Lead of the Inclusive Healthcare Innovation Initiative (IHI), at the Bertha Centre for Social Innovation and Entrepreneurship, Dr Lindi van Niekerk, talks about the importance of healthcare innovation and its impact on eHealth in SA.

What is your background and how did you get involved in IHI?

I studied medicine with the hope of bringing about a positive change in peoples’ lives. However, as a junior doctor I soon realised the need for change was far greater than I originally envisioned. Not only was this need present in our patients but also in the way we were delivering care. During my intern year, my colleagues and I started an end of life care programme that has since been further developed and replicated in other health facilities. Challenging the status quo and developing something new and different always comes with opposition – as it did with the end of life programme – but these days when I hear “this is not the way things are done”, I celebrate it as a sign that we are on the right track.

From the experience of implementing an innovative solution, I realised that even as a junior doctor it was possible to bring about positive change, hence my firm belief that there are lots of other health workers, students, community members with great ideas but who aren’t always given the opportunity to develop them. Supporting others to become innovators in their own right is what led to the establishment of our Inclusive Healthcare Innovation Initiative at the UCT Bertha Centre for Social Innovation and Entrepreneurship, based at the Graduate School of Business. Our work focuses on building a supportive platform that enables more people to go from idea to implementation. We have such an abundance of opportunity to improve healthcare in South Africa and the simplest solution can bring about a big change for many people in need of equitable, affordable and dignified care.

Let’s talk about the Bertha Centre’s involvement and what led to Groote Schuur Hospital (GSH) becoming the ‘Innovation Hub’?

The Bertha Centre is an amazing, creative and free-thinking space and the Graduate School of Business is very encouraging of innovation. Despite not having any formal training in the innovation field, my experience as a clinician has been invaluable in seeing where the gaps in the system are and what our patients and fellow health workers really need. Currently, the work of the Bertha Centre extends from innovation in education, finance, policy and systems. I still, however, am most excited by applying a social innovation lens to healthcare and exploring how this could offer an alternate approach to transforming our health system from the ground-up.

GSH Innovation Hub - EHN

GSH Innovation Hub. Haldane Martin design.

In 2014, our vision for health care innovation co-incided with that of the CEO of GSH, Dr Bhavna Patel. Dr Patel saw an opportunity to focus on ‘innovation, leadership and change’ as three strategic goals for improving health services. We were fortunate to also have the involvement of the UCT Faculty of Health Sciences and together, we co-created a new idea of an Innovation Hub, something that has never been tried before in a public hospital in SA and we believe in Africa – yet.

Innovation is really as much about trying to encourage a cultural shift in our hospitals as it is about developing new solutions to better patient care. Before we started this journey at GSH, we spent an extensive period of time speaking to and listening to the staff, allowing us to gain an in-depth understanding of the challenges from their perspective and then designed a space and a programme to support them from the day they got their idea to when they could implement and test it.

When space was made available in GSH for the Hub it demonstrated how serious the hospital was about innovation; that it’s not something that happens behind the scenes but rather something that’s front and centre. The Innovation Hub is an inclusive space that doesn’t belong to any specific department but is open to anyone from a cleaning assistant to departmental head. Here all people can come and share new ideas to reimagine healthcare.

Which organisations are involved in the Hub?

The Innovation Initiative at Groote Schuur is a great alignment between partners; the programme is funded through the GSH facility’s board, which is supported by Hospital management, and the Hub was invested in by the Bertha Centre and the faculty of Health Sciences at UCT.

The Hub has now also been donated to the Western Province which furthers cements our vision that the Hub will become a vibrant meeting space from within the healthcare system where staff from different hospitals, or even with people from the community, can come together to share ideas, think of new solutions and collaborate to build bridges across facilities, including the public and private sectors. The Hub is a space where a greater understanding can be gained about challenges in our health care system, where people can come develop new skills and protoype ideas and also meet other like-minded individuals.

What impact has the programme had on the staff?

It has an important human resource component because innovation is just as much about people and culture as ideas and technology. A lot of the work we’ve been doing has been about trying to change the bureaucratic and hierarchical culture of healthcare that has been institutionalised for many years. It’s challenging, but it’s also exciting for frontline staff who suddenly feel empowered and find an opportunity to share their thoughts and ideas.

Dr Bhavna Patel, Dr Francois Bonnici, Dr Beth Engelbrecht, Dr Lindi Van Niekerk, Prof Wim de Villiers & Dr Reno Morar. Haldane Martin design.

Dr Bhavna Patel, Dr Francois Bonnici, Dr Beth Engelbrecht, Dr Lindi van Niekerk, Prof Wim de Villiers & Dr Reno Morar. Haldane Martin design.

Some people were initially nervous about coming to the Hub, and said: “I’m not sure but I think I’ve got an idea.” It’s been amazing to see the personal journey of the staff who have been participating and how their confidence and sense of ownership has developed since we launched this programme in October 2014. They are achieving fantastic results, while still carrying out their full workload.

Our under-resourced, under staffed and overburdened healthcare system is a difficult environment to be in day in and day out. Staff attitudes are an issue that we get a lot of complaints about from patients and I think that part of that comes down to a challenging work environment. So how do we change that? We offer them the opportunity to affect change, to feel valued and make a difference to their environment that will have a knock on effect and we hope ultimately benefit their patients. There is so much intellectual and creative capital in our healthcare workers within the public sector.

So from an empowerment point of view the programme has been huge, but of course innovation still seems risky to some and it may take many years for this new culture to become institutionalised.

