In health care, awareness of the need for better management of systems and processes is finally starting to take root. Leaders are keen to become familiar with examples of how institutions achieve it in practice. I am the CEO of the ThedaCare Center for Healthcare Value, where we are doing this important work, and I have visited 174 health care systems in 17 countries to study their management systems as well.
What I’ve learned is that effective management cedes control to frontline workers (physicians, nurses, technicians, and others) so that they can identify and solve problems themselves in real time. That means fixing defects as soon as they are identified, not subjecting them to the protracted analyses of top-down committees. And it means empowering people to define value from the patient perspective.
Unfortunately, many health care executive leaders adhere to outdated, often autocratic management methods that focus on meeting so-called “management objectives” at almost any cost, including layoffs or even falsification of data (as happened at some Veterans Administration facilities). Instead of management governed by objectives, I prefer W. Edwards Deming’s approach of “management by process,” whereby managerial competencies and systems govern behavior. That means redesigning care delivery so that steps that have no value for patients are eliminated and the input of caregivers is not merely heard and respected but actually used on a daily basis.
In the context of that vision, I’d like to share what my own institution and several other organizations have done to implement change in the spirit of Deming’s approach to management.
Eliminate Steps That Add No Value
As ThedaCare’s CEO, I participated on a team (involving nurses, obstetricians, and patients) that carefully studied the time from when a baby is born to the baby’s first outpatient doctor visit. This team comprised 10 people, including obstetricians, OB nurses, OB clinical technologists, a receptionist, an IT expert, a former OB patient who had a poor experience with her delivery, and me. (As someone who knew nothing about this process, I offered a set of fresh eyes.)
For example, when the team discussed the process of administering intramuscular injections to the baby after birth, the patient member of the team said that although she valued the nurse’s availability to inject the drug, she saw no value in the time the nurse spent going to the nurses’ station to obtain the injection. The improvement team therefore arranged to have medication-containing lockboxes installed at new mothers’ bedsides (not for some medications, such as narcotics, but for most). This significant change and others enabled nurses to spend an average of roughly one extra hour at patients’ bedsides per shift.
In addition, ThedaCare’s inpatient units are now equipped with bedside “nurse servers,” where most supplies can be restocked every 12 hours so that nurses don’t have to run around hunting for items they need. This change alone has boosted nurse productivity by 20% in some units. That type of process adjustment, to eliminate steps that have no value to the patient, improves quality of care, lowers costs, and increases staff and patient satisfaction.
Limit the Number of Strategies and Metrics
Senior leaders often create a dizzying array of strategies and metrics that confuse frontline workers. I recently visited a health care system in North Carolina that had 242 strategic initiatives. Its leaders explained to me how important each initiative was. What they didn’t see was that when physicians and nurses try to meet the goals of so many initiatives, they have less time to solve real problems and improve processes that directly affect patients. Reducing the list of important strategies to a more manageable number, such as 3 to 5, is more likely to achieve the desired ends.
For instance, at Children’s Hospital of Eastern Ontario, leaders now focus on just 5 key metrics. One of them is to reduce the number of days kids wait for tests — with a target goal of reducing “wait days” by 50,000 within the next 2 years. Everyone who works there is empowered to figure out how they can contribute to improving that metric. And having just 5 key metrics in all means they can give each one their valuable attention.
Metrics, too, should be narrowed to the most important set. In January 2016, executives at Munson Healthcare, a midsize community delivery system in Michigan, spent two days working together to reduce their number of key metrics — from more than 50 to just these remaining 7: readmission rate, hospital-acquired conditions, employee injury rate, patient-safety event-reporting rate, “great place to work” ranking, operating income, and HCAHPS composite score. The leaders also set annual targets for improvement on each metric, which they are now working toward.
Penetrate the Daily Work
To be effective at implementing change, executives and senior mangers must become familiar with frontline workers’ daily challenges.
At Zuckerberg San Francisco General Hospital, a large safety-net hospital, the chief operating officer has a daily 10-minute conversation with her direct reports, to familiarize herself with that day’s problems. These so-called “catchball” conversations, conducted while participants remain standing, extend through the entire reporting structure such that information is continuously transmitted up and down the chain. These exchanges may identify, for example, workflow problems between the emergency department (ED) and the medicine unit or, perhaps, whether the ICU is appropriately staffed.
The chief of staff at the same hospital, an anesthesiologist, facilitates improvement workshops in the ED. His colleague and medical director have a weekly standup meeting with the entire physician anesthesia staff to identify recent problems. A small team of volunteer operating-room staff is empowered to use the hospital’s standard problem-solving process to address the challenge. As a result, work flows become more predictable, thereby streamlining patient care.
At Stanford Children’s Hospital, in California, every morning and afternoon since July 2015, the lead anesthesiologist has a standup meeting with managers in the peri-op, pre-op, lab, surgery, and post-op departments. The morning schedule is reviewed for potential problems (e.g., labs not on the chart, consent agreements not signed, surgeons in emergencies, etc.) that can be proactively managed before the day begins. The afternoon conversation focuses on coordinating tasks to achieve near-perfect patient flow the next day. The result: Cancelled surgeries went from a high of 14 per week in July 2015 to zero in February 2016. On-time surgical starts also improved.
A Basic Framework for Process Management
The organizations mentioned above ground their management of process in three basic areas, depicted in the graphic. (These organizations actually use this framework, which was developed by the Institute for Enterprise Excellence and adapted for health care settings by the ThedaCare Center for Healthcare Value.) Here is an overview:
- Align: Leaders articulate a vision, identify the critical 3 to 5 strategies (not 242) in achieving that vision, pinpoint the essential metrics, and communicate the direction on a regular basis. This alignment is driven by frontline workers’ insights, not by micromanagement of their work.
- Enable: Leaders actually visit the work areas to gain insights into daily tasks and challenges, energize people to develop and overcome barriers to change, embrace failures as learning experiences, and celebrate successes.
- Improve: Leaders continuously learn by listening, see and translate observations, and empower front-line teams to develop new care models that improve the patient experience.
Achieving a better patient experience means eschewing top-down objectives and instead empowering frontline caregivers to give patients what they say they actually value. In this way, we can improve the daily functioning of the health care system, one institution at a time. I think W. Edwards Deming would approve.