Lynne Maher

JB: Well, I’m very lucky today to have with me Dr Lynne Maher who spent most of
her career working in clinical and operational roles at local and national level in the
NHS and has now moved to New Zealand as the Director for Innovation at Ko
Awatea in Auckland.

JB: Lynne, thanks very much for talking to me. I wonder if we could, perhaps start
with you telling us a little bit about the similarities and differences between the two
health systems, we’ve got this huge health service in the UK with lots of challenges, is
this similar in New Zealand?

LM: Thank you John, yes, I have found that the New Zealand (NZ) health system is
similar to the NHS although it’s on a much smaller as there are only around 4.6
million people living here. Most services are free at the point of need and the levels of
clinical care are of a similar high quality as in England. The main differences are that
in NZ is that there is a payment to be made when you visit your GP, although there is
support for those who are unable to pay, and there seems to be a higher proportion of
people who have private health insurance, other than that NZ has very similar
standards and challenges.

JB: How does Ko Awatea contribute?

LM: The name Ko Awatea was gifted to us by our local Maori Community. It means
new beginnings and relates to the dawn or ‘first light’. It is a department which sits
within Middlemore Hospital and provides support for innovation, improvement and
education both within the local Counties Manukau health system and more widely
across NZ. Areas of focus include exploring ways to create equity for all to access
health and care services, creating new models of care, reducing waste in the system
for example the level of Did not attend’ s for out patient appointments, testing the
increased use of technology to streamline work and of course increasing safety.
Health care workers are supported through coaching, guides and toolkits including
virtual or ‘e’ learning, we have also developed capability building programmes in
leading improvement which are not only available to our local staff but for others
across NZ.

JB: So, it’s very much a support for the practitioners across the health service, but it’s
providing them with tools and resources, but you’re feeding that, also, with your own
research so that you’re generating new tools, new techniques, new approaches.

LM: Yes, we like to consider ourselves as ‘thought leaders’. So, we are absolutely
searching for new approaches and working with people to test these so we can be
clear about the benefits they can bring to health services. We work with frontline
practitioners, administrative staff, senior leaders, consumers and family members. We
also contribute to activities such as the New Zealand Innovation Awards helping to
seek out and nominate teams for the awards and assessing entries. This is an activity
that I am personally involved in and am amazed at the increasing number and quality
of entries and how these concepts can benefit health. For example, entries focussed on
education, technology, design and engineering often have fantastic ideas that would
benefit health.
JB: So, very much the work is around how to manage innovation more effectively and
how to engage all the players in the health system.
LM: Yes, and our focus is on how to help people to make a practical difference, being
on site in the hospital and physically in the community really helps with that.

JB: Absolutely. Within that context, I know one of the things you’ve been working on
is what you’ve called ‘experience-based design’. I wonder if you could tell us a little
bit about that and perhaps give us a couple of examples

LM: Yes, I started working with others to develop a way that we could specifically
partner with patients and families and learn from their ‘lived’ experiences of receiving
health care about 10 years ago while I was in the NHS. Working in this way was usual
practice in other industries who provided some sort of service for example, hotels,
airlines and theme parks. Mental health services were also pioneers but other areas of
health and care services were not really use these approaches at that time.
We started to explore these concepts and came across some fantastic work being
undertaken by design agencies. They have expertise in understanding customers
experiences and then by working with those customers and using their insights about
what works well and what doesn’t, they are able to make improvements which lead to
better experiences of those services. This includes the way we check in and out of
hotels, our journey through airports, our experience in the retail sector and restaurants,
how we interact with the internet and our mobile phone. Designers work very closely
with the end customer to create services that provide the best experience possible, one
of the reasons for this is that if the consumer has had a good experience, they will use
the service or brand again, this customer loyalty is precious.
Now, even though that example is set in a commercial world, we realised that there
was a great opportunity to use the methods within healthcare environments. We all
really want patients to have high quality, effective and safe care and, we also want
them to have a good or great experience. The concept is also just as relevant and
important for health care staff, if we can learn from staff experiences, gather their
ideas and work closely with them to make improvements, then their experience of
delivering care can also be improved.

We regularly find that even if a process of care is seemingly very slick, very efficient,
very safe, it could be that the patient’s experience of that care was diabolical, in some
respects. Alternatively, we have spoken to patients who had not had the best clinical
care that we would wish, but, what they describe as respectful and honest
communications and positive relationships with staff had influenced their overall
experience, which they subsequently rated highly. We repeatedly find that patients
really value being treated with respect, want to be able to ask questions and
understand what is happening at every step of their journey, want to be involved in
decisions about their care and want to know how they can best contribute. Actually, if
we think about it, this is what any single one of us would want isn’t it.
Being able to understand experiences of delivering and receiving care provides us
with essential data which will inform any improvements or innovations. Many studies
are finding a significant relationship between staff experience of delivering care and
patient experiences of receiving that care, we need to focus on both.
Co-design is a way to understand health services from multiple perspectives this
‘data’ yields what I describe as ‘golden nuggets’, insights that we would not have had
without working closely with staff, patients and families. For example, a better
understanding of why patients don’t come to specialist appointments, they ‘do not
attend (DNA) with reasons that range from; I did not understand what the purpose of
the appointment was, to I simply cannot risk taking time off work, to I am just to
scared in case I find out something bad. A common practice to improve these DNA
rates is to send out text reminders, these reminders will be helpful for some but do not
influence those who don’t understand, cannot leave work or are fearful. This reminds
me of a quote that is attributed to a few people including Henry Ford “If you always
do what you’ve always done, you always get what you’ve always gotten”. By
working closely with staff and patients we are much more likely to understand the
root cause of healthcare challenges and better understand opportunities for
improvement that can transform peoples’ experiences and health services.

