Most inflight magazines feature an advertisement for “The Best Doctors in America.” These ads are a convention of inflight magazines that we see often and don’t really think much about. But as I came across one on a recent flight, the thought struck me: Why don’t we ever see advertisements for “The Best Pilots in America” when thumbing through magazines at the doctor’s office? Don’t we care about the qualifications of the person responsible for taking us 40,000 feet off the ground at 600 miles per hour? Pilots, after all, are likely to hold our life in their hands more often than our physician. Why don’t we seek out the most qualified pilots as we plan our trip from San Francisco to Boston, or from Spokane to Kansas City?
Perhaps the answer lies in the fact that the airline industry has continually refined its systematic approach to travel delivery. Individuals in charge of transporting some 1.73 million people a day in the United States alone are following standardized routines, with the aid of useful information available at their fingertips and well-understood procedures, such as checklists.
While healthcare is still largely at the “craftsman” stage, the airline industry has evolved to the stage of a “system of production.” Consider that pilot training involves hundreds of hours with increasingly sophisticated flight simulators, while medical school and residency continue to be based on the apprentice-master relationship dating back to at least the 17th century.
Healthcare has remained entrenched in its cottage-industry style of operation, even within huge medical centers and in the face of significant medical innovation. Most hospitals, for example, still organize their staff around departments rather than care processes – which are more representative of how care is delivered to individual patients. Physicians are pretty much left on their own to sift through and digest the ever-expanding universe of medical information and data. What’s more, medicine often embraces traditional ways of doing things, even when they are outmoded or unproven.
The result, as documented by Dr. John Wennberg’s Dartmouth Atlas of Health Care project, is unwarranted variation in the practice of medicine and in the use of medical resources.1 Over and over, Wennberg has found that the quality of your care depends on where you get it. Geography is destiny. At a time when more evidence is available than ever before on what actually works and doesn’t work in medicine, that is a sad state of affairs. The root of the problem, Wennberg concludes, is that there is no healthcare “system.”
How to systematize our healthcare system
The healthcare system needs to move away from its craftsman roots and evolve toward a system of production. Any organization can pursue this goal – and improve clinical effectiveness, reduce waste, and improve patient safety – by adopting a systematic approach in three key areas:
- Healthcare analytics (or the data, technology, and processes to inform improvement strategies and measure their effectiveness);
- Adoption (or how teams and work are organized to promote adoption of best practices across the enterprise); and
- Best practices (or how best practices are gathered, evaluated, and disseminated for adoption).
Implementing just one of these systems isn’t enough. All three must work together to create lasting, meaningful improvement in clinical and financial outcomes.
1. A systematic approach to healthcare analytics
Healthcare analysts should not have to spend most of their time as “hunter-gatherers” looking for data in various places, retyping it into spreadsheets, and then creating reports. Unfortunately, this kind of analytics work – far from systematic – is common in many healthcare organizations. Instead, analysts should have data at their fingertips and should be able to focus on interpreting that data in a way that provides essential information to decision-makers. To make this happen, most organizations need to upgrade their analytics system.
The first step in establishing an effective analytics system is unlocking the data. This requires implementing a healthcare enterprise data warehouse (EDW), which enables an organization to eliminate the manual gathering process and automate data distribution. Analysts can then devote the vast majority of their time to discovering patterns in the data that can be used to understand where changes need to be made.
2. A systematic approach to adoption
Many organizations send in a swat team of quality-improvement experts to solve the latest crisis caused by a bad quality score. Quality-improvement teams can be effective at finding solutions. Unfortunately, what often happens is, once the team moves on to the next crisis in another department, staff revert back to their default mode of behavior. Without ongoing attention, old habits return. This is a common sign of a weak adoption system.
A better approach to promoting enterprise-wide adoption of improvement strategies is to organize permanent cross-functional teams of both clinicians and technical personnel, organized for scalable, iterative improvement. They own improvement for all aspects of care delivery for a particular care process over the long term and can make a real difference in standardizing care-delivery work processes. With this permanent team in place, organizations can promote adoption of best practices in such a way that they are able to sustain improvements in the long term.
Naturally, this adoption system works hand in hand with the analytics system. Integrating data into the work of these permanent teams enables team members to quickly identify the root causes of a problem and then easily monitor compliance to standards they design to improve care delivery.
3. A systematic approach to evaluating and disseminating best practices
Today, for most organizations, the time between medical knowledge discovery and broad adoption by the majority of clinicians is measured in years. With patients’ health and welfare on the line, this timeframe must change. A well-designed best practice system makes rapid deployment of new clinical approaches possible.
From a clinical perspective, a best practice system should consist of standardized knowledge assets that include evidence-based practice (EBP) guidelines, treatment cascade models, indications for intervention, indications for referral, and standing order sets and protocols. The goal is to systematize how providers decide, for example, when to do surgery and when to order physical therapy. From the operational or departmental side, the best practice system should include standard work, operational checklists, and workflows.
As the permanent teams (part of the adoption system) develop systematic methods of accomplishing specific tasks, each key process step can be measured using the analytic system to improve efficiency and measure variation from the standard. The teams work to continuously understand what standards already exist, refine the standard, and then systematize its practice. Measuring its adoption and outcomes will ensure that change happens and that it is sustainable.
Three systems, working together
Looking at other industries, like the airlines, it becomes clear that systems can help people do the right thing. Systematization is not something to be avoided in the healthcare industry. Rather, it is the key to ensuring that patients get the best possible care regardless of where they live or what facility they visit.
However, systematizing healthcare requires more than just a surface approach. A truly systematized healthcare system is actually three systems – analytics, adoption, and best practices – working together seamlessly. This kind of deep approach can ignite changes in how clinicians practice, so they become fully engaged in transforming healthcare for the betterment of patients.
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