Robert Klaber, MD, is a pediatrician and Associate Medical Director for Quality Improvement at Imperial College Health Care NHS Trust, a member of IHI’s Health Improvement Alliance Europe. He sat down with IHI for an interview at the most recent International Forum on Quality & Safety in Healthcare to explain why collaboration across settings and systems is necessary, how it can work, and how it might be the answer to many of health care's most pressing challenges.
On the organization where he works
[Imperial College Health Care NHS Trust] is one of a few health care providers looking after over 2 million people live in Northwest London. We have over one million outpatient contacts a year and a major trauma center. We have 11,000 staff in a big, bustling place. Collaborating, learning, and working together becomes all the more important in a complex health care environment like ours that’s quite fragmented.
On why collaboration is important for patients
If you talk to patients, they will often tell you they receive poor care or their needs aren’t met when they fall between different providers. Support for patients often isn’t joined up, so it’s crucial that we collaborate much more thoughtfully. Unfortunately, the levers in the system still point away from that.
More widely than that, how do we collaborate with our communities, and the people at the heart of them? As we start to move [away] from a model of fixing illness toward one focused on health and wellbeing, our old methods just don’t stack up. We need to learn from the people and parts of society that have been doing more of this than health care.
We still need hospitals to be brilliant at looking after people safely when they have sepsis, major trauma, or a host of other things. But we’ve got to be honest with ourselves, and admit that much of current hospital care doesn’t deliver outcomes that a modern, forward-looking society needs us to deliver. We have to connect and collaborate much more, and the traditional professional tribes that exist are unhelpful.
On how one patient helped him see the value of collaboration
There was a lovely little girl who tragically burnt the inside of her throat. She had picked out a bottle out of the dustbin that her dad had used to dispose of some caustic soda. She needed multiple operations.
She came under my care in the hospital with a very bad pneumonia. It was probably related to the fact that she couldn’t swallow properly, so her secretions went into her lungs. She was very unwell, and was treated on antibiotics and oxygen and got better.
But I was shocked and distraught by how upset she was about being in hospital. No children like being in hospital, but she was really scared because every time she was in, she had anesthetics, people put scopes down her throat, and it was a horrible experience for her.
I thought, “Right, I need to do something different here,” so I phoned up her GP, who I didn’t know. I said to him, “Can I come and see her in the practice? We’ll see her together. It just feels like the right thing for her.” A community nurse joined us. I remember sitting on the floor with this girl in this practice in Northwest London. We spent about an hour, and it was the most wonderful consultation because she [seemed like] a different girl. She was calm because she felt comfortable in that environment.
Her GP and I looked at each other and thought, “Wow, we need to do this more.” We started to think about how to systematize what we’d done. We did a lot of co-design work with children and young people and their parents and asked them, “What are the things that matter to you? How can we behave differently?”
On getting population health results from collaboration
I’ve been very involved in co-leading a program with one of my colleagues, Dr. Mando Watson, called Connecting Care for Children over the last five years. Six [hospital-based] pediatricians go into 27 general practitioner (GP) practices on a monthly basis. These practices come together as a hub, and we’re using the GP-registered population as [the focus of] our population health [efforts].
We ask the group to tell us about the 4,600 children registered on their list. Who are the children with complex health needs? How could we as pediatricians help you to look after them?
We have multidisciplinary team meetings with GPs, health visitors, school nurses, mental health and social care colleagues, and dieticians where we talk holistically about children. What’s wonderful is that all the answers don’t necessarily come from the pediatricians — which is what people tend to assume will happen — and the outcomes have been amazing. In the first hub we set up and evaluated, we found an 80 percent reduction in the use of [outpatient care], fantastic outcomes around building up the capability of the people involved, and [high] patient experience [scores]. Because we’ve built relationships, we talk on the phone, and email each other between meetings to share ideas and continue collaborating.
On how to make the case for collaboration
There’s a hardline angle that says, “We absolutely have no choice. It is the only way by which we’re going to be able to sustain health care.” People have got very animated in the NHS in discussions about the financial sustainability of health care. I think that’s valid, but in my mind it’s [not the most important issue].
It’s more important that we sustainably develop a workforce who has a sense of meaning and purpose, and the skills to do what our patients need us to do. The fact that our traditional models of health care don’t meet our patient needs should also be a bigger issue. How do we start to deliver outcomes that really matter to patients, and aren’t just a traditional, often hospital-based process that we’ve had in place since Victorian times? Better collaboration could help with all these priorities.
On the value of collaboration between academic research and improvement
There’s an opportunity to have lots more collaboration between [the improvement movement] and traditional academics who are doing outstanding research, but struggling to translate their research into real change. We have a lot to offer academics because much of the learning, techniques, and behaviors [of improvement] can help researchers translate their work into what I call “real impact factor.” [Academic journals] get measured on “impact factor” [a measure of the frequency with which the average article in a journal has been cited in a year]. A journal may have an impact factor of, say, 47. That doesn’t mean anything to my patient. The real impact factor is where learning, innovation, and discovery translate into better care and better outcomes that matter for patients.
On the promise of collaboration across the NHS
I was at a meeting in London during the first year of the IHI Health Improvement Alliance Europe. Hugh McCaughey, Chief Executive of South Eastern Health & Social Care Trust in Belfast, did a super talk about the promising collaborative work his organization is doing with the East London NHS Foundation Trust (ELFT) in London.
He said something like, “These networks and collaboratives are great. They’re fun. But it’s not good enough for our organizations, our populations, or the taxpayers for us to come together and have a nice time. We have to do something meaningful together.”
His challenge inspired Suzie Bailey, from NHS Improvement, James Mountford, from the Royal Free London NHS Foundation Trust, and I to set up a little improvement collaborative. It’s a great group, but we were not the most obvious organizations to put together — Two traditional, academic teaching hospitals with medical schools who’ve largely ignored each other over the years, and our regulator, who providers don’t traditionally collaborate with particularly well.
We’ve now met for four half-days, and we’ve done some good work around measurement for improvement and psychological safety. We’ve started talking about equity and diversity and how health care needs to become much more inclusive. We’ve been doing some thinking around reducing unwarranted variation, and we’ve been exploring organizational relationships and behaviors. It’s exciting work, and I’m convinced it’ll lead to all sorts of wonderful things going forward.
On how to promote joy in work
I feel privileged and greedy that I’m a pediatrician, have a leadership role in improvement, and do work around education. For me, joy in work means having meaning and purpose.
We need to do more to connect everyone at all levels in health care to connect with what gives them meaning and purpose. For a business that gets disproportionately kind, selfless people applying for jobs in it, health care can sometimes be an extraordinarily difficult and unkind environment. We’ve got to be much more generous, and appreciative of people and the sacrifices they make to do the jobs they do.
That means better role modeling and being tough on poor behaviors. The poor behaviors that go on in and between organizations are completely unacceptable. For generations, we’ve just accepted it and said, “Oh, health care’s a difficult business.” Does that excuse people bullying? It doesn’t in any way at all.
The fact that health care is difficult makes it more important that we’re kind and supportive to each other. Too many of us are bystanders to poor behavior. We don’t like it, and we recognize it’s poor, and we do nothing about it, and that needs to change.