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PbR needs emergency measures

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One of the key arguments in favour of a payment by results approach to commissioning is that the focus on outcomes allows for flexibility and innovation and radical change in how we approach such entrenched social problems as crime and drug misuse.

At the moment, the various PbR pilot schemes are more about consolidating and expanding on best practice, rather than trying new approaches. The focus on outcomes  is great for driving commitment and quality, but the prospect of not being paid can tend to discourage rather than promote the risk-taking that is inherent in trying out new ways of working.

However, this doesn’t have to be the case. I was inspired by reading a case study in SuperFreakonomics about the way Craig Feied (pronoucnced “FEE-ed”), an Emergency Room Doctor and computer nerd, turned Washington’s  worst performing ER into its best.

[See the post on Prison-Probation Collaboretition for my love of the @Freakonomics authors and their investigations in the arena of incentives and perverse consequences.]

When Feied assessed the problems of Washington Hospital Center’s ER, he found that doctors were spending 60% of their time trying to gather diagnostic information and just 15% actually treating patients.

His response was a state of the art computer system which made a whole range of medical information immediately available to doctors in the emergency room. The immediacy was key:

“a person using a computer experiences cognitive drift  if more than one second elapses between clicking the mouse and seeing new data on the screen. If ten seconds pass, the person’s mind is somewhere else entirely.”

When ER doctors’ minds aren’t on the job, they make mistakes which result in patients dying.

His battle to get the computer system funded, designed, built, and ultimately used by all the ER staff was beset by resistance at every level – particularly the bureaucratic one. One administrator was so opposed to the project that he regularly logged into the procurement system at night to cancel Feied’s requests.  Readers currently implementing PbR schemes across government departments should take heart that battles against red tape and officialdom can be won.

Feied’s results were impressive. Although the new system made four times as much information available to doctors, they now spent only 25% of their time on managing information and over twice as much time as before on direct patient care. The headline achievements were:

  • Patient outcomes improved.
  • Waiting times slashed (starting from an average of 8 hours, 60% patients are now in and out of the ER in under 2 hours).
  • The hospital dealt with double the number of cases with just a 30% increase in resources.
  • Doctors were delighted – and made less errors.

You would think that this would be enough of a success story already.

But read on.

For a start, Microsoft bought the system and installed it in dozens of other hospitals – it worked equally well in a range of non-emergency settings.

The accumulation of such a wealth of data gave rise to many more opportunities:

  • Billing was more straightforward (releasing money for patient care).
  • The long-held dream of electronic medical records was suddenly possible.
  • Even better, doctors stated interrogating the data to seek out markers for diseases in patients that hadn’t even sought treatment yet.
  • Because the system collects data from across the US in real time, it greatly improved early warning systems for disease outbreaks.

And all this was achieved in the late 1990s before the world wide web make this sort of technical solution much easier.

Craig Feied wasn’t paid by results (although he ended up earning a lot more at Microsoft). But he was brave and clever enough to realise that some entrenched problems need a radical approach.

Let’s hope that the PbR approach stimulates the same level of original thought – and successful outcomes.


Next time: How the same Freakonomics case study explains why a PbR approach to police pay won’t work.


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