood pressure cuff to measure their weight, blood pressure and heart rate each morning. 

With the iGetBetter system participants were provided an iPad Mini tablet computer equipped with cellular connectivity to view their measurements via the Internet. The IVR system provided patients with an alternative way to manually record their measurement and care activities. 

The iGetBetter system includes a web platform, interactive voice response (IVR) telephone system and wireless personal connected health devices that measure and collect key vital signs. Patients received a Bluetooth weight scale and self-inflating blood pressure cuff to measure their weight, blood pressure and heart rate each morning. Participants were also provided an iPad Mini tablet computer equipped with cellular connectivity to view their measurements via the Internet. The IVR system provided patients with an alternative way to manually record their measurement and care activities. - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

The iGetBetter system includes a web platform, interactive voice response (IVR) telephone system and wireless personal connected health devices that measure and collect key vital signs. Patients received a Bluetooth weight scale and self-inflating blood pressure cuff to measure their weight, blood pressure and heart rate each morning. Participants were also provided an iPad Mini tablet computer equipped with cellular connectivity to view their measurements via the Internet. The IVR system provided patients with an alternative way to manually record their measurement and care activities. - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

The iGetBetter system includes a web platform, interactive voice response (IVR) telephone system and wireless personal connected health devices that measure and collect key vital signs. Patients received a Bluetooth weight scale and self-inflating blood pressure cuff to measure their weight, blood pressure and heart rate each morning. Participants were also provided an iPad Mini tablet computer equipped with cellular connectivity to view their measurements via the Internet. The IVR system provided patients with an alternative way to manually record their measurement and care activities. - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

For more details you can Visit their website here.

Its important to acknowledge that this is a only a pilot study and too small to have statistical significance and also that there are elements of this type of program that would be difficult to replicate on a big scale (i.e. providing people with iPads).  Furthermore its important to implement technology solutions that are more appropriate for your organisation and ojectives and budget.  That said, it is useful to have awareness of the successes organisations are having with technology initiatives.

Mobile Web-Based Remote Monitoring Study Demonstrates Improved Patient Engagement - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

Mobile Web-Based Remote Monitoring Study Demonstrates Improved Patient Engagement - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

Study Conducted by Partners Connected Health Demonstrates Improved Patient Engagement and Self-Management in Patients with Heart Failure - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

Study Conducted by Partners Connected Health Demonstrates Improved Patient Engagement and Self-Management in Patients with Heart Failure - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpufMore specifically it identifies how mobile web-based remote monitoring demonstrates improved patient engagement and self management in patients with heart failure. 

April issue of the Journal of Medical Internet Research mHealth and uHealth - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

April issue of the Journal of Medical Internet Research mHealth and uHealth - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

Healthcare Integration Self Assessment.

Those of us working in healthcare management and even those working to evolve and improve the system can all have days where we feel bogged down by the complexities, or what seems to simply be a lack of a good system. 

Its understandable!  Some people will even argue that modern healthcare systems in countries like Australia, New Zealand or the UK are not actually single coordinated systems, but a complex collection of inter-related services and products that can vary extremely in levels of integration.  In simple language...at times it can appear to be a bit of an overwhelming mess!

When we have days like this and we're feeling a bit overwhelmed, it can be useful to have a reference point to turn to.  A simple set of reminders, that clarifies what we are striving to work towards and achieve.  With that in mind, the following systemic review, published by Karoline Nicholson and colleagues from the Western University in London, provides just that.  Published in December 2013, it still holds relevance today.  The systemic review is written in article format and offers 'A Governance model for Integrated Primary/Secondary Care for the Health-Reforming First World'.

They explain clearly that their aim is to synthesise the existing published literature on elements of current integrated primary/seconday health care.  Their focus was clearly on studies that evaluated the structure and governance models of services rather than those that evaluated the success of the actual intervention.

In summary, they identified ten elements that are relevant for integrated primary/secondary health care governance across a regional setting. 

1. Joint planning
2. integrated infomration communication technology
3. change management
4. shared clinical priorities
5. incentives
6. population focus
7. measurement - using data as a quality improvement tool
8. continuing professional development supporting joint working
9. patient/community engagement; and,
10. innovation

They found that 'all examples of successful primary/secondary care integration reported in the literature have focused on a combination of some, if not all, of the ten elements.'  They highlighted that ' whilst no one model fits all systems, these elements provide a focus for setting up integration initiatives which need to be flexible for adapting to local conditions and settings.'    

