E DI TO R IA L
BJD
British Journal of Dermatology
Innovation in dermatology
DOI: 10.1111/bjd.12833
A reductionist summary of a patient’s requirements of health care shows just two jobs that need to be done. The first is, ‘I need to know what the problem is, what is causing it, and what I can do to correct it’. The second is: ‘Now that I know what needs to be done to fix my problem, I need it done effectively, affordably and conveniently’.1 This issue of the BJD includes an example of creative problem solving focused on addressing patient needs for the second of these two jobs. Oostveen et al., from Nijmegen, the Netherlands, still use topical dithranol in the treatment of childhood psoriasis despite recognizing that this treatment is difficult and inconvenient for patients.2 Their study involved comparing conventional dithranol treatment of childhood psoriasis delivered by hospital-based day care with less frequent attendance complemented by telemedicine consultations. This prospective study set out to assess whether the use of telemedicine would enhance their paediatric dithranol service provision, by decreasing the need for day-care attendance, which would save travel time for patients and require less time off school. Although the study was small, did not include a wash-out phase and was not randomized, it seemed to show that telemedicine did indeed enhance the standard day care model of dithranol treatment, with significant patient benefit. This innovation was rooted in the acknowledgment that dithranol day care from highly trained professionals is inconvenient for patients and inherently expensive. Technology in this example acts as the enabler with the potential to widen access, improve quality and reduce costs. The word ‘innovation’ is widely used, but what does it really mean? A textbook definition is that innovation is a process of original ideas and insights that have value, and are then implemented so that they are accepted by significant numbers of people. A shorter, more condensed definition is that innovation is a process of creative problem recognition and problem solving. It follows that problem solving without a creative element is not usually innovative. Innovation for most dermatologists is often about how we interact with our patients; success may be characterized by improved information about services we offer, improved and wider access to these services, and improved quality of the service. Less frequent but just as important, is innovation, where the standard model of care is made redundant by a new model that transforms the way in which dermatology services are provided. What drives the process of innovation? This is often complex but usually occurs by necessity rather than by design. For example, mounting problems with a long-standing model of care may prompt the dermatology team to rethink what they © 2014 British Association of Dermatologists
are doing. Thus, the main drivers for innovation are the symptoms and signs that current service is ailing: lengthening waiting lists, growing numbers of complaints, things going wrong, and anxiety in the dermatology team members in response to increasing demand without provision of extra resources. Perhaps the most telling symptom of a dermatology service in crisis is the sense of loss of control for team members as this situation becomes the norm. However, as with so many things in life, the looming crisis presents the dermatology team with opportunities as well as threats. For example, rethinking the service model may generate novel ideas that can widen patient access, reduce costs and lead to more patient-centred care. For this to occur, the dermatology team must listen to the patient voice and become more adept at seeing health care through their patient’s eyes. Incremental innovation describes the small improvements to service delivery adopted by dermatology teams throughout the world as they strive to be better, smarter, more efficient and faster with the care that they provide. Incremental innovation is the process of constantly trying to improve and build upon existing systems for service provision. This type of innovation requires regular team meetings, performance management, target setting, cost-reduction programmes, audit of actual performance against desired performance, and a relentless focus on efficiency. Although important, incremental innovation is not in itself enough to respond to all of the healthcare and economic challenges that face dermatology teams throughout the world. There is a limit to how much more can be squeezed out of existing models of care by repetitive cycles of improvement and efficiencies. When the dermatology team become demoralized, and the healthcare problems start to mount up, it is probably time for a rethink. A time out for the team, with strong support and facilitation from experts in change and innovation, may get the creative juices flowing and generate ideas for solutions. How does this work in practice? Oostveen et al. have started along a path that is transforming their dithranol day-care service by making the service more affordable and accessible so that a larger population can benefit. Their technological enabler was web-based teleconsultations, which converted their previously unstructured process of intuitive one-to-one nursing care to a more structured and accessible solution. The model they describe is simple, but currently retains much of the old model. It seems likely that subsequent iterations of this internet-enhanced service will involve less hospital-based intuitive care as the new model creates the prospect of many more patients benefiting from care provided by a single nurse. Thus, this small example from the Netherlands has the potential to transform care by addressing a fundamental flaw in most British Journal of Dermatology (2014) 170, pp229–230
