How many days start with the letter T?

The other day I attended a leadership event at our local hospital. One of the speakers asked us “How many days of the week start with the letter T?”

The obvious answer is of course two, Tuesday and Thursday – but he said there’s another answer someone once gave him during a workshop, which is also correct: Tuesday, Thursday, today and tomorrow.

The point he made was that together people often solve problems in ways they wouldn’t have thought of on their own. Transformational ideas and break-through inventions are usually incremental processes that occur when different minds work together or build on each other’s work.

Steve Job’s iPod was based on existing mp3-players. Thomas Edison didn’t invent the lightbulb but improved it. The invention of the automobile and the airplane was the work of many; Henry Ford and the Wright Brothers just refined the ideas.

It never ceases to amaze me how people in a group – when the circumstances are right – develop creative ideas to solve challenging problems.

That evening, during dinner, I asked my children ‘Who knows how many days of the week start with T?” We had a bit of a discussion as a family until my 10-year old daughter said, “Seven days dad, because I always start my day with a tea.”

Talking governance: Getting rid of the disconnect

As the Royal Australian College of General Practitioners (RACGP) has been growing rapidly to 34,000 members, one of the big issues the College grapples with is the perceived ‘disconnect’ between the College and its members. A new proposed governance model aims to better connect the membership with College leaders.

Every organisation needs to review itself once in a while. The RACGP last did this 16 years ago so it’s about time for an organisational update. The proposal includes a GP-led, partly skills-based Board and a larger representative Council. The two structures would be set up to hold each other accountable.

Conflicted

One of the reasons behind the proposed governance model is that the old structure is somewhat conflicted. The problem all Councillors have had up to now is that they represent a group or state within the College on the one hand, and are directors on the other.

This can lead to Councillors having to take a position such as this: “The group I am representing wants A but, putting my directors hat on, I think we should do B in the interest of the organisation” (excuse the simple example to illustrate the point).

In other words: Council, at present, may be faced with situations where it is not able to represent the membership well because directors’ duties, by law, take priority. We can’t be good directors and good representatives at the same time – but are probably managing ok overall. However, this is one of the reasons why there is a perceived structural ‘disconnect’ in the organisation.

Fresh approach

The proposed new governance model splits these two functions (representation vs directorship) between a Council and a Board which will hold each other accountable. This is an essential, but much overlooked, purpose of the new model.

It will improve the representative function of Councillors by freeing them up to work purely on behalf of our members, while Board members (directors) will mainly look after the business side of the RACGP. This model is not new and is used in other colleges and not-for-profit organisations to manage this very issue.

I believe the proposed model breathes new life into the RACGP and general practice by creating a Council that will better reflect its membership. The model creates places for New Fellows as well as Registrars and will foster new leaders with a greater diversity of voices and thinking.

Over to members now – please vote on May 30.

Disclaimer and disclosure notice. Follow me on Twitter: @EdwinKruys.

Talking Governance: Why board diversity is important for success

Should the Royal Australian College of General Practitioners (RACGP) be lead by GPs only or a more diverse mix of directors? In the lead up to the College’s general meeting on May 30 board diversity has been one of the topics of debate.

The composition of boards and councils of other Colleges has been used as an example but, more important than what has been happening so far, is where we will be in 5, 10 or 20 years time. A new Governance Model should prepare the RACGP for future challenges. This requires more than just looking at what other Colleges do today.

The Trump response

When President Donald Trump ordered a closure of the US borders to prevent Muslim refugees and visitors entering the country, the Scientific American republished How Diversity Makes Us Smarter by Katherine Phillips, Professor of Leadership and Ethics and senior vice dean at Columbia Business School.

“Simply being exposed to diversity can change the way you think”

Professor Phillips argues that diverse teams are more innovative than homogenous teams, referring to a body of research by organisational scientists, psychologists, sociologists, economists and demographers.

“Diversity enhances creativity”, she says. “It encourages the search for novel information and perspectives, leading to better decision-making and problem solving. Diversity can improve the bottom line of companies and lead to unfettered discoveries and breakthrough innovations. Even simply being exposed to diversity can change the way you think.”

