Today’s health care management is in need of an overhaul. The classic top down model, which has existed for more than 50 years, does not empower frontline workers to identify and solve problems. It must be replaced by a model for management that supports and encourages frontline caregivers to do just that.
Based on close study of 11 organizations, The ThedaCare Center for Healthcare Value developed a framework for transforming health care delivery through improvement management techniques akin to the “management by process” espoused by Edwards Deming in the 1980s. The organizations included in the analysis comprise all types of delivery systems, from an academic medical center in Toronto, to a 1,200-physician multispecialty clinic in Palo Alto, California. We visited operations at each institution and observed firsthand how they had applied improvement management system principles.
The framework we describe is studded with principles from great manufacturing companies like Toyota—now successfully applied to health care—and is centered on the concepts of Plan-Do-Study-Act (PDSA) thinking, developing model cell areas to test new concepts, spreading new processes, and building new sets of standards for leadership and daily management.
Applying The Plan-Do-Study-Act Cycle
One management principle critical in health care is the scientific Plan-Do-Study-Act cycle used to solve problems rapidly. At HealthEast in St. Paul Minnesota, frontline nurses and other health care workers huddle each morning to identify and solve problems. One such huddle dealt with missing equipment required for patient care. When a nurse can’t find an IV pole, it can take many minutes of precious time from the bedside.
Working through the Plan-Do-Study-Act process, the improvement team taught the nurses and other health care workers to develop a “supermarket,” where taped-off areas in supply rooms store the necessary equipment. When the taped off areas don’t contain the equipment, it is a visual cue for staff to “resupply” the supermarket so they have the equipment when they need it. This year, frontline staff at HealthEast will identify and solve more than 30,000 health care problems using the Plan-Do-Study-Act process.
Creating Model Cells
A model cell is a place, usually a clinic or a department, where care is completely redesigned. The process change leads to new roles and responsibilities for everyone involved. At the Palo Alto Medical Foundation in California, there was a need to deliver a better patient service experience while reducing cost.
A well-known health maintenance organization (HMO) was aggressively competing with Palo Alto with better quality at a lower cost, so the organization’s leaders began model cell work in one clinic in Fremont, California. They eliminated doctors’ private offices, developed dyads between doctors and medical assistants, started two-minute morning huddles to understand demand for the day, and in one year, completely redesigned the entire outpatient experience. Subsequently, Consumer Reports rated Palo Alto Medical Foundation one of the highest quality clinics in the Bay Area in 2014.
Customizing Standard Work
In applying the learnings from Fremont across all its clinics, the Palo Alto Medical Foundation didn’t use a copy/paste approach. Instead it was copy/improve.
They learned each clinic must have the option to put its fingerprints on the new standards established at Fremont. It was important that each clinic had standard work; not that the standard work was exactly the same across all clinics. With the ability to customize standard work to their own clinics, doctors and staff became engaged and actually embraced change. In 15 months, all 30-plus clinics at Palo Alto had adopted—and in some cases adapted—the new standards.
Developing Lean Leadership
Fostering the skills to redesign processes and lead in a different way requires a system of learning. At MemorialCare in Long Beach, California, a group of specially-trained facilitators teach the management team how to be successful “lean” managers. This is not training in a classroom with PowerPoint slides. Instead, it is applying principles and tools to the real work; where value is created for the patient at the bedside.
Facilitators train leaders in “visual management,” which involves setting up visual management boards, identifying and posting key metrics that relate to performance of the department, and encouraging staff to post ideas for improvement. Managers are also trained to teach frontline staff to identify and solve problems, and how to map processes of care to understand which steps in the process are non-value-added to the patient.
None of these skills were learned in school, which is why it is important to develop a Central Improvement Office, sometimes referred to as a Kaizen Improvement, or a lean central office. It is where the facilitators who support frontline teams are trained in the standards of teaching improvement throughout the organization.
Establishing A System Of “Management By Process”
The management by process system described by Deming sets out standard work for leaders and managers. Most health care organizations use standard work for clinical processes—for example, the process of inserting a central line—but have not identified standard work for management. Management processes are usually left up to each individual manager to decide. A management-by-process system requires that the roles, responsibilities, and competencies of every manager and executive are clearly defined.
One example of standard work for management is a daily status sheet. This is a conversation which occurs each day between a manager and frontline lead nurse. The organization develops a set of questions that help the nurse and manager better manage patient care that day. For example, a typical question is “do we have any fall risks on the unit?” This triggers a conversation regarding the standard work in place on the unit to prevent falls and allows the team to implement processes to mitigate risks immediately rather than waiting until there is a problem to react.
Administrative support functions must also be involved in establishing management by process. Human Resources and the Central Improvement Office need to be joined at the hip in developing the type of leader needed in an improvement organization. Lean leaders and managers are different. Being humble, curious, and a good listener is more important than having all the answers. Human Resources departments do not usually focus on these core leadership traits.
Finance leaders must also change — from being budget cops to taking an active role in improvement. Budgets must give way to rolling forecasts and teams focused on financial improvement rather than on spending. Finance experts need to be redeployed to frontline teams, and managers need help understanding where financial opportunities may exist.
Information Technology supports the journey to management by process by designing information flows to help frontline workers understand the daily clinical and business results, known as “Clinical Business Intelligence.” For example, at Salem Health in Oregon, where Clostridium Difficile infections had become alarmingly high in some units, the Clinical Business Intelligence team worked with operations to create a reporting system that allowed frontline doctors and nurses to examine and compare infection reports across hospital units. Clinicians designed a process enabling early identification and isolation of the infection, administration of optimal treatment, and more systematic cleaning and disinfection procedures for the environments in question. The infection rates in the two original pilot units were reduced to zero.
“Lean” works in health care. In my book, Management on the Mend, I explore more deeply how organizations such as Palo Alto Medical Foundation, Salem Health, Memorial Care, HealthEast, Thedacare, and many others have applied a set of proven principles that have transformed the organization. These leaders have created a new management system for health care which is radically changing the behavior and actions of executives, managers, and caregivers, resulting in highly reliable cost and quality outcomes for patients.
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