229
230 Editorial
models of dermatology day care: attending hospital is inconvenient, time consuming and costly for most of our patients. A disruptive innovation for dermatology day-care services must focus on the job to be done, as Oostveen et al. have attempted to do. How can we tell whether an innovation such as this is a disruptive innovation? We can tell by seeing how rapidly the old model is jettisoned once the new model becomes more established. Additionally, the best innovative ideas are rapidly adopted by others as the shortcomings of the original model become apparent. Importantly, this study shows that the best creative thinking happens at the front lines of healthcare.3 The British Journal of Dermatology has a section devoted to Epidemiology and Health Services Research and would like to include publications on the best disruptive innovations in dermatology health care. Such studies must be scholarly, well designed and well executed, with the potential to act as an agent for improving dermatology models of care around the world. How do dermatology teams become research active in this area? They do this by thinking about the two jobs that
British Journal of Dermatology (2014) 170, pp229–230
our patients need to have done: the need to know what the problem is, what is causing it, and what can be done to correct it; and the need for management to be done effectively, affordably and conveniently. Aneurin Bevan University Health Board, Newport, Gwent, U.K. E-mail: [email protected]
A. ANSTEY
References 1 Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription: A Disruptive Solution for Healthcare. New York, NY: McGraw Hill, 2009. 2 Oostveen AM, Beulens CA, van de Kerkhof PC et al. The effectiveness and safety of short-contact dithranol therapy in paediatric psoriasis: a prospective comparison of regular day care and day care with telemedicine. Br J Dermatol 2014; 170: 454–57. 3 Martin RL. The innovation catalysts. Harv Bus Rev 2011; 89:82–7, 136.
© 2014 British Association of Dermatologists
BJD
British Journal of Dermatology
Innovation in dermatology
DOI: 10.1111/bjd.12833
A reductionist summary of a patient’s requirements of health care shows just two jobs that need to be done. The first is, ‘I need to know what the problem is, what is causing it, and what I can do to correct it’. The second is: ‘Now that I know what needs to be done to fix my problem, I need it done effectively, affordably and conveniently’.1 This issue of the BJD includes an example of creative problem solving focused on addressing patient needs for the second of these two jobs. Oostveen et al., from Nijmegen, the Netherlands, still use topical dithranol in the treatment of childhood psoriasis despite recognizing that this treatment is difficult and inconvenient for patients.2 Their study involved comparing conventional dithranol treatment of childhood psoriasis delivered by hospital-based day care with less frequent attendance complemented by telemedicine consultations. This prospective study set out to assess whether the use of telemedicine would enhance their paediatric dithranol service provision, by decreasing the need for day-care attendance, which would save travel time for patients and require less time off school. Although the study was small, did not include a wash-out phase and was not randomized, it seemed to show that telemedicine did indeed enhance the standard day care model of dithranol treatment, with significant patient benefit. This innovation was rooted in the acknowledgment that dithranol day care from highly trained professionals is inconvenient for patients and inherently expensive. Technology in this example acts as the enabler with the potential to widen access, improve quality and reduce costs. The word ‘innovation’ is widely used, but what does it really mean? A textbook definition is that innovation is a process of original ideas and insights that have value, and are then implemented so that they are accepted by significant numbers of people. A shorter, more condensed definition is that innovation is a process of creative problem recognition and problem solving. It follows that problem solving without a creative element is not usually innovative. Innovation for most dermatologists is often about how we interact with our patients; success may be characterized by improved information about services we offer, improved and wider access to these services, and improved quality of the service. Less frequent but just as important, is innovation, where the standard model of care is made redundant by a new model that transforms the way in which dermatology services are provided. What drives the process of innovation? This is often complex but usually occurs by necessity rather than by design. For example, mounting problems with a long-standing model of care may prompt the dermatology team to rethink what they © 2014 British Association of Dermatologists