Not-for-profit boards

Vernetta Walker of BoardSource, an organisation based in Washington supporting nonprofit board leadership, says that achieving diversity on a nonprofit board is a challenging but doable and essential task.

“Don’t assume everyone agrees about what diversity and inclusion mean for the board,” she says. “Before asking ‘How do we become more diverse?’ boards must ask ‘Why do we need to become diverse?’

“Boards with a good gender balance perform better”

The evidence to answer that question is coming largely from the field of gender diversity. Louise Pocock, Deputy Executive Director of the Australian Governance Leadership Centre says that several studies have shown that boards with a good gender balance perform better.

Although board diversity often refers to gender, momentum is growing that diversity is also about other aspects such as ethnic and cultural background, age, education, skills, experience and boardroom behaviours and attitudes.

“A board comprised of diverse individuals brings a variety of life experiences, capabilities and strengths to the boardroom,” she says. “There is greater diversity of thought and a broader range of insights, perspectives and views in relation to issues affecting the organisation.”

“Diversity of thought may, in turn, encourage more open-mindedness in the boardroom, help generate cognitive conflict and facilitate problem solving, and also foster greater creativity and innovation. It also reduces the risk of ‘group think’ – where board members’ efforts to achieve consensus overrides their ability to identify and realistically appraise alternative ideas or options in relation to the organisation.”

Reluctance to adapt

Sally Freeman and Peter Nash from KPMG Australia state that boards of tomorrow need to be nimble, and responsive to the rapidly changing environment.

The authors say that, in order to create board diversity it is important for boards to recognise their conscious and unconscious biases. The key to good diversity is getting the mix right to achieve a shared purpose – overcoming biases and assumptions – and then, how that mix is managed, which requires a chair who is adept at facilitating open and robust discussion. Boards don’t make a huge number of key decisions but the ones they do make need to consider the breadth of challenges and opportunities faced by the business.”

“Sometimes boards are reluctant to adapt”

“However, sometimes boards are reluctant to adapt. These are the boards that struggle to see how current social, environmental, geo-political or technological issues could impact their business – at times only recognising the consequences once it’s too late. There is further evolution required for those boards who take the view that these issues are ‘not real’ or do not impact their organisation. Diversity can assist with surviving this evolution.”

Long-term success

Suzanne Ardagh from the Australian Institute of Company Directors (AICD) says that board diversity is a component of a strong performing board and that research now shows that high performing boards are very much aware of how their board composition could contribute or detract from robust discussions, decision-making and ultimately, performance.

She says that a mindset shift is required to create more diversity on boards and that this is essential to set up an organisation for the future and for long-term success. “I would urge Chairs and Directors to make that change which society is seeking. Boards need to become more inclusive of the wide and diverse community that we are – it is an imperative that becomes more acute every day.”

“A mindset shift is required to create more diversity on boards”

Vanetta Walker advises boards to expand diversity, but limit board size. “Many organisations identify their needs for inclusiveness and diversity only to confront the biggest challenge of all: how to fill all those needs without weighing down the board with too many members. When a board is too large, some members may feel disengaged, and decision-making can become cumbersome.”

“Diversity really impacts decision-making, and good decision-making is good governance,” says CH2M Hill board member Georgia Nelson (see video). “Having diverse folks around the table really drives you to let go of conventional thinking. You get out of traditional boundaries and you begin to think about things in a different way, and by doing that innovation grows and prospers.”

Disclaimer and disclosure notice. Follow me on Twitter: @EdwinKruys.

Sources:

How should Primary Health Networks support GPs?

It appears the new  Primary Health Networks (PHNs) are here to for the long haul. There is an enormous opportunity for PHNs to add value where they support quality primary healthcare services to the community.

RACGP Queensland has developed a draft position statement identifying 4 concrete targets that should be aimed for in primary healthcare reform at a local level.

The targets are presented below. I believe that PHNs could play an important role in achieving these goals – in collaboration with GPs.

