I have spent way too much time (supporting friends and relatives) in hospitals. And, there are several lessons to be learned about how not to run an organization—any organization:
While people are important, if you don’t have process and tools, it is impossible (especially on a large scale) to rise above mediocrity when it comes to both service delivery and outcomes. Teaching hospitals have a lot of really smart people, but they are inefficient and the outcomes are too often (judging by the size of insurance premiums that the doctors and hospitals have to pay) severely lacking. I would argue that the reason hospitals aren’t complete disasters is the people, but their ability to truly excel is hampered by the lack of process and tools.
A couple of examples. While spending a lot of time visiting a relative who was in a large teaching hospital, I notice that the most efficient process was food delivery. The person who came to the room to take breakfast lunch and dinner orders was very customer oriented, he had a computer that allowed him to quickly take and order and even heavily customize it. The food arrived as ordered even when customized.
Contrast that with the process that was used to call for help. It was essentially an intercom that connected the patient to a person at a desk several hundred feet away from the patient’s room. The sound quality was bad, so the communication was often garbled, 20% of the time the request was dropped, i.e. the request had to be called in a second time and the person who showed up to fulfill the request was not the one best (skill set) to do the work.
Further, there is no coordination or thought put into the objectives and scheduling of services provided by physicians and staff. This led to times when no one was monitoring the patient and other where doctors, nurses and other support staff all showed up at the same time causing no one to get their job done. Further, I would observe that often doctors showed up with no objective and as a result did NO more than say: “hi”.
You get the picture, the best (most efficient with consistent quality) run process was not the mission critical provision of health care. It was properly supported by people, process and tools. The rest of the processes (those that were mission critical to providing quality health care) just had people. I observed (I was at this hospital for approximately 120 hours over the course of a week) incredible inefficiency and waste. I spent 40+ years consulting and in operating roles with companies and have never seen anything this bad, probably because the business would have never survived.
You must live your values, not just state them. Culture is important and it is defined not by what you say, but what you do. Every room had a sign on it that said:
- Kind Greeting
- Notice needs
- Own it
- Wow them
- Next steps
There was also a sign listing of 10 values that the staff were supposed to observe.
There were two problems with these signs:
- The staff wasn’t living them. They were not part of their consciousness. Culture is more than signs. It has to be constantly reinforced and given the mix of employees and contractors, I am guessing that there was not sufficent time devoted to developing and inculcating culture. The best organizations I ever worked for/with (PW, GE, Kellogg, Textura) had very well pronounced cultures that were clearly and concisely articulated. At PW it was (in this order): 1) The best and brightest; 2) an obsession with client service; and 3) choose your clients carefully. It was clear to every person what that meant and what it implied in terms of how you did your work.
- They were too complicated. A list of 15 things that people have to remember every time they engage with a customer is not practical. People don’t retain lists of more than 5 to 7 (I would say 2 to 5) things. I could deal with almost any client situation by referring to the three PW values I listed above—really!
The domain experts (in this case, doctors, nurses and other healthcare professionals, cannot do this alone. I volunteered to clean up what we at PW used to call a “troublesome practice matter”, a project gone wrong. A team of PW consultants had been assigned assist a multinational client in an effort to replace a distribution/digital rights management system. I believe that we won the job because the team understood the client’s business problem—they were domain experts. What they weren’t were technology experts and when it came time to deliver “the system”, they couldn’t make it work. While I had seen this issue before and recognized it immediately, this experience cemented (through 2 painful years of reimplementing a system that should have been done when I got there) my understanding that unless a process improvement project has domain experts, process improvement experts and technology experts, it is very unlikely that you will get an optimal outcome. The bottom line is that domain experts (doctors, nurses, pharmacists, etc.) aren’t likely to address this challenge unless they get help from very experienced (given the size and scope of the issue) process improvement and technology talent.
Industries that get complacent are dinosaurs that will go the way of their reptilian namesakes. Change is hard. The retail industry is in turmoil, the taxi industry is dying and doesn’t really know it and healthcare is next. If the people currently responsible for healthcare don’t take care of this problem, someone else will. This is another way of saying you can do it the easy (less painful) way or the hard (more painful) way. Either way it is going to be disruptive and there will be pain, but it is always better to be part of the solution than not. It is always better to be the proactive driver of change (that is what good leaders-managers do) than to have it imposed upon you from the outside.
The issues that the US healthcare industry has with cost effectiveness and efficacy are fixable. The cost will be high, but the payback will be even bigger. I understand the size and scope of the problem. Actually, I probably don’t, but I know it is HUGE. That doesn’t mean it can be done. We just have to have the will to do it. And, the payback, both in terms of better outcomes and improvement in the value for money equation will be even HUGEer.
While this post was inspired by a recent experience, I looked back over the past several years and my experiences with multiple healthcare organizations (several of them large teaching hospitals which are supposed to be the best a delivering quality outcomes) and decided that while some were marginally better than others, they all suffer from the same issues. When asked by a family member who was frustrated with their recent experience at a large teaching hospital and was considering moving their care to another: “don’t bother, while you might get some initial satisfaction from leaving this provider, you will find that the alternative is no better than where you currently are.
What does amaze me is that organizations that are as challenged as the hospitals I have observed, perform as well as they do. That doesn’t mean that I believe that they perform well—I refer back to the cost of malpractice insurance, which certainly wouldn’t be as high as it is unless there were costs associated with serious malpractice issues.
And, there are both outsiders (Amazon, Berkshire Hathaway and JPMorgan Chase) and insiders (CVS buying Aetna) who have seen the same thing I have. It will be interesting to see if they can craft a better solution than we have today. Amazon has done that to retail another industry, that was/is notable for its complacency, lack of innovation both in terms of tools and delivery. It will be interesting to see what it can do with its tools and process expertise when applied to healthcare. To do this they will have to bring together all of the experts (domain, process and technology) and work together to craft solutions that are innovative, address the needs of the customer and are complete and well designed.
Finally, I am not suggesting that this post is based on anything but observation. There was no large scale statistical analysis of data. But, I have many years of experience working with large scale high performing organizations and I can tell you, that by many measures, hospitals don’t fit into that category. So, don’t get sick!
Copyright 2018 Howard Niden
— you can find this (days earlier) and other posts at www.niden.com
and if you like this post: 1) please let me know; and 2) pass on your “find” to others.
Jeff McGurk says