Cracks between institutions
It is well known that danger arises when care is fragmented over many organisations (hospital, general practice, community care, social services, care home, etc.). With the rise in the proportion of patients with chronic and multiple diseases, fragmented care may have become the number one safety issue in modern health care. Confusion of responsibility, silo thinking, contradictory instructions, and over and under treatment are all heightened risks when care is shared between multiple providers – patients will tell you that. The risk is clearly identified, but how can it be mitigated? There is a limit to what can be achieved by structural change – Accountable Care Organisations featured in a recent blog, for instance. Irrespective of the way care is structured, front line staff need to learn how to function in a multidisciplinary, inter-agency setting so that they can properly care for people with complex needs. Simply studying different ways of organising care, as recommended by NICE, does not get to the heart of the problem in our view. The business aphorism “culture eats strategy for breakfast” applies equally to inter-sectoral working in health and social care. Studying how care givers in different places can better work in teams to provide integrated care is hard, but the need to do so cannot be ignored; we must try. We propose first, a method to enhance performance at the sharp end of care, and second, a system to sustain the improvement.
Improving performance of clinicians who need to work as a team, when the members of the team are scattered across different places, and patients have different, complex needs, is a challenge. For a start, there is no fixed syllabus based on ‘proverbial knowledge’. Guidelines deal with conditions one at a time. There can be no set of guidelines that reconciles all possible combinations of disease-specific guidelines for patients suffering from many diseases.  Everything is a matter of balance – the need to avoid giving patients more medicines than they can cope with is in tension with the need to provide evidence-based medicines for each condition. The greater the number of medicines prescribed, the lower is the adherence rate to each prescribed medicine, but it is not possible to pre-specify where the optimal prescribing threshold lies. The lack of a specifiable syllabus does not mean performance cannot be enhanced – it is not just proverbial knowledge that can be enhanced through education, tacit knowledge can be too.[7-9] There is an extensive theoretical and empirical literature concerning the teaching of tacit skills; the central idea is for people to work together in solving the kinds of problems they will encounter in the real world. In the process some, previously tacit, knowledge may be abstracted from deliberations to become proverbial (for an example, see box). Management is a topic that is hard to codify. So (highly remunerated) business schools use case studies as the basis for discussion in the expectation that tacit knowledge will be enhanced. We plan to build on theory and experience to implement learning in facilitated groups to help clinical staff provide better integrated care – we will create opportunities for staff of different types to work through scenarios from real life in facilitated groups. We will use published case studies  as a template for further scenario development. Group deliberations will be informed by published guidelines that aim to enhance care of patients with multi-morbidity (although these have been written to guide individual consultations rather than to assist management across sectors).[11-13] In the process group members will gain tacit knowledge (and perhaps some proverbial knowledge will emerge as in the example in the box). CLAHRC WM is implementing this method in a study funded by an NIHR Programme Development grant. But how can it be made sustainable?
Box: Hypothetical Scenario Where Proverbial Knowledge Emerges from Discussion of a Complex Topic
The topic of conflicting information came up in a facilitated work group. A general practitioner argued that this was a difficult problem to avoid, since a practitioner could not know what a patient may have been told by another of their many care-givers. One of the patient participants observed that contradictory advice was not just confusing, but distressing. A community physiotherapist said that he usually elicited previous advice from patients so that he would not inadvertently contradict, or appear to contradict, previous advice. The group deliberated the point and concluded that finding out what advice a patient had received was a good idea, and should be included as a default tenet of good practice.
Again we turn to management theory – there are lots to choose from, but they embody similar ideas. We will take for Ferlie and Shortell. To make a method stick, three organisational levels must be synchronised:
- Practitioners at the sharp end who must implement change. They will be invited to join multi-disciplinary groupings and participate in the proposed work groups, as above.
- The middle level of management who can facilitate or frustrate a new initiative must make staff development an on-going priority, for example by scheduling team-building activities in time tables. Our CLAHRC is conducting a project on making care safer in care homes, where much can be done to reduce risk at interfaces in care.
- The highest levels of management, who can commit resources and drive culture change by force of personality and the authority of high office, must be engaged. This includes hospitals at board levels and local authorities. Patients have a big role to play – they are the only people who experience the entire care pathway and hence who are experts in it. They can campaign for change and for buy-in from top managers.
CLAHRC WM has deep commitment from major participating hospitals in the West Midlands, from Clinical Commissioning Groups, and local authorities. These organisations are all actively engaged in improving interfaces in care, and the draft Sustainability and Transferability Partnership strategy for Birmingham and Solihull includes plans to better integrate care. We will build on these changes to promote and sustain bottom-up education, supported by the Behavioural Psychology group at Warwick Business School, to drive forward this most challenging but important of all initiatives – improving safety across interfaces in care.
— Richard Lilford, CLAHRC WM Director
- Lilford RJ. Accountable Care Organisations. NIHR CLAHRC West Midlands. 11 November 2016.
- National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management. London, UK: NICE, 2016.
- Wyatt KD, Stuart LM, Brito JP, et al. Out of Context: Clinical Practice Guidelines and Patients with Multiple Chronic Conditions. A Systematic Review. Med Care. 2014; 52 (3s2): s92-100.
- Lilford RJ. Multi-morbidity. NIHR CLAHRC West Midlands. 20 November 2015.
- Boyd CM, Darer J, Boult C, et al. Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid Diseases: Implications for Pay for Performance. JAMA. 2005; 294(6): 716-24.
- Tinetti ME, Bogardus ST, Agostini JV. Potential Pitfalls of Disease-Specific Guidelines for Patients with Multiple Conditions. New Engl J Med. 2014; 351: 2870-4.
- Patel V, Arocha J, Kaufman D. Expertise and tacit knowledge in medicine. In: Tact knowledge in professional practice: researcher and practitioner perspectives. Sternberg RJ (ed). Mahwah, NJ: Lawrence Erlbaum Associates, 1999.
- Nonaka I, von Krogh G. Tacit knowledge and knowledge conversion: Controversy and advancement in organizational knowledge creation theory. Organ Sci. 2009; 23(3): 635-52.
- Eraut M. Non-formal learning and tacit knowledge in professional work. Brit J Ed Psychol. 2000; 70: 113-36.
- Lilford RJ. Tacit and Explicit Knowledge in Health Care. NIHR CLAHRC West Midlands. 14 August 2015.
- American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians. J Am Geriatr Soc. 2012; 60(10): E1-25.
- Muth C, van den Akker M, Blom JW, et al. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Medicine. 2014; 12: 223.
- American Geriatrics Society Expert Panel on the Care of Older Adults with Diabetes Mellitus. Guidelines Abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update. J Am Geriatr Soc. 2013; 61(11): 2020-6.
- Lilford, Combes, Taylor, Mallan, Mendelsohn. Improving clinical decisions and teamwork for patients with multimorbidity in primary care through multidisciplinary education and facilitation. NIHR Programme Grant. 2016-2017.
- Ferlie E, & Shortell S. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Quart. 2001;79(2): 281-315.