I have been privileged to be involved in co-design projects and programmes that have
made tangible differences for example; the difficulty in finding your way within
hospitals can be stressful at least but can also result in people being late for
appointments or even missing them altogether. One project team who was working
closely with patients discovered that appointment letters clearly stated that a test
would take place in the x-ray department. However, there was no sign in the hospital
that said ‘x-ray’, the sign for that department said Radiology. Many people had
missed diagnostic appointments which was worrying for them and also caused
additional work for staff who had a gap in their schedule and also needed to
reorganise the appointment. This team had previously tried to improve the rate of
patients turning up on time but the had not looked closely at the detail of their
appointment letter, not one staff member had realised the mistake before they worked
with patients but it was one that could quickly be changed and in turn saved the
anxiety for the patients, reduced wasted time in the schedule and saved staff from
needed to re book. An example with similar results happened when patients arrived
for diagnostic tests but were not prepared as well as they needed to be which led to the
cancellation and re arrangement of the tests. When working closely with patients we
found that the instructions they had were actually incorrect and the phone number that
was provided if patients wanted help had been mistyped and was actually
disconnected. Once again staff had assumed that patients were just not paying enough
attention to what they were being asked to do, but by working with them discovered
the errors in the instructions given. In both of these examples staff had been working
on improvements for a while but until they worked closely with patients they were not
armed with the root cause of the problems; the ‘golden nuggets’.

JB: This is fascinating stuff and, clearly, it has a link to some of the innovation
theories around bringing users into the innovation process right at the front end.
You’ve given some great examples. I guess the other question that begs is what are
the difficulties in actually making this kind of thing happen? It seems to me almost a
no brainer that we want to have a better quality experience all round. What are the
difficulties in actually making that happen?

LM: I think some of challenges are around our mindset. Many organisations would
say that they do engage patients and cite examples such as through their annual
forums, satisfaction surveys and net promotor systems that ask patients to indicate
“How likely is it that you would recommend our service to a friend or colleague?”
These are all helpful and do provide an indication in broad terms of how patients
would rate services. However, if satisfaction drops or people are increasingly saying
that they would not recommend the service we often don’t know the detail behind that
which means we can’t be sure what we need to do to improve it. By exploring
experiences in more depth, actually talking to people, we can gather information
which is more likely to provide the level of detail that we need in order to improve
services.

There is often concern that if we ask patients about how we could improve, they will
identify things that our health services just cannot afford. The opposite is true, patients
identify points in the process that either don’t make sense or don’t add value or that
can be achieved in a much more cost-effective way. Patients are aware of the fact that
health services have finite resources and they want to play their part in helping us to
provide the best we can within those resources.

We also find that for some staff the transition of relating to patients in a
different way can be difficult. Their professional expertise is still highly valued but
now the expertise that the patient brings including their lived experience of care and
expertise from their industry, workplace or community becomes equal and that
changes the conversation. However, I think it’s a gift. Not only are we gaining more
insights about peoples experiences of health but also their insights and ideas from
their industry, workplace or community. This is often how innovation happens; taking
ideas that might be commonplace in one industry but not in your industry but if
adopted could lead to significant improvements. I have worked with women who are
managing children, unwell parents and a community initiative; they are fantastic at
project management! I have worked with people from manufacturing, the retail
industry, lawyers, IT specialist, fisheries experts, film makers and so on, they all bring
excellent new ideas from their industry to ours.

Like any project or initiative this work does need strong leadership support. The
support for staff to have time to undertake the work, help with any challenges that
happen and advice on how to create a compelling story of the benefits achieved. If
you ask anyone who has worked on a project what has been their biggest challenge or
what is the most precious commodity?’ they will say it’s time, ‘we haven’t got time.’
We do need to find time for people to be involved in improvement and innovation,
because if we can find time now, we can actually save time that is wasted for example
by reducing rework as I mentioned earlier.

JB: One last question prompted by this discussion of the user’s experience, the
patient’s experience: many of the examples you’ve given are around improving the
quality of what’s actually happening for everybody concerned and that’s, as we know
from so many sectors, hugely important. Are there examples where that process
also generates a completely new way of thinking, perhaps opens up completely new
innovations?

LM: Yes, now that the concept of understanding experiences and co-designing
improvements is becoming more accepted we also have more examples of innovations
internationally. In New Zealand the health system in Canterbury needed to completely
redesign its health system and they set up a way of working where people in the
community could; share their experiences, articulate what was important for them and
discuss their ideas for improvement. This has already resulted in changes to the
design of buildings and processes but also to the whole system of care which now has
a much higher provision of services based in the community. An even more radical
example is from Alaska which resulted in the local native community taking greater
control over their health services. Their role changed from them being ‘recipients of
services’ to ‘owners’ of their health system, which they not only helped to redesign
but also now manage. The Kings Fund has written case studies about both of these
examples and they are available to read if anyone would like to explore further.

Canturbury- [Link]
social-care

Alaska- [Link]
system-care-alaska

Another interesting change is the British Medical Journal who made a radical move to
very meaningfully partner with patients. They now co-produce the content they
publish with patients and ask others writing articles to do the same. They have
patients on their editorial board and at major conferences that they are involved with.
It’s a major change in the industry and they are pioneers and role models in partnering
with patients.

JB: That’s absolutely fascinating. Thank you very much indeed, Lynne.

LM: Thank you.