Pursuing Perfection: The View from Across the Pond

​So, how has the notoriously cautious National Health Service (NHS) coped with a concept as bold, brash, and American as "Pursuing Perfection"? Some pessimists feared the very term would ensure the NHS never took it seriously. But four years after a small group of English health and social care communities began pursuing perfection in the NHS they have some remarkable success stories to report.
 
The National Health Service (NHS) was set up 56 years ago and is now the largest organization in Europe. It is recognized as one of the best health services in the world by the World Health Organization but the NHS believes it has to improve to cope with the demands of the 21st century.
 
There have been a variety of problems (longstanding in some cases) that have been in the sights of improvement experts. These are: delays in the system, difficulty getting needed services, and, outcomes for patients that were less than 100 percent satisfactory.  Patients and providers alike noted how frustrating the system could be, yet few could find solutions to the persistent problems. Leaders at the NHS Modernisation Agency (a government body established in 2001 to support the NHS and partner organizations in the task of modernizing services and improving outcomes and experiences for patients within the NHS) recognized that joining NHS health and social care communities with the Pursuing Perfection program enabled people with energy in the UK to marry their motivations with a highly energized program in the US. And, the results have been impressive.
 
Health care leaders in the UK have learned lessons about setting and achieving improvement goals that have profound implications for the whole NHS planning system. They have developed radical plans for delivering care beyond any existing NHS provision — and many of their plans have already become reality. They demonstrate some of the most mature and effective models of partnership working in the NHS. The ambitions of these partnerships stand in stark contrast to those of many NHS organisations that limit their aspirations to complying with the minimum requirements of the government's health care reform program, such as maintaining fiscal balance or ensuring that no one waits more than four hours to be treated in hospital emergency departments.
 
Of course, it has not all been smooth sailing. Each community has had its setbacks as well as its triumphs. But all of them have achieved noteworthy changes they never thought possible a few years ago, and they now have solid foundations on which to build for the future.
 
Bradford Health and Social Care Community: Involving Patients in Improvement
Things were never quite the same again after a patient in the stroke unit at Bradford Hospitals Trust turned to staff and posed a difficult question: "If we're all different and every stroke is different," they asked, "then why are we all treated the same?"
 
Since then Bradford Health and Social Care Community has taken to heart the importance of involving patients in its efforts to transform services. Before Pursuing Perfection, Bradford’s hospitals — serving 500,000 people in the north of England in the country's eighth most deprived area — had more than 60 groups of staff, patients, and family members offering feedback, yet few of these members had any expectation that they could take part in improving services alongside health professionals. Pursuing Perfection helped the Bradford Trust change that by engaging patients in reshaping care, without any centrally imposed blueprint for how it should be done.
 
As a result, patients are becoming less passive recipients of care and more like collaborators for change. Clinicians are beginning to abandon their traditionally remote styles to lead collaborations of patients and staff groups, testing small changes, and acting on results. As one consultant surgeon told a patient attending a multidisciplinary team meeting: "We take on board all that you are saying — we are listening.”
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"Collaborators for change" in the Bradford Health and Social Community — a nurse and patient discuss next steps for treatment
 
In the stroke unit, patients can now choose between rehabilitation activities ranging from gardening to discussion groups. They can use personal stereos for relaxation or education. And providing patients with their own whiteboards has proved popular with everyone. These can be used for informal communication and planning the day; if visitors are expected at a particular hour or the patient has a hair appointment, staff can schedule care and therapy accordingly. A 120-strong group of patients and caregivers with lots of experience coping with strokes directly influenced these developments.
 
Bradford Pursuing Perfection Assistant Programme Director, Beverley Slater, says the patient's role is "to create energy for change by triggering health professionals' dissatisfaction, to challenge their assumptions about what's needed, and to ask, 'Why do you do this? Why don't you do that instead?'". The organization must respond by understanding and honoring what the patient wants — and recognizing when it is putting its own needs before the patients'.
 
“When all their tests had been completed, patients with Haematuria (blood in urine) were being called for follow-up appointments whether or not anything suspicious had been found," says Ms. Slater. "Patients were telling consultants that they had to take a day off work just for a two-minute appointment that reported nothing was found."
 
The patients' group suggested the hospital could send this information by letter with the offer of an appointment if the patient wished. "That's been very successful," says Ms. Slater. "Only one patient out of 30 has requested an appointment, and we project a reduction in outpatient appointments of 300 a year."
 