Therefore, what we are trying to do is to prototype a model that enables people on the frontline to realise their potential and innovate. Our ultimate vision is create a network of these inclusive spaces within healthcare systems across Africa that can catalyse healthcare worker-led innovation.

Is there such a thing as a bad idea at Innovation Hub? How do you guide the process of developing ideas?

The idea doesn’t even matter that much initially compared to the courage and willingness shown by the person who comes forward with it. Our aim is to guide that person through a process to identify the core problem and refine their idea as they go along. We’ve seen some staff change their idea 180 degrees after sending them out to get feedback and input from their patients and colleagues. Basically, a good idea starts with a solution that addresses the need and asking patients how and what they want their service to be. Often what matters to the patient is very different from what the doctor thought mattered, so patient engagement in the innovation process is key.

How can the private sector get involved in the programme?

There are definitely some challenges across the board when it comes to how we can improve the experience of care. The private sector needs innovation around reducing the cost of care because it’s resource intensive, which is not sustainable. We would love to have the private sector come and experience the challenges that exist within state facilities, and bring a different way of thinking and approach to those challenges from their side. We might be stimulated by something that has been working in the private sector that we wouldn’t have otherwise considered and vice versa. There has already been a lot of interest from the private sector, and it would be great to build a bridge between the two sectors and collaborate in strengthening the health system.

What are some of the top health innovation challenges in SA?

A big challenge is how patients experience care, so even if we can’t do more in terms of the treatment we provide, it’s the experience we give them that’s important. The traditional structures in place are designed to meet the operational needs of the system, not of the patient. For example, we see a lot of inefficiencies in our hospitals where patients go from one clinic to the next seeing different providers but never receiving a consolidated answer they understand. Reallocating our existing resources is a huge opportunity for innovation in dealing with this issue.

There are also innovation opportunities within our communities, which is completely untapped in the system. Other countries are using family members to provide care through peer-to-peer care pathways and programmes. SA is very exclusive about who can come into the health space and who is allowed to get involved. Having a more inclusive approach of who could be contributing to care is another great opportunity.

How could eHealth fix the problems you just described?

It’s important to see technology as an enabler, because we often make the mistake of thinking of it as a solution to a problem but neglect the human component.

One of the projects teams working here at the Innovation Hub, which has secured R400,000 investment so far, is an electronic referral system we’ve dubbed Referrals 1.0. The premise was to come up with an better way to manage referrals between facilities and GSH. In a traditional pathway, a doctor writes a letter that gets faxed to hospital, somebody picks up the letter and puts it in the pigeon hole. Administration then sets a date for an appointment which is posted to the patient. It’s a very inefficient process and open to all kinds of mistakes which could put the patient at risk of not receiving timely care.

It’s a problem that extends across all areas of care and as an example, the project was actually proposed by four departments – orthopaedics, cardiology, neurology and dermatology. Initially, each team proposed a different solution, ranging from a web-based system to a mobile app. The teams were asked to collaborate because in order to address the root of the problem, a single unified system that refers all patients the same way was necessary.

The first step for the team was to define what the referral needs were and to identify similarities in each department’s referral pathway. From there, they needed to find a basic platform that could work, and start thinking about the system’s design.

The wider health system would be very interested in this solution because it’s a problem faced by many healthcare facilities. It will likely take a lot more than R400,000 to fully develop and implement the end solution so for now, the main focus is providing the opportunity for clinician-led eHealth innovation  and getting them to design the right protoype that is interoperable with existing IT infrastructure.

Are there other digital IHI innovations?

Other than Referrals 1.0 there are two others – the Time Machine and the eHealth Board.

Dr Peter Raubenheimer’s team is trying to come up with an at-a-glance electronic board that will display patient information, patient locations and bed numbers within a ward. At the moment there’s no system in place to find a patient or bed in a quick and easy way in our hospitals and most records are handwritten. This results in an extra burden on the staff, as well as delays and inefficiencies for patients.  The eBoard tool will be a great solution to improve communication between the various members of the clinical team and as well as reduce unnecessary delays in finding a hospital bed to admit a patient.

The Time Machine aims to get better efficiency out of radio nucleus scanners for oncology patients. The team realised that if they allocate their staff slightly differently they could be more efficient and see more patients. This led to them developing a prototype that will allow them to see how they’ve allocated staff numbers, but their goal is to digitise the system so that they can see what the outputs are and how many patients they are seeing in real-time.

What are your views on NHI? 

I think NHI is a necessity, but I also think that we are missing a huge opportunity for innovation. We could be using NHI pilot sites as a testing ground for new models of care that would completely redesign our healthcare system– which, when it comes down to it, is what NHI aims to do.

Ideally, NHI will be the mechanism that allows the public and private sectors to work together to provide a service that is high quality but low cost. And I think that finding that middle ground will make an enormous difference because we could cater for patients that can’t afford private care but who want to avoid the under resourced public system. It would love to see more models like, for example like the Aravind Eye Care System in India, where cross subsidisation between private and public patients allows everybody to receive high quality care.

I also believe that NHI should be about building an African-based health system that’s appropriate to the needs and culture of the population, not a western model that we’ve adopted and are now trying to make work over many years.

What’s your vision for healthcare innovation?

We like to dream big and want to see an innovation movement across Africa that makes people believe that they’ve got a role to play in facilitating change in healthcare and that there’s an opportunity for them to do so. There needs to be an inclusive, open opportunity for everyone to participate as a collective. One project makes a difference, but imagine the difference if we can have numerous innovation projects running simultaneously across multiple hospitals on the continent. The hardest work is changing mind-sets, but once we’ve done that the rest happens – people put in the extra time and effort to go above and beyond.

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