  1. PHNs are in an excellent position to assist healthcare providers and organisations to build effective relationships. PHNs should facilitate a shared health vision for their local area, exceeding disciplinary and organisational boundaries.
  2. PHNs should encourage continuity of care and make sure new models and initiatives do not further fragment our health system and/or adversely affect health outcomes.
  3. PHNs need to play an important role in facilitating better information exchange and communication between healthcare providers.
  4. PHNs should encourage the development of innovative models of care that introduce genuine integration between the various parts of the health system.

Integrated health services, what do you mean?

It has been described as the holy grail of healthcare: the patient at the centre and the care team working seamlessly together, no matter where the team members are located, what tribe they belong to or who the paymaster is.

Integration has been talked about for many years. The fact that it’s high on the current political agenda means that there’s still a lot to wish for. Although we have high quality healthcare services, our patients tell us that their journey through the system is everything but smooth. Most health professionals are painfully aware of the shortcomings in the the system.

What is integration?

So what do we mean when we talk about integration? Co-location of health professionals? Team meetings between doctors, nurses and allied health professionals? Hospital departments talking to each other? Communication between GPs and specialists? Working across sectors? Packaging preventative and curative services? Patient participation? One electronic health record? A shared management and funding system?

Integrating health services means different things to different people. For that reason the WHO proposes the following definition:

“Integrated service delivery is the organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.

Integration is a means to an end, not an end in itself. Sharing resources may provide cost savings but, says the WHO, integration is not a cure for inadequate resources. Obviously, integrating services doesn’t automatically result in better quality. It’s also worthwhile noting that co-locating services does not equal integration.

There is a difference between integration from a consumer point of view, which often implies seamless access to services, and professional integration, which is achieved through mixing skills and better collaboration. These two types of integration don’t necessarily go hand in hand.

So it is useful to ask: what problem are we trying to solve? Are we trying to improve the patient journey through the health system? Do we want to support health professionals to deliver better care? Or is the main driver government concerns about costs?

How to achieve it?

One thing is certain: we must fight fragmentation. This is challenging as we are seeing a wave of commercially driven, disruptive services appearing in the healthcare sector. These solutions may be attractive to consumers because they are convenient, but they usually don’t contribute to a better or more integrated health system.

Unfortunately the evidence around integration is limited, but the authors of this MJA article are suggesting a way forward. They have looked at international health reform initiatives improving integration between community and acute care delivery, and they found that the following 10 governance elements are essential to support integration:

  1. Joint planning. Governance arrangements included formal agreements such as memoranda of understanding
  2. Integrated information communication technologies
  3. Effective change management, requiring a shared vision
  4. Shared clinical priorities, including the use of multidisciplinary clinician networks, a team-based approach and pathways across the continuum to optimise care
  5. Aligning incentives to support the clinical integration strategy, includes pooling multiple funding streams and creating equitable incentive structures
  6. Providing care across organisations for a geographical population, required a form of enrolment, maximised patient accessibility and minimised duplication
  7. Use of data as a measurement tool across the continuum for quality improvement and redesign. This requires agreement to share relevant data
  8. Professional development supporting joint working, allowed alignment of differing cultures and agreement on clinical guidelines
  9. An identified need for consumer/patient engagement, achieved by encouraging community participation at multiple governance levels
  10. The need for adequate resources to support innovation to allow adaptation of evidence into care delivery.

Major paradigm shift

The first thing we need is a shared vision. A major paradigm shift towards more integration requires motivated and engaged stakeholders and champions, a shared sense of purpose and a culture of trust. This should be established before embarking on a new journey. We must avoid making the same mistakes that have caused so much havoc in projects like the PCEHR.

It will be a challenge to get health professionals to focus more on coordination instead of daily care delivery. An essential step here is to increase capacity. The last thing we need is an overloaded primary care sector such as in the UK. The RACGP is suggesting an overhaul of primary care funding to faciliate integration and coordination. Similar changes will be required to free up hospital doctors to e.g. discuss patient cases with primary care providers.

The big question is: who will take the lead? It is likely that a lot of  work will happen at a local level and primary health networks could play a crucial role here. A shared agenda, clear goals and genuine stakeholder involvement are keys to success.