are doing. Thus, the main drivers for innovation are the symptoms and signs that current service is ailing: lengthening waiting lists, growing numbers of complaints, things going wrong, and anxiety in the dermatology team members in response to increasing demand without provision of extra resources. Perhaps the most telling symptom of a dermatology service in crisis is the sense of loss of control for team members as this situation becomes the norm. However, as with so many things in life, the looming crisis presents the dermatology team with opportunities as well as threats. For example, rethinking the service model may generate novel ideas that can widen patient access, reduce costs and lead to more patient-centred care. For this to occur, the dermatology team must listen to the patient voice and become more adept at seeing health care through their patient’s eyes. Incremental innovation describes the small improvements to service delivery adopted by dermatology teams throughout the world as they strive to be better, smarter, more efficient and faster with the care that they provide. Incremental innovation is the process of constantly trying to improve and build upon existing systems for service provision. This type of innovation requires regular team meetings, performance management, target setting, cost-reduction programmes, audit of actual performance against desired performance, and a relentless focus on efficiency. Although important, incremental innovation is not in itself enough to respond to all of the healthcare and economic challenges that face dermatology teams throughout the world. There is a limit to how much more can be squeezed out of existing models of care by repetitive cycles of improvement and efficiencies. When the dermatology team become demoralized, and the healthcare problems start to mount up, it is probably time for a rethink. A time out for the team, with strong support and facilitation from experts in change and innovation, may get the creative juices flowing and generate ideas for solutions. How does this work in practice? Oostveen et al. have started along a path that is transforming their dithranol day-care service by making the service more affordable and accessible so that a larger population can benefit. Their technological enabler was web-based teleconsultations, which converted their previously unstructured process of intuitive one-to-one nursing care to a more structured and accessible solution. The model they describe is simple, but currently retains much of the old model. It seems likely that subsequent iterations of this internet-enhanced service will involve less hospital-based intuitive care as the new model creates the prospect of many more patients benefiting from care provided by a single nurse. Thus, this small example from the Netherlands has the potential to transform care by addressing a fundamental flaw in most British Journal of Dermatology (2014) 170, pp229–230
229
230 Editorial
models of dermatology day care: attending hospital is inconvenient, time consuming and costly for most of our patients. A disruptive innovation for dermatology day-care services must focus on the job to be done, as Oostveen et al. have attempted to do. How can we tell whether an innovation such as this is a disruptive innovation? We can tell by seeing how rapidly the old model is jettisoned once the new model becomes more established. Additionally, the best innovative ideas are rapidly adopted by others as the shortcomings of the original model become apparent. Importantly, this study shows that the best creative thinking happens at the front lines of healthcare.3 The British Journal of Dermatology has a section devoted to Epidemiology and Health Services Research and would like to include publications on the best disruptive innovations in dermatology health care. Such studies must be scholarly, well designed and well executed, with the potential to act as an agent for improving dermatology models of care around the world. How do dermatology teams become research active in this area? They do this by thinking about the two jobs that
British Journal of Dermatology (2014) 170, pp229–230
our patients need to have done: the need to know what the problem is, what is causing it, and what can be done to correct it; and the need for management to be done effectively, affordably and conveniently. Aneurin Bevan University Health Board, Newport, Gwent, U.K. E-mail: [email protected]
A. ANSTEY
References 1 Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription: A Disruptive Solution for Healthcare. New York, NY: McGraw Hill, 2009. 2 Oostveen AM, Beulens CA, van de Kerkhof PC et al. The effectiveness and safety of short-contact dithranol therapy in paediatric psoriasis: a prospective comparison of regular day care and day care with telemedicine. Br J Dermatol 2014; 170: 454–57. 3 Martin RL. The innovation catalysts. Harv Bus Rev 2011; 89:82–7, 136.
© 2014 British Association of Dermatologists
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