• 5 Ways to Apply 'The Art of War' to Service Redesign

    By Pei-Fen Lin

    One day in 2008, while I was third-year resident on emergency duty, a patient came in with a three-year history of an unspecified problem. After an exam, I determined that he had 20/20 vision and that he shouldn’t have been sent to the eye emergency clinic at all.

    I remember thinking, there has to be a better way of making sure these patients could be seen in the correct clinical setting and not come into the emergency department at 2 a.m. 

    So, when I became an ophthalmologist consultant and emergency eye care service lead in 2017, I was determined to redesign our services to avoid unnecessary visits like this one. With the help of an extraordinary team, we overhauled our emergency eye services and cut inappropriate visits by 49%. Since then, I caught the service redesign bug. 

    COVID-19 forced us to review the value of face-to-face consultations. Combining this unique opportunity and my passion for digital innovations and service redesign, I piloted the digital cataract service pathway in 2020. The process involved moving the core consultation online with telemedicine. 

    Patients are no longer examined with the traditional slit lamp. Brand new patients are referred in for cataract surgery and consultation with imaging is done to plan for surgery. This clinic has demonstrated its efficiency and safety and popularity among the patients.

    However, both projects faced challenges, as it questioned the status quo and confronted comfort zones.

    Sun Tzu said in his military treatise “The Art of War,” "If you know the enemy and know yourself you need not fear the results of a hundred battles.” Ophthalmologists are in a constant battle with time and making sure we care for our patients as efficiently as possible. Here are five lessons I learned through my projects that I hope may be useful for your own redesign adventures:

    1. Arm yourself with data.

    We need to understand our processes and our intricate systems before implementing change. In the case of our emergency eye clinic, mapping our processes and auditing older eye emergencies was key — it demonstrated that 72% of all emergency eye visits were clinically unnecessary. 

    This data was hard to deny when suggesting change to our stakeholders. I remember saying “72%” often to my board of directors, and it was impossible for them to say no to the reforms.

    2. Don’t be a 'space pen.'

    Legend has it that NASA spent millions developing the space pen so that astronauts could use an ink pen in space. The Russians won this space race using the humble pencil. The problem here is not how to use a pen in space, it's how to write things down with zero gravity. Asking the right questions means you define the problem so that you don’t end up down a dark alley. Telemedicine would not have been considered if the question was, “How do we review uncomplicated post-cataract surgery patients face-to-face in a pandemic?” But telemedicine was the obvious solution when the question was reframed as “How do we follow up patients in a pandemic?”

    3. Money isn’t everything, but cost is.

    Understanding the cost of a service, whether human or financial, was vital in implementing the correct solution. The audit we did of eye emergencies demonstrated the enormous human and financial burden of a walk-in service. When we implemented change, the goal was to implement a virtually pretriaged model with no walk-ins, eliminating clinical visits that were not emergencies. This not only saved a significant amount of money for the health system, but also reduced human cost by allowing the clinical team to focus their energy on true emergencies. A team that works and finishes on time each day is a happy team. 

    4. Love your haters.

    Both my projects faced their own pack of haters. Haters are the ones that call my project “babies” ugly. However, haters did prevent me from having tunnel vision. One hater of my digital cataract service project once gleefully pointed out that patients with a learning disability or dementia would not be able to use telemedicine platforms and would be disadvantaged. This made me reconsider my patient inclusion criteria. Instead of restricting digital service to only “IT suitable” patients, I included all patients and set up a back-up plan if patients were unable to attend the virtual consultation. Interestingly, the data demonstrated that 10% of my digital clinic patients fall into this IT-disadvantaged category but accessed the virtual consultation by proxy successfully. And this reduced unnecessary and stressful journeys and long waits in face-to-face clinics for these patients and their caretakers. The result: The hater ultimately refined the project and made it better.

    5. Slow is smooth, and smooth is fast.

    This saying from the U.S Navy Seals reminds me to slow down, plan and do the job right first time. Slow careful planning and smooth implementation means fast adaptation of a new pathway. Both projects took around six months of planning and are still under constant review and refinement. But the planning is paying off as we are seeing the emergency clinic passing our fourth year of sustained change and the digital cataract service establishing itself as the new mainstream. 

    I have other plans to challenge the status quo. My ultimate dream is to teleconsult and operate via a remotely controlled surgical robot pod airdropped into patients’ homes by drone. 

    Impossible you say? Someone once said this about Steve Jobs with his dream of the iPhone too. Look how well that turned out.

    About the author: Dr. Pei-Fen Lin is an ophthalmologist consultant at Moorfields Eye Hospital in Croydon, England.