HIGH PERFORMANCE HEALTHCARE

The McGraw-Hill Companies, Inc.

Contents

Chapter One

Coordination of care, for which personnel are constantly striving but know they are not often attaining, is something of a mirage except for the most standardized of trajectories. Its attainment is something of a miracle when it does occur.

We could easily become discouraged. Despite having some of the best clinicians and health policy analysts in the world, the U.S. healthcare industry is failing to deliver cost- effective quality care. The McKinsey Global Institute found recently that "even after adjusting for its higher per capita income levels, the United States spends some $477 billion more on healthcare than its peer countries" per year. Meanwhile we suffer from an epidemic of medical errors that threatens our well-being—even our lives—with medical errors that cause 44,000 to 98,000 deaths annually, at a cost of $17 billion to $29 billion. To add insult to injury, a growing number of our fellow citizens live with the fear that they will not have access to care when illness strikes.

Some of these problems, such as the prevalence of medical errors and the costs associated with them, can be addressed in part through improved clinical training and expanded information systems. Other problems, such as lack of access and the associated costs, are likely to be addressed under our new political leadership as we finally garner the will to ensure universal access to healthcare. But many of our cost and quality problems are more fundamental and cannot be resolved by these means alone.

Indeed, the source of our cost and quality problems goes deeper into the very work processes through which healthcare is delivered. Healthcare is complex, with high levels of specialization that are driven—perhaps inevitably—by the complexity of the human body, the human mind, and the social world in which we live. The complexity and fragmentation of healthcare make coordination exceedingly difficult. Patients are often required to sort their way through the system, receiving diagnoses and treatments from a fragmented, loosely connected set of providers. Patients with diabetes typically see 8 distinct physicians belonging to five distinct medical practices, and patients with coronary artery disease typically see 10 distinct physicians belonging to six distinct medical practices. Even within the hospital setting, where resources presumably are brought together within a single organization to improve the coordination of their deployment, the responsibility for coordination often falls to the patient and his or her family members.

Coordination problems appear to have gotten worse rather than better over the years. The Institute of Medicine identified coordination as one of the most critical problems plaguing the U.S. healthcare system: "In the current system, care is taken to protect professional prerogatives and separate roles. The current system shows too little cooperation and teamwork. Instead, each discipline and type of organization tends to defend its authority at the expense of the total system's function." A recent study by the Commonwealth Fund found that the most common quality problems reported by physicians are related to problems of coordination. A physician leader at Brigham and Women's Hospital explained: "The communication line just wasn't there. We thought it was, but it wasn't. We talk to nurses every day but we aren't really communicating." Nurses tend to agree. A nurse administrator at Massachusetts General Hospital explained: "Miscommunication between the physician and the nurse is common because so many things are happening so quickly. But because patients are in and out of the hospital so quickly, it's even more important to communicate well."

Coordination is not a problem that is unique to the U.S. healthcare system. Even in countries such as England, Canada, and Belgium, whose systems for ensuring access to care are dramatically different from ours, healthcare providers are working hard to overcome fragmentation and achieve better-coordinated patient care. In Belgium, a consortium of healthcare providers has been meeting to figure out how to coordinate care between primary care, home care, and acute care, particularly for patients who are elderly or who have chronic conditions. The fragmentation they describe sounds remarkably similar to the U.S. system. Thus, it is not just the peculiar U.S. approach to healthcare financing that makes coordination such a challenge, though policy changes can certainly help, as I argue in the final chapter of this book.

Instead, coordination is a fundamental problem of work process that requires a process- level solution. Work process improvements can help organizations achieve high performance healthcare, for example, by using the reengineering, total quality improvement, and lean strategies that have helped other industries streamline and coordinate their work. Don Berwick and his colleagues at the Institute for Healthcare Improvement have transformed healthcare by redesigning work flows for hospitals and primary care practices, often starting from the patients' point of view. Although these steps are useful, healthcare administrators who have engaged in work process redesign often point out that by themselves they are often not sufficient. As Robert Hendler, regional chief medical officer and vice president of clinical quality for Tenet Healthcare, explained:

We've been doing process improvement for several years, and we think we're on the right track. But we've tried a number of tools for process improvement, and they just don't address the relationship issues that are holding us back.

The biggest challenge for coordinating work—how we work together and, more often, how we fail to work together—cannot be addressed solely through reengineering or total quality management. In complex systems such as healthcare (or airlines or auto manufacturing or professional services), work is divided into areas of functional specialization. As we will see in Chapter 2, these areas of specialization often become the basis for dividing colleagues into distinct thought worlds with distinct goals, distinct knowledge, and distinct levels of status. Although this division of labor can be a powerful source of quality and efficiency, as Adam Smith taught over 200 years ago, it can also lead to fragmentation and a breakdown of coordination. Healthcare organizations benefit from the division of labor but they also suffer from the fragmentation that can result from it.

