Monday 8 March 2010

Learning organisation or measuring organisation?

The Sunday Times’ article yesterday about the failings of the NHS performance management system was disturbing: Labour hid ugly truth about National Health Service.

Any organisation that gives higher priority to performance measures, rather than to its core business, needs to ask some harsh questions. In this instance it will be the country asking the questions – not only of the NHS but also of the government.

Since the days of Florence Nightingale we have understood the need for basic hygiene in order to prevent infection. It seems that performance measures were able to wipe away 250 years of performance improvement by not following the most basic of health procedures.

So when results like this are achieved from a performance measurement system that we can only presume was meant well, where does the blame lie?

It would be both true and too easy to say the blame lies with the leadership. Fish rot from the head down, and those in positions of leadership must shoulder the greatest share of the responsibility. But when a trained nurse does not pay attention to basics such as washing hands, or disinfecting areas where patients are cared for, there is either a massive culture problem, or a problem with basic training. My money would be on the issues of culture, many of which have been well documented.

However, those who devised and rolled out the targets must be feeling uncomfortable now the results of their performance management exercise have been revelealed:
“Most targets and standards appear to be defined in professional, organisational and political terms, not in patients’ experience of care.”

Maybe that’s easy to say with hindsight, but for the rest of us it is a chilling reminder that performance measures must be appropriate, tested, and constantly reviewed to ensure the organisation is achieving the results it needs. And not dysfunctional results it doesn’t want.

Performance measures are a way to understand and learn what works and what doesn’t. We all make mistakes, and performance measures are not easy to get right. But what is unforgiveable is to let such a bad situation go on so long. Performance measures should be a tool for the learning organisation, not a control mechanism for the measuring organisation.


  1. After the realisation that slavish pursuit of vote catching targets caused loss of life, what's most shocking about the Times story, is that the DoH commissioned three leading consultancies, IHI, Joint Commission International, and Rand to gain insight into quality improvement in the NHS to inform Darzi's review. These reports were written with the intention of improving the service and highlighted failings and actions to effect improvement. That they were ignored is astounding. What's also shocking is that he DoH effectively paid three international agencies to find weaknesses in the NHS, add that intelligence to their own commercial business strategy and then leave the NHS without any of he benefits from that work.

    This is a story that goes beyond metrics and to the heart of an inability of politicians to deal with the truth and respect the electorate sufficiently to allow them to be party to the truth.

  2. Interesting how the NHS always seems to be everyone's best example of poor management/system/organisational practises....

    I agree the the political situation must be the root cause of this.

    Below is an extract from an email I received today (about the US government, but the principle applied here too I am sure) which may help exaplain:

    "On a recent Glenn Beck Show, he had a graph that illustrated the percentage of each past president's cabinet who had worked in the private business sector prior to their appointment to the cabinet. You know what the private business sector is... A real life business, not a government job. Here are the percentages discussed by Mr. Beck.

    T. Roosevelt.............. 38%
    Wilson ....................... 52%
    Coolidge.................... 48%
    Hoover ...................... 42%
    F. Roosevelt.............. 50%
    Eisenhower............... 57%
    Kennedy.................... 30%
    Nixon.......................... 53%
    Ford........................... 42%
    Carter........................ 32%
    GH Bush.................... 51%
    Clinton ...................... 39%
    GW Bush................... 55%

    And the winner of the Chicken Dinner is..............

    Obama................ 8% !!!

  3. The NHS is probably as extreme an example of metric madness as it is possible to get and, yes, culture lies at the heart of the problem. However, there is no party in this mess with clean hands (excuse the pun).

    If we look back to the foundation of the NHS there was an acknowledged tension that existed between the nursing profession and the doctors, whereby the former had long sought to improve their status. This tension was known but ignored from the outset and I believe that the Royal College of Nursing has been complicit in the lack of a patient-centric culture. They have allowed themselves to be bought off with higher grades, pay and consultant status when they could and should have drawn attention back to the patients’ needs.

    An example: nurses used to be taught that washing a patient, making their bed and engaging in conversation with the patient was an essential way of monitoring health and progress. Today these ‘menial tasks’ have been farmed out to nursing auxiliaries who lack the training (or even interest) to take on the required observational duties while the nursing staff frequently focus on ‘performance’ measures.

    I have personal horror stories of the NHS and its focus on anything but the patient (although I can also say, having had my life saved on two occasions by the NHS that when you are in intensive care, that is exactly what you get). How can the nurses achieve better standards of cleanliness when the manpower and standards of performance are handled well away from the front line (and with a very different chain of command)?

    The new culture of excessive central control also seeks to overcome the ‘power’ of the consultants with an unhealthy mixture of metrics and management. The result is one NHS Trust I know of where 12% of consultants are currently on sick leave with stress. And who is targeted to focus upon the patient.

    These simple examples are just a part of the problem. A larger one is lack of a holistic approach to health in our society that Government simply cannot see. How do we make the NHS more efficient when we fail to educate a large sector of our society on the benefits of a healthy diet and lifestyle? Is the NHS a learning organisation? Yes, but it has learnt the wrong things from the top down.

    What’s to be done? I suspect Caroline has practical tools and techniques to hand but I venture to suggest that with 1.5m people, the NHS is now simply too large to function effectively. Freed of central control and managed locally, it would be possible to put patient needs first. I hope that a change of Government can achieve this.

  4. Top stuff!

    This is exactly the thought-provoking kind of post which I love - I had to read it through three times before I could find a point of equivocation.

    I don't agree that there is any fundamental reason why large organisations must necessarily fail, only that because they are larger there is more opportunity for their intrinsic culture to break down and therefore it is more likely. From a policy perspective leadership so easily and quickly gets confused with control when it is done at arms length with no real connection to the front line - so when it does break down it is not the fault of leadership, but of their lack of leadership and direction.

    I think the important point is to remember your tool of choice (be it a statistical league table, a public health care provider or a simple sculptor's chisel) is never value-neutral as it is always in the hands of those who hold and operate it. Therefore what is produced is the expression of the whole.

    Consequently the challenge is, as Caroline correctly says, to ensure more relevant feedback and a more naturally-conscious process.

  5. Panorama's take on this was equally thought provoking last night. Suggesting that NHS trusts could not be left to self assess, noting that random checks by the Care Quality Commission had found a number of inconsistencies across all the trusts surveyed. Interesting, not only because it suggests a degree of pulling the wool, but because the metrics set around policy and targets don't hold value for the organisations themselves. That's to say, they're measuring (approximately!) but they're not measuring with the intent or desire to act on those measures of make their measures meaningful to a local context.

    As ever, we need leaders, who can take work with policy and translate it into quality services (or products) for patients (or customers), driving improvement from a sound value base that puts patients (customers) first.

    Only other thing about Panorama, is I would say that looking at one or two problem hospitals is taking a very very partial view - while there are massive problems with measures (how do you measure quality - this is being grappled with at the highest levels and by some of the smartest people I know) - and their use and abue, there are many many more hospitals that are striving to deliver excellence. Would be good to hear more about those...

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