For the future, Bradford is keen to ensure the lessons from its Pursuing Perfection projects are absorbed into mainstream ways of working. "We've taken very seriously the learning we've gained from involving patients in these projects," says Ms. Slater. "Other projects arise all the time and we will always seek to involve patients now."
 
North and East Devon Health and Social Care Community: Embedding Pursuing Perfection on the Front Line
The Royal Devon and Exeter Hospital recently closed its discharge lounge, where patients returning home waited for transport or for the pharmacy to bring any drugs they needed to take with them. North and East Devon's Pursuing Perfection program has so improved coordination of patients' discharge from hospital and eradicated delays that the lounge became unnecessary. But perhaps even more significant is the fact that it wasn’t the hospital that made the decision to close the lounge, but one of its partner organizations. Royal Devon and Exeter Hospital Chief Executive, Angela Pedder, found out only later. Many senior managers might bristle at such a blatant intrusion onto their turf, but she is sanguine — even proud — of this chain of events.
 
"It was fine. It was the right decision. I knew that it was always a possible outcome. Staff has permission to change things, and they don't always have to go through a bureaucratic hierarchy," she explains.
 
Pursuing Perfection has indeed helped foster new levels of trust and cooperation between managers and staff, and between organizations in North and East Devon, an area of 490,000 people in the southwest of England that includes remote rural areas, seaside towns, and the city of Exeter. When the collaboration began, one of the biggest challenges facing the entire community was a steady, ten-year rise in non-emergency admissions such that the flow of patients through the disparate primary, secondary, and social care system had developed snags and blockages. Any solution would have to involve everyone working together throughout the whole system.
 
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 Pursuing Perfection has led to behavioural changes throughout the North and East Devon Health and Social Care Community
 
The subsequent Pursuing Perfection Admissions Avoidance and Delayed Discharge Project — skittishly referred to as “P2 A2 D2” — helped avoid 700 unnecessary admissions in 15 months. As part of the project, the team developed software to predict daily, monthly, and yearly discharges, and held daily multidisciplinary meetings to manage the flow of patients through the hospital. By freeing beds as a result, it is now rare for patients to have to spend time on an inappropriate ward or be forced to move — sometimes up to five times — between wards.
 
"We reduced these 'medical outliers' from the high 60s to zero," says Ms. Pedder. Clinical teams benefit too by being able to concentrate on patients with conditions relevant to their expertise.
 
Success hinged partly on breaking down organizational boundaries among frontline staff, not just managers. For example, an access team of occupational therapists and social workers is now based in the hospital emergency department. "I'm never too sure who they are employed by," says John Keast, who formerly led the P2 A2 D2 project. In fact it is the Primary Care Trust (PCT), not the hospital.
 
Allowing staff room to use their initiative has been decisive. "There seems to be a transformation of staff once they become truly empowered," says Mr. Keast. He cites the example of ambulance crews, who are now able to refer patients to social services. "That came about from an off-the-cuff discussion."
 
Ms. Pedder says, "It was always too easy in the past to blame a problem on someone else. Now everyone is focused on their own bit of the problem and how we work together."
 
Lambeth and Southwark Health and Social Care Community: Looking After Long-Term Conditions
Almost a fifth of the patients turning up at the emergency department of King's College Hospital in South London three years ago were found to be suffering respiratory problems, and a small number accounted for more than a tenth of all the inpatient activity for such conditions. Average length of stay for those with chronic obstructive pulmonary disease (COPD) was 14 days, and although patients had to endure a three-month wait to be assessed for rehabilitation, only 28 percent ever completed the program. So with help from Pursuing Perfection, the Lambeth and Southwark Health and Social Care Community — of which the hospital is part — set up a project to redesign the COPD patient's pathway through the system.
 
Today, length of stay for COPD is 6.6 days and patients can access far more support to keep out of hospital altogether. They need wait only two to three weeks for pulmonary rehabilitation and 70 percent complete the program. The hospital has seen an 11 percent fall in the number of occupied bed days attributed to COPD patients. Lessons from the project are now being applied to a range of other long-term conditions across Lambeth and Southwark, an area of 600,000 ethnically and culturally diverse people, many of them elderly and poor.
 