When doctors, nurses, therapists, case managers, social workers, other clinical staff, and administrative staff are connected by shared goals, shared knowledge, and mutual respect, their communication tends to be more frequent, timely, accurate, and focused on problem solving, enabling them to deliver cost-effective, high quality patient care. More often, however, these diverse providers lack shared goals, shared knowledge, and mutual respect, even when they are working with the same patients, so that their communication with one another is infrequent, delayed, inaccurate, and more often focused on finger- pointing than on problem solving. When this happens, everyone's best efforts to deliver high-quality care without wasting resources are frustrated. Relationships are an essential ingredient of any workable solution to the coordination problem because they drive the communication through which coordination occurs.

High quality relationships between care providers also require high quality collaborative labor-management relationships. Even though healthcare is the most rapidly growing union sector in the United States, it has inherited a long history of adversarial relationships between unions and employers. Yet there is an alternative. Labor-management partnerships that promote coordination and engagement among care providers have developed in a small number of healthcare settings such as Kaiser Permanente. American labor policy will need to support these types of labor-management partnerships if it is to make sustainable progress toward improving the quality and efficiency of healthcare delivery.

These insights are not new. In an earlier study of the airline industry, I found that shared goals, shared knowledge, and mutual respect—key elements of relational coordination—were at the heart of the longstanding success of Southwest Airlines, which continues to be the most successful airline in the United States and by many measures the most successful in the world. Southwest is also the most highly unionized company in the U.S. airline industry. However, unlike most others, it accepted unionization without a fight with its workers and has treated union leaders as partners from the beginning. Despite the stresses of September 11, 2001, ever-rising fuel costs, a well- compensated workforce, and constant growth, Southwest Airlines continues to have nearly the lowest unit costs in the industry (just above the unit costs of the much younger JetBlue Airways), the best on-time performance, and the lowest customer complaints of any major airline, resulting in an unbroken record of profitability for 38 years. As I demonstrated in The Southwest Airlines Way, these impressive results are driven by the relational coordination that Southwest has built and sustained through the ups and downs of the airline industry.

The good news is that healthcare organizations are waking up to the reality that they need to improve the coordination of care. Their leaders understand that cost pressures have increased the importance of achieving well-coordinated patient care. Payers have reduced the number of days they will reimburse for any specific episode of care, often by more than one-half, from 12 to 5 days for a hip replacement, for example, and are pressing for faster discharge from acute care to get patients into subacute care more quickly. As the director of patient care and quality management at the Hospital for Special Surgery explained: "Managed care companies are pushing acute care to the subacute providers to save money. They are pushing out the boundary between acute and subacute." Hospitals are able to keep patients longer than the number of reimbursed days if they choose to do so, but at a financial loss. Alternatively, payers provide a fixed fee to the hospital for a patient with a particular diagnosis so that a hospital earns money if the patient is discharged quickly and loses money if the patient stays longer. Shorter lengths of stay increase the need for coordination within the hospital setting to move patients quickly through testing and treatments to achieve the target dates of discharge.

Hospitals are also under pressure to reduce staffing costs and have been working to achieve those reductions through a combination of leaner staffing and staffing with a lower skill mix, assigning some previously high-skilled tasks to lower-skilled aides. But these changes often increase the number of handoffs, further increasing the need for coordination.

Pressures to increase quality have grown alongside of pressures to reduce costs. Hospitals compete for managed care contracts and referrals not only on the basis of their cost-effectiveness but also on the basis of the quality of care they provide, measured by their quality ratings. In addition to being accountable to patients, clinical personnel, and their professional associations for the quality of patient care, hospitals increasingly are being held accountable by accreditation boards such as Joint Commission for the Accreditation of Healthcare Organizations as well as by managed care organizations that rate hospitals on the quality of care they deliver to patients. The former chief operating officer of the Hospital for Special Surgery Lou Harris argued: "In airlines, you had downsizing but customer expectations were going down too. In healthcare, you have patient expectations going up. We are getting squeezed between patient expectations and payer pressures."

These pressures have motivated intensive efforts to improve the coordination of patient care. The chief of social work at Beth Israel Deaconess described her hospital's efforts:

We didn't used to focus on processes, just on individual clinician responsibility. As the screws have tightened, we've had to look at processes. We've moved from patients experiencing individuals as caregivers to experiencing systems as caregivers. Our length of stay is 4.9 or 5.0 days now, while it was 8.0 in the recent past. Because of the reduction in length of stay and downsizing, you have to substitute many more caregivers, and there's less time to build individual relationships. Handoffs have become much more critical.... It's not just individual brilliance that matters anymore. It's a coordinated effort.