So if you are a health management professional and you are feeling stuck, or bogged down by the system, try something different.  Go and find a quiet place to review your program or your project against these ten elements.  You can make it as simple:

1. assessing how well your project scores against each of the elements
2. create an action plan to address one or more of the low scorers.

I am managing occupational health programs in my current role, and have even been able to apply this review process to my work as a 'check in'.  For access to the fully article visit http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4234138/

 

Innovative Payment Systems

A very interesting 'alternative' payment system (and operating model) is the one practiced by Westgate Health, in western Melbourne.  I am not directly involved with the organisation so am speaking about second hand knowledge, but a look at their website highlights immediately that they are a 'Co-op'. 

The organisation doesn't just engage with patients...its owned by patients!  approximately 5000 community members who are called upon to be board members and who are actively surveyed on a regular basis.

Community member fees are used to subsidise the costs and spread them across the local community, and membership entitles you to a range of benefits, which is a similar model to that utilised successfully within the insurance industry.  The difference with alot of insurance companies is the philosophy and investment back into the organistion as a not-for profit entity.  They highlight on their 'Fees & Payments' page that 'They help cover the costs associated with operating our two clinics. We believe that the Co-op’s philosophy of membership fees provides a more equitable system of providing high-quality health care to the whole community, rather than having to charge a fee for every medical service'.   

By providing this example, I am not implying that the payment system for the wider primary health sector is ok.  I'm providing an example of how one health organisation is using social-innovation to deal with some of the issues raised about the current state of the health system including:

• being in it for the money more than for improving health  
• application of quality measures
• aligning funding systems towards prevention

 I'd love to hear what others think of the pro's and con's of this example.

$48 Billion on the table for the health industry!

I recently posted an article summarising a recent recent PricewaterhouseCoopers (PwC) health industry report (HealthCast: Global Best Practices in Bending the Cost Curve) which identifies a number of key trends for health organisations to focus on for performance improvement and what my personal experiences are with these 'on the ground'.  Out of all the current trends which I summarised in a previous blog, in this article I am going to discuss.

1. Data analytics and measurement

Why have I chosen these topics?  Well its for two reasons, firstly, I am currently heavily involved in a number of health innovation based technology projects including Lean-Agile run business transformation project.  Data management is a big topic within this project, so it's on my mind.

Secondly, those good people at PwC must be a very industrious lot because I noticed an article this week in The Australian newspaper highlighting a new PwC report identified that $48 billion was left on the table last year - unused, courtesy of the inability of Australian industry - and particularly the health industry - to fully leverage the potential of data-driven innovation.

According to PwC’s new Data Innovation Index, it is the health industry that is lagging behind the rest and therefore stands to benefit most in the future based on its size, international competitiveness, and assets including technical skill, talent, and volume of data.  For those of us involved in health innovation its not a surprise but still useful to be aware of.  

“It’s the lack of urgency to act on that data, that’s the issue,” Mr Sammy Kumar, PwC’s managing partner for PwC strategy; transformation, told Business Spectator.  He identified specifically that there is an inability to correlate the data set to achieve efficiencies that’s proving to be a problem.  Furthermore that there’s an urgent need to encourage wider awareness of the role data can play in driving efficiencies and productivity.

The key takeaway was that there’s plenty of room for improvement, especially when you compare Australia to a country like Canada. 

IT led innovation is a  core component of the organisation I work at.  UHG has created and developed some innovative solutions over the years and was recognised last year as the BRWs 19th most innovative company in Australia.  The work my team does, managing the delivery of occupational health and wellness services into orgnaisations is highly dependant on IT systems and in the course of providing health services we collect a reasonable amount of data.

In my experiences working with clients, I have observed that because this blossoming access to data is a relatively new phenomenom many people in occupational health management roles simply do not know how best to use it.  Many people in these decision making positions are experts in other areas of management but are not experts in data analysis or data management.  If you were in school in the 70s, 80s or even into the 90s, you would not have not been educated about 'databases' or 'mega-data trends' because they simply didn't exist.

Actually, electronic databases have been in existance since the 1960's.  In the 1980s and early 1990s dBASE was one of the top selling software titles.  But how many people remember that?  I certainly don't, I discovered it just now via Wikipedia!  This leads me into my point, that we need to embrace this new phenomenon and learn about how to get the most from data.