Using the Pursuing Perfection approach, the project combined patients' and professionals' expertise with COPD and used all available evidence to identify the components of ideal care. These included rapid and accurate diagnosis, 24-hour support, patient education, care at home, and pulmonary rehabilitation. But Lambeth and Southwark's original rehabilitation program — involving training in self-management skills and structured exercise — was based on a "one size fits all" model. Regardless of the patient's individual needs, preferences, or circumstances, rehab offered seven inflexible weeks of hospital-based group participation, leading inevitably to high non-attendance and drop-out rates.
 
Seeking ways to offer more choice, the project team "segmented" patients into nine groups according to the severity of their condition and their ability and motivation to manage it themselves. Then the team devised different packages of support for each group. These included written information, support from patient groups, and exercise programs for use at home, in a local leisure centre, or in the hospital. Each package was adapted to suit the patient's needs.  
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A Pulmonary Rehabilitation Coordinator at Lambeth and Southwark provides exercise training to a COPD patient who has helped design the program as part of the BreathEasy group and Pursuing Perfection
 
Today, the segmentation technique enables resources to be targeted more effectively, reducing input for more able and better-motivated patients while refocusing it on those who need most help. It has proved so cost-effective that it is now being used in case management for older people, and for patients dealing with diabetes, non-emergency knee surgery, falls, and pediatric occupational therapy. "It's been very important," says Malcolm Lowe-Laurie, Chief Executive of King's College Hospital.
 
In fact he describes Pursuing Perfection’s effect on Lambeth and Southwark's entire strategy for long-term conditions as "pretty influential." The Health and Social Care Community is now thinking about combining parts of its seven organizations responsible for managing long-term conditions. "Without Pursuing Perfection we wouldn't have got to this point," Lowe-Laurie says. "We would still be on first base."
 
Central Norfolk Health and Social Care Community: Springboard to Elsewhere
Alone among the NHS's Pursuing Perfection health and social care communities, Central Norfolk has now left the program to pursue its own transformation work. Local circumstances forced the decision. Several of the chief executives leading Pursuing Perfection in nine Norfolk organizations taking part left for other posts, while major financial problems facing the community demanded urgent top management time, making maintaining Pursuing Perfection impossible.
 
But the new, local transformation program, "Better Care for Norfolk," has inherited a rich legacy from the three other projects and applied them to caring for patients with a fractured neck of femur (broken hip), COPD, or diabetes. "Pursuing Perfection laid the bedrock," says Diana Clarke, Chief Executive of North Norfolk Primary Care Trust. "We haven't discarded anything, and we've got a firm foundation from which to build our new program."
 
One of Pursuing Perfection’s most significant effects was to bring together Norfolk's health and social care organizations for the first time. "We'd met, of course," says Ms. Clarke, "but we'd never tackled issues collectively. Pursuing Perfection made us focus on common issues and common goals. That was really good."
 
It also built bridges between managers and medics. "Pursuing Perfection brought managers and clinicians together to talk about things that interested clinicians. Common agendas began to be established. One of the spin-offs was better relations and a willingness to tackle problems rather than ignore them."
 
Patients benefited too, with the average length of stay for fractured neck of femur falling from 12 days to five. One patient in particular made an impression on Ms. Clarke. "She was home in five days, and then had an hour's physiotherapy. After that she said she was fine, and told the physiotherapist she needn't come back. Before Pursuing Perfection she could potentially have been languishing in bed for another seven days at that point."
 
Ms. Clarke adds: "That project brought together lots of clinicians — a multidisciplinary team on the ward and in community services, orthopaedic consultants, and medicine-for-the-elderly consultants. They have survived and grown as a group."
 
But Pursuing Perfection in Norfolk, a mainly rural area about 100 miles northeast of London, was very project-based. The Health and Social Care Community felt it wanted to focus its new transformation program across its entire system rather than concentrate on individual projects.
 
Still, the Pursuing Perfection vision  — no needless death or disease, pain, helplessness, delay, or waste — has had a lasting effect on Norfolk. "It's something that a lot of people here keep in the back of their minds as the real vision," says Ms. Clarke.
 
Pursuing Perfection in England has been successful on many fronts. In every community, positive changes lead to better results for the patients and the trusts. Not only did each of these communities extend themselves and make dramatic changes, but they were also truly innovative in their pursuit of perfection. They pioneered concepts around customization to patients’ needs, engaged patients in the design of care, and broke down barriers among providers to give the right services at the right time and place. Each of these efforts sparked new approaches among their fellow Pursuing Perfection organizations around the world. 
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