Infrastructure Eats Culture for Lunch

Article · November 10, 2017

Watch Brent James’ health care leadership talk on clinical protocols and the importance of creating infrastructure.


If culture eats strategy for breakfast, then infrastructure eats culture for lunch, says Brent James, Vice President and Chief Quality Officer for Intermountain Healthcare. In other words, infrastructure lays the foundation for culture, and it can act as a tool for reducing stress and increasing resilience in the care delivery workforce.

“Clinicians are the only ones who have fundamental knowledge about the workflows that define their care. But they don’t control the systems that set the context within which they work,” James says. “The key question for a leader is, how do we make it easy for them to do it right?”

Infrastructure traditionally includes vision, culture, and common tools — the normal job list for leadership, says James. But there are other aspects as well: workflow and clinical processes, transparency into interactions with patients, and information technology. “In your role as a leader, the infrastructure that you create is your hand that reaches beyond the organizational grid. It will last long after you are gone, far longer than anything else you do,” emphasizes James. “You can create an environment that changes the future.”

James outlines development of shared baseline protocols — a form of Lean — at Intermountain Healthcare, in six steps:

  1. Identify a high-priority clinical process.
  2. Build an evidence-based best practice guideline around that process. “We have evidence for best practice only about 15–25% of the time; 75, 85% of the time, clinicians can hold legitimate differences of opinion about what’s best,” adds James. “You can’t write a protocol that perfectly fits any patient,” says James, but he encourages leaders to build the guideline anyway.
  3. Blend it into clinical workflow so that it doesn’t rely on human memory. “Doctor, sleep in, don’t touch it, be absolutely lazy,” says James. “On full automatic, what the system will produce is evidence-based best care.” This frees physicians to focus on what matters: their patients. “The key to effective variation is standardization,” James adds.
  4. Build a data system. The data system has two purposes: tracking variations from protocol — “that they vary the nature of the variants turns out to be the most efficient variants measurement you could possibly devise” — and knowing what happened with patients.
  5. Place a thinking mind at the interface. “It’s not that we allow or even encourage — we demand that our clinicians vary from protocol based on individual patient need,” says James. That trained expert mind can then focus on a narrow band of questions that can make a real difference.
  6. Feed variation data in the context of patient outcomes back to the team. This Lean learning loop leads to dynamic, adaptive protocols that track to new knowledge over time and best care over time, continuously improving the environment.

To make it easy to do it right, leaders need to design clinical workflows, as above. The second point James makes is that leaders must look for choke points in the workflow where they can drive change.

For example, the biggest clinical process at Intermountain Healthcare is pregnancy, labor, and delivery.  In 2010, Intermountain deployed guidelines from the American College of Obstetricians and Gynecologists (ACOG) for appropriate elective induction, along with Bishop scores, into the nursing workflow. If a woman decides to end her pregnancy early, Intermountain nurses run the ACOG criteria, which is built into the electronic medical record along with the Bishop score. Four months after implementation, inappropriate elective induction rates fell from 26% to 3% and are still at 3% today — James reminds us that you can’t write a protocol that perfectly fits every patient. Among other impacts, the protocol reduced length of labor at Intermountain by about 140,000 minutes per year, enabling 1,500 more deliveries without the need for additional staff or delivery suite. “Serious gains in efficiency,” says James. Newborn ICU admission rates also dropped. Tallied up, the protocol saves Utah $50 million a year, according to James.

“I have more than 100 similar examples,” adds James, noting that many of them relate to mortality.

Better care isn’t always cheaper care. This approach has dropped operation costs at Intermountain by 13% over $700 million in financial savings over the past 5 years, which is a critical element in a competitive market, says James. But more than that, he adds, “these aspirations are what brought all of us into medicine, into clinical practice in its various forms, and it’s what keeps us here. They frame what it means to be a physician, a nurse, a clinician.”

“When you are asked, ‘how’s the water today?’ remember that clinical leaders can build the water clear, pure, clean, fast, so that our colleagues can deliver world-class care. Our job is to make it easy to do it right.”

From the NEJM Catalyst event Physicians Leading | Leading Physicians at Intermountain Healthcare, July 12, 2017.

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