• Embrace learning about data...its here to stay

I figure that if a boofhead like me who spent school messing around on the sports field can embrace data anybody can.  If you're never going to be a PhD in data analytics its ok.  Find somebody else who is, type 'free data courses' in to google, or just commit to learning a little bit each month.  It just takes the right attitude and a bit of practice.  To make the most of data you need to know what you want to assess or measure.  The more data you collect, the more ways to slice and dice and compare it there are.  If you do not have a crystal clear idea of the objectives and/or the KPIs that are guiding your program or project, then its going to be difficult to know how to use your data.

Program or project objectives need to be determined right at the beginning of an activity.  This implies that part of making the most of data, is being disciplined in how you manage projects.  You have to take the time and effort to get to the essence of what you are trying to achieve so you can clearly articulate your aims.  This is the only way that you can then decide what data you will need and eventually look at to assess results.

•  Understand your objectives...simplify, simplify, simplify

My final point is that using data to uncover inefficiencies and achieve change requires leadership.
The PwC report highlighted that the health industry is conservative.  It is not the market leader in these areas of innovation and has a lot of areas of inefficiency.  Conservative people like to make changes slowly and can even be described by some as 'resistant to change'.

To lead change in the health industry you need to be proactive and prepared to take action but you also need to bring those around you along for the ride.  There are always alot of hoops to jump through, so you have to be prepared to educate the health professionals and other colleagues around you, and help them understand the value and benefits of embracing innovation.  To do this you need to believe that change is possible, and that others around you can change.  You need to be committed, you need to be an effective leader.

• Effective use of data requires good leadership

This is not an exhaustive list by any means, just a few observations but hopefully it provides food for thought and action.
    

 

Real Life Experiences with Tele-Health

The purpose of this article is to provide examples of innovation in action and to encourage the health industry to try new ideas!  

A recent PWC health industry report (HealthCast: Global Best Practices in Bending the Cost Curve) identifies a number of themes with associated innovation hotspots for health organisations to focus on for performance improvement.  The themes are generally similar to what we see coming up time and time again in good industry reports but there are a couple of interesting ideas in there:

1. Leadership
2. Strategic partnership models
3. Integrated care
4. Care anywhere through technology development
5. Data analytics and measurement
6. Process improvement in hospitals
7. Caring for an aging population
8. Precision medicine through research developments (e.g. genetics)
9. Bioclusters

Whilst I do not have any direct experience with bioclusters, or genetic medicine advancements.  Its good to be able to say that I have experience in a number of these areas and also that my workplace, which is an insurance health services and occupational health provider, UHG is actively innovative in a number of these areas.

I believe that any innovation that supports improved productivity is useful and, due to its pervading effect on all aspects of business, I have a strong person interest in leadership and leadership systems that encourage and support collaborative workstyles and productivity improvement through increased engagement.  But this article will focus on point four involving 'Care anywhere'.

The PWC report explains Whether in the hands of individuals or institutions, technology frees patients to be treated anywhere, at any time, by a much broader array of providers. Consequently business leaders are embracing new models, such as mobile health (mHealth) and mobile applications.

So what are we doing in practice at UHG?  Well the UHG vision is 'connecting  business and healthcare' and our specialty is probably telephone based support services.  UHG is good at 'Tele-health'.  UHGs biggest innovation in the occupational health space is its telephone based medical advisory line.  It offers corporate clients with people and offices spread all over Australia a 24/7, telephone based triage service for injuries or biological exposure.  A good example of success is how we recently assisted a client during recent outbreaks of measles and swine flu.

The service provides direct access to skilled allied health professionals who triage calls, who can connect callers directly to occupational health specialist doctors over the phone, proactively book appointments within local clinics, and follow up with callers to proactively manage cases over a 3 day period.  Its an effective service that helps organisations reduce lost times injuries and it is a telehealth model that has potential application in the wider health industry.

This is only one of a wide range of services we provide to be able to provide health services to populations spread far and wide.  Another mobile health assessment program which provides onsite bi-annual health assessments for around 2500 emergency workers across Victoria is supported by a Melbourne based 'program manager' and online clinical case management software.  This allows for any follow up clinical issues to be managed centrally, records to be sent and recieved securely if required post appointment, and if required for telephone based follow up to be provided by an occupational physician.

So in short, UHG has the experience and strong evidence to show that telehealth can work.  The purpose of this article has been to provide some real life examples of innovation in action and to encourage health administrators to try new things!  I hope its been useful.