Leadership

How Health Care Systems Can Effectively Manage Process

Article · June 20, 2016

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Unfortunately, many health care executive leaders adhere to outdated, often autocratic management methods that focus on meeting so-called “management objectives” at almost any cost, including layoffs or even falsification of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.
Basic Framework for Process Management

Basic Framework for Process Management. Click To Enlarge.

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.

New Call for Submissions ­to NEJM Catalyst

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership
East London NHS Foundation Trust Non-Clinical Quality Improvement Days Taken to Complete Disciplinary Process

Quality Improvement for Non-Clinical Teams

Administrative QI projects save money, streamline processes, and even improve patient care for the U.K.’s National Health Service.

Physician Clinician Burnout Is Extensive

Leadership Survey: Immunization Against Burnout

Clinician burnout is far from being eliminated at health care organizations, but leaders, frontline physicians, and nurses are joining forces to get to the roots of the crisis.

Fleisher03_pullquote Physicians-in-Training - An Untapped Resource for Health Care Innovation

Physicians-in-Training: An Untapped Resource for Health Care Innovation

Five strategies that can support long-term leadership development and open opportunities for system transformation.

Tait Shanafelt

Beyond Burnout — Redesigning Care to Restore Meaning and Sanity for Physicians

There’s a growing recognition that organizations need to redesign the way that clinical care is delivered to address the national physician burnout epidemic. Measuring rates of physician burnout is the first step.

Sample Testimonials from Fresh Eyes Action Learning Program

Action Learning–Based Leadership Development at an Academic Medical Center

How Mayo Clinic utilized an action learning–based program to foster the leadership skills needed to navigate the changing landscape of health care.

Many Different Definitions of Stakeholder Alignment in a Health Care Organization

Leadership Survey: Why Big Gaps in Organizational Alignment Matter

An NEJM Catalyst Insights Council survey finds that clinicians and leaders do not see eye-to-eye on many aspects of health care delivery.

Physician Coaching Models Interview Large Headshots - Rana Awdish Dale Glenn Ghazala Sharieff Tom Howell Namita Seth Mohta

Physician Coaching Models: Solutions and Impediments

A group of care experience leaders from across the United States discuss innovative physician coaching models at their respective organizations.

University of Utah Family Medicine Residency Program Value Improvement Projects - Practice-Based Learning and Improvement PBLI Milestones Score by Year of Residency

How the University of Utah Prepares Family Medicine Residents to Lead Value Improvement Efforts

A rigorous 3-year program helps physicians focus on improvement through interprofessional collaboration.

Integrating Product Management Education into Health Care - Example of How Curriculum Would Help Physician Tackle Clinical Need in Tandem with Engineer and Business Lead

The Case for Product Management Education in Clinical Training

How can physicians learn to speak the language of innovation and claim a role for themselves within the innovation ecosystem?

Della Lin picture

Lessons in Leadership: Della Lin

How lessons from a concert pianist in timing, audience connection, and intent apply to health care leadership.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Physician Burnout

34 Articles

Leadership Survey: Immunization Against Burnout

Clinician burnout is far from being eliminated at health care organizations, but leaders, frontline physicians,…

Leading Transformation

193 Articles

Amazon and CVS: Short-Lived Unicorns in…

Will Amazon–Berkshire Hathaway–JP Morgan and CVS-Aetna change the health care game? To one health care…

Leading Teams

130 Articles

Action Learning–Based Leadership Development at an…

How Mayo Clinic utilized an action learning–based program to foster the leadership skills needed to…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now