The journey of a thousand steps

The journey of a thousand steps

Article Type: Editorial From: International Journal of Health Care Quality Assurance, Volume 29, Issue 4.

As a great strategist, Lao Tzu is often quoted. His writings have become essential reading for many on the journey to management enlightenment. However, as with the output of many great thinkers, we have focused on one or two clichéd expressions from him. And one of the most clichéd is that a journey of 1,000 miles begins with a single step. There is no denying that this is both figuratively and anatomically correct but the reality is that we can see more than one step ahead at a time. We want to think in multiples of steps and push the horizon as far away as we can.

In this issue, we have a number of articles where the authors have delineated the first number of steps that need to be taken in order for the rest of us to push out the healthcare horizon farther than we currently do. But in order for us to push out that horizon, we need to be sure of, and reassured of, the solidity of the ground on which we will take those first few steps.

Walton et al. explore the principles and practices of ward rounds, one of those essential elements of daily life in a hospital environment. Indeed it has struck me that this age-old ingredient of hospital life has little evidence-based research published about it. How is it that we follow this routine blindly without a thorough knowledge of the underpinnings of the activity?

And though most inpatients measure their stays using the interval between the last ward round and the forthcoming one as a unit of time in hospital, they also see the interval between one meal and the next as another unit of time. Kai Hansen explores the research behind the world of catering in healthcare institutions.

Though we say we are patient centred in our focus, a quick examination of the needs of patients is often and repeatedly required. Why do we bring patients back to the institution to shake their hand, speak to them for a few minutes and discharge them when so much of this interaction could take place over the phone? Patients like this approach and Hoffman and Pelosini tell us that it is a safe and effective way of making ophthalmology care easier for patients (and for staff). Making things efficient for surgeons is clearly a good thing but macro-system changes may not be the way to go if you want significant gains. In the Japanese healthcare reimbursement model, recent changes to the fee schedule and funding arrangements have provided an opportunity to compare and contrast behaviours within the theatre environment. Nakata et al. provide us with very interesting evidence that surgeons’ productivity is not clear cut and that all of the constituent elements (such as the presence or absence of assistants and the grade of surgeon operating) must be factored into the costing structures when operative interventions are scrutinised.

Making surgery more efficient is clearly important, but making healthcare safer is much more important. There are a plethora of risk management tools available to analyse and map patient safety issues, but the bow-tie method is one that I had not heard of before. Perhaps because I wear bow ties on occasions, I feel an affinity to this very descriptive means of mapping safety issues, but I found bow ties to be one of the most efficient methods of neck adornment. Adbi et al. highlight the use of this very descriptive and engaging method in a way that has convinced me to use bow ties for more than decoration.

Just as when you put on a bow tie to complete the outfit before you look in the mirror to judge how well everything looks in its entirety, it is important to see the organisation in its entirety to judge how well individual elements sit together. Kriendler et al. look at the overall elements of patient involvement in the healthcare of mental health services and Yan-Han Huang et al. look at the adoption of health technology in a macro fashion but in “micro” institutions. It made me reflect on how we continue to think that one size fits all when we roll out elements such as ICT technologies to organisations big and small and expect them to work similarly in all settings.

But one of the underdeveloped aspects of this technology roll out is the element of patient choice in appointment time. Going back to the old saw of patient centred healthcare, I continue to wonder at the lack of patient focus in organisations when it comes to patients picking their appointment slots. But we continue to be baffled, annoyed or even relieved when the patient does not show up. Yu-Li Huang and Hanauer give us some lovely insights into the modelling of no-shows into the overall efficient running of an appointment service.

I hope that this issue gives you as much food for thought as it did me. It has shown me that the ground is firm, I can lace up my boots, and the only thing stopping me now may be my lack of imagination as to where the journey will end. So to leave you with another cliché; is it true that it is better to travel than to arrive?

Ian Callanan