Pressures from managed care have intensified the focus on coordination at Baylor University Medical Center. Baylor's director of case management explained:

As managed care has evolved in our market, the need to achieve both quality and efficiency has become greater. There's the need to show that you have high quality care and that it's cost-effective—that's the whole challenge that we face now. The market demands that in order to get business, you have to create the value. So the demand to think in terms of care processes is greater because you have to manage the processes to get both quality and efficiency results.

From the point of view of a social worker at Beth Israel Deaconess, coordination has helped fill the gap created by the loss of one-on-one relationships:

Caregivers can't have that totally personal relationship with the patient anymore. There isn't the time.... Since we can't have strong one-on-one relationships with our patients, they need to feel that we are talking with each other behind their backs.

Increased coordination is particularly important from the patient's point of view, according to the CEO of Brigham and Women's Hospital:

First and foremost, improving coordination is better for the patient. That is number one—the quality and the experience that people have in the healthcare system are much improved when everything is integrated. Especially as people get more specialized in the healthcare industry, the need to assimilate and integrate and oversee all of the information about a person's healthcare has become more and more important. It becomes more important that somebody is there integrating all of the data and all of the opinions and all of the consultants' reports into a whole, because all of these things are interrelated in somebody's body and their state of mind and their state of health.

Coordination has even risen to the attention of the board in some healthcare organizations. A board member of Massachusetts General Hospital explained:

Coordination is a huge subject, the big thing. Our strategic plan is all about operations improvement. The whole business about delivering patient care. The need to be more efficient and more pleasing to patients. Outpatient links. Providing a continuum of care. ... The end result is that we hope we can live within the limits of managed care and federal government cutbacks without jeopardizing teaching and research.

Due to their tradition of independence, physicians have in some cases been the last group to recognize the need for greater interdisciplinary coordination. One physician leader explained:

We are finally beginning to recognize that healthcare is a multidisciplinary process, with the need to communicate with people inside and outside the discipline. We have to recognize that each discipline has its own track but that they have to go in the same direction.

But while many healthcare organizations are now seeking to improve the coordination of care among physicians, nurses, therapists, social workers, and other members of the care provider team, some have achieved far more success than others by investing in work practices that support relational coordination. The remainder of Part 1 will explain what relational coordination is and how it drives healthcare performance. Part 2 will describe a unique high performance work system that enables care providers to achieve relational coordination consistently every day—and show how the wrong work practices, however well intended, will have the opposite effect. Part 3 shows how relational coordination helps care providers respond resiliently to the pressures they face and how healthcare organizations can build high performance work systems that support relational coordination, outlining an improvement process that can help them to move in the right direction. High Performance Healthcare concludes by exploring powerful barriers to high performance healthcare and suggesting key elements to include in the current overhaul of U.S. health policy.

Chapter Two

In a nutshell, relational coordination is the coordination of work through relationships of shared goals, shared knowledge, and mutual respect.

The basic coordination needs for a patient include getting information from those who cared for the patient previously; sharing that information among the care providers assigned to the patient; keeping one another informed as tests, diagnoses, and interventions are performed; bringing that information together to determine the discharge time and destination; and passing that information along to those who will care for the patient after discharge. These requirements seem fairly straightforward. But as we visited nine hospitals that were working to accomplish the same goals for the same kinds of patients, we observed that the coordination of patient care, like the coordination of other complex work processes such as airline departures, is very difficult to achieve. As a result of specialization, there are multiple parties involved in the care of each patient. As the vice president of human resources at Beth Israel Deaconess pointed out:

Handoffs in the hospital are even more complicated than in an airline. It's not just doctors, nurses, and technicians but all the distinctions among them. We have about 9,000 employees and 4,000 titles. It is an enormously complex place, but we want care to be seamless.

In Exhibit 2-1, the lines connecting the providers indicate that the tasks performed by the different providers were often highly interdependent, meaning that physical or informational outputs from one task were needed for the successful completion of another task. These task interdependencies resulted from the division of labor, the interdependencies among subsystems of the body, and the interdependencies between clinical interventions and the resources used to carry out those interventions.

(Continues...)

Excerpted from HIGH PERFORMANCE HEALTHCAREby JODY HOFFER GITTELL Copyright © 2009 by Jody Hoffer Gittell. Excerpted by permission of The McGraw-Hill Companies, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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