Technology is a great thing, and has advanced the human race at an almost unimaginable pace over the last few years. I love being almost a native when it comes to IT and technology. I am not overly confused when a new technology comes out, can sort of understand the way the web works, and don’t completely lose it when it comes to cloud computing ( something my parents don’t really feel comfortable with)
But, I am also a bit of a Luddite, and find pleasures in timeless pursuits, like walking up hills, camping, sitting by a fire, reading from paper (although the majority of my reading is now on a screen of one sort or another)
When it comes to healthcare, I have pretty similar views, and appreciate all of the advances that can be made with our new technologies, but also find fascination in the seemingly simpler, but often more complex interactions between individuals, especially patients and doctors.
This week I got to see all of the things I find interesting rolled into one. The meeting I went to was the North Central London cohort review. Cohort review is a method of rolling audit if you like, in which a service reviews it’s most recent cases, checks on performance and outcome, and tries to lear lessons along the way. Each case seen by a service is presented by the case manager to a panel of experts, with an audience of their peers from their own, and other services. Various essential pieces of data are presented, including detailed information on outcomes of treatment, adverse events, and the results of contact tracing. the presentation is made to a panel consisting of an independent chair, senior case managers, an epidemiologist, a microbiologist with access to a vast array of lab data, and public health representatives. In future editions, local primary care physicians will be invited.
The Cohort Review process was used in New York in the 1990’s to reverse a trend of increasing TB incidence, and is credited, along with other changes in management as one of the main reasons incidence of TB in NYC is falling, rather than rising as it is in most major capitals. (see here for more information)
So, what is so special and why did I get so excited.
#1. Cohort review is not an audit in the sense of a junior doctor clinical audit, but falls more in the category of continuous quality improvement, with lessons learned on the hoof, solutions thought of and shared by those on the ground ( the TB case managers) and a process of rolling review to see how improvements have impacted on the outcomes achieved.
#2. Cohort review is a public test of how well you are performing as a service, with your peers scrutinising your practice, and competition between services being very much on outcomes and reputation (see Muir Gray’s blog for more on this). It is slightly unusual in the health service to hold people to account in a robust way, but this meeting made that possible, and clearly drove people onwards to achieve higher standards. The fact that this meeting covered a number of neighbouring services, but remained local enhanced this sense of being held to account, but by those who understand and sympathise with the local context. An independent, respected, and expert chair helped to keep this a robust, but fair process.
#3. Cohort review combined the latest in technology with something very basic, and this brought out amazing opportunities to fight a disease. TB is caused by a mycobacterium, and each of these can be strained by analysing it’s ‘fingerprint’. When this fingerprint data is added to the clinical, and demographic data, it is possible to see clusters forming, and data from the ground can highlight areas of social interaction, which in turn allow targeted efforts at controlling the spread of the disease.
So the strain typing is the high tech bit, but the simply all getting together in a room, not with just the directors if each service, but the foot soldiers, allowed the tacit knowledge from the front line to inform those with a high level overview ( an epidemiologist and public health doctor attend the cohort review) and create strategies for investigation in real time. (an example was a cluster of 17 cases presenting to a large number of services, but with common geographical and epidemiological data, highlighting a very specific area of high transmission – a charity mission as it happened)
#4. This is scaleable. Solutions to problems are often very situation specific, and transplanting one solution into another context can rob it of any chance of working, but the principles which make the CR process so effective, in my mind, can be applied to many different fields, especially where we are moving to distributed networks of practice.
So, competition between services, but experienced in a meaningful forum (not just a league table produced every few years), a continuous process of improvement, with accountability for performance being felt at the front line, along with a blending of high tech, and simple communication between those looking at a problem from different perspectives.
All these ingredients made me more excited about this process, and brightened up my Thursday morning more than I could have hoped for. Now I need to look at where else this could be applied, and see if I can sow the seeds. Get in touch if you would like more info.