Warning: digital challenges ahead

There were a few interesting tech news facts this week. I thought this one was interesting: a Dutch campaign group used a drone to deliver abortion pills to Polish women, in an attempt to highlight Poland’s restrictive laws against pregnancy terminations.

There was scary news too: a private health insurer encouraged its members to use a Facebook-owned exercise app to qualify for free cinema tickets. Not surprisingly, Facebook was entitled to disclose all information shared via the app, including personal identity information, to its affiliates.

But there was also this: Telstra has launched its ReadyCare telehealth service. For those willing to pay $76, a doctor on the other end of the phone or video link is ready to care for you. No need to visit a GP or emergency department.

The telecom provider will offer the service to other parties like aged-care facilities and health insurance funds. Telstra is aiming for a $1 billion annual revenue.

Digital revolution

Digital developments increasingly create new opportunities, challenges and risks, but we have yet to find ways to incorporate the new technologies in our existing healthcare system.

In an interview in the Weekend Australian Magazine Google Australia boss Maile Carnegie warned that the digital revolution has only just started and that Australia is not ready for the digital challenges ahead.

Carnegie said that 99% of the internet’s uses have yet to be discovered and although Australia is the 12th largest economy in the world, it ranks only 17th on the Global Innovation Index.

She said that Australia has become a world expert at risk-minimisation and rule-making. Unfortunately this seems to slow down innovation.

“We are either going to put in place the incentives and the enablers to create the next version of Australia as a best-in-class innovation country or we’re not,” she said. “And I think it’s going to be a very stark choice that we have to make as a community.”

Who’s taking the lead?

In the last ten years we have seen major progress in for example mobile technology, but my day-to-day work hasn’t changed much. Healthcare has difficulty harnessing the benefits of the digital revolution.

Is the industry leading the way and letting governments, software developers and other parties know what is required? Do we have industry-wide think tanks to prepare for the near future? Have we listened to what our patients need and expect from us in the 21st century?

Disruption in healthcare is happening (whether we like it or not)

Healthcare, and particularly medicine, are slow-moving beasts. This doesn’t mean that innovation isn’t happening. In fact, it’s happening at an alarming speed and doctors are grappling with a quickly expanding knowledge base.

But the highly regulated, traditional industry is vulnerable to external disruption, and we’re seeing more and more examples:

  • DIY tests like skin cancer apps and pap smears
  • Online script services
  • Skin checks at the pharmacy
  • Vaccination services outside medical practices
  • Medical tourism

The flip side of convenience

Disruption is not necessarily the same as innovation. Disruptive services or products are simpler and more convenient to use, but their quality is often poorer.

In healthcare, the risk of disruption is that it affects health outcomes. It may lead to fragmentation and loss of opportunistic screening. I’ll give two examples:

Example 1:  More providers does not equal better care

A busy family doesn’t have the time to visit the doctor and decides to use convenient online health services. As a result they hardly ever visit their family doctor, and if they do, their doctor does not have the complete picture as more health providers are involved in the care.

Example 2: Convenience does not equal safety

Women doing their own pap smears at home may take incorrect samples. Although avoiding the ‘stirrups’ in the doctor’s office is a big plus, the risk of avoiding an expert examination is that things get missed.

The way forward

Disruption in healthcare is happening, whether we like it or not. “Successful entrepreneurs naturally look at opportunities in terms of the jobs they can do for customers,” say the authors of this article. Although it is unlikely that the doctor can be replaced by technology, certain aspects of the healthcare process can.

I believe there are 3 ways the healthcare industry should respond to external disruption:

  1. Continue to listen to health consumers
  2. Develop our own disruption processes
  3. Communicate the strengths and qualities of our services

Marcus Tan, GP and CEO of HealthEngine said in Australian Doctor magazine: “GPs are ideally suited to lead this cultural shift. GPs are highly skilled in managing risk and uncertainty, and are well equipped to make the leaps required to innovate.”

Indeed, if we don’t do it ourselves, others will.