It was running a session with a group of older people’s health clinicians about eight years ago that triggered it. We had been talking about lean thinking and how identifying and eliminating waste in the system was necessary to add value to both patients’ and staff time.
Then, in a moment of inspiration, a fully formed construct of patient time emerged in my head. It goes like this: in most developed countries, if you’re a Caucasian woman, you can expect to live to the age of 83. If you are a Caucasian man, you can expect to live to the age of 79. But supposing you’re an 80 year-old woman, or a 76 year-old man, what do you have left?
What you have left is 1,000 days.
While demographically the longer you live, the longer you can expect to live and if you survive past the age of 10 your life expectancy goes up too – 1,000 days is really a metaphor for our lives.
It acknowledges that in developed countries health systems, many of those we care for and care about are older people in their last 1,000 days. It’s why using patient time as the most important currency in health care transcends access targets and pressures, it becomes a moral issue of what we are about as health professionals. It’s why every day a person spends in hospital more than they must is stealing their time, why their waiting needlessly for an appointment is stealing their time, and why older people, who are sometimes treated as if they have all the time in the world, are actually in a hurry.
The second key construct to patient time that we formed was the notion that the collective patient time; from the time of need to the time of fulfilment of that need, is the equivalent of the inventory of the health system. The more collective time we have in the system awaiting an outcome, the less effective we become, the more real waste of human capital in the population. Couple this concept to the idea that approx. 80% of the cost of NZ health systems is buying staff time (approx. 60% in UK), we quickly realised that it’s not money that connects the health system but time. The more staff time can be redirected to supporting patient care by removing system wastes, for example through the local deployment of Releasing Time to Care (Productive Ward), the more time becomes available to remove the delays to patient time.
Time is the real currency of the health system, a currency understood by all, motivating us to do the right thing.
That said, in order to value patients’ time, we must also value our staffs’ time. We must recognise and be comfortable with the notion that while we are busy and our time is important, our patients’ time is sacred. In doing so we become renewed in our efforts to create new ways of working to stop wasting staff time and give that time saved to patients.In so many ways, this seductively simple and yet challenging concept drives so much of the Canterbury Health System in New Zealand. Patient time and 1,000 days as a construct evolved from discussions, initially with Dr Nigel Millar (@nigelmillarnz), then Chief Medical Officer, Canterbury District Health Board (CDHB), David Meates CDHB CEO, Carolyn Gullery (@CarolynGullery ) GM [Exec Director] Planning & Funding, Mary Gordon, Executive Director of Nursing, Richard Hamilton, Manager, Organisational Development Unit and myself.
It’s about thinking past the silos of organisations into how people live their own lives and knowing that hospitals are not as big a feature of them as we like to think. Patient time is the fulcrum on which the three strategic goals of Canterbury Health System are balanced. These are:
- People take greater responsibility for their own health
- People stay well in their own homes and communities
- People receive timely and appropriate complex care
Canterbury is on a journey of transformation focused on a shared vision of ‘a connected system’, centred on people that aims not to 'waste their time’. The responsibility of system leaders is not to provide the answers, but to frame the right questions and trust the clinicians to make the health system better, valuing both theirs and their patients’ time. It moves the language away from ‘targets’ to ‘professional standards for care’.
In essence, patient time as the key metric of performance and quality is best measured from the perspective of the person and is a journey not an event.
In ‘Grapes of Wrath’, a story of recognisably unsettled times in America, John Steinbeck wrote, “Up ahead they's a thousan' lives we might live, but when it comes, it'll on'y be one”. Hopefully, one day in the distant future, when we are in our own last 1,000 days, we will be able to look back and acknowledge that while we may not have got rich or famous, we will have made a difference to our families, our patients, our professions and our communities. That we led a life that mattered.
And we will know that the time we had on this earth counted for something.
Author: Brian Dolan, Director of Service Improvement, Canterbury District Health Board, New Zealand (@brianwdolan)