To Improve Health Care, Focus on Fixing Systems - Not People PDF

HBR / Digital Article / To Improve Health Care, Focus on Fixing Systems — Not People To Improve Health Care, Focus on Fixing Systems — Not People Leadership and culture are often blamed when underlying systems are the real problem. by Kedar S. Mate, Josh Clark, and Jeff Salvon- Harman Published on...

HBR / Digital Article / To Improve Health Care, Focus on Fixing Systems — Not People To Improve Health Care, Focus on Fixing Systems — Not People Leadership and culture are often blamed when underlying systems are the real problem. by Kedar S. Mate, Josh Clark, and Jeff Salvon- Harman Published on HBR.org / July 12, 2024 / Reprint H08AQU Paul Taylor/Getty Images Over the past three decades, many health systems have pursued improvements in care delivery to make it safer, more effective, and more efficient. Many banners have flown over this work: quality improvement, systems change, lean daily management, performance improvement, to name a few. When these activities fail to deliver on expected goals, two common and inter-related failure modes are usually Copyright © 2024 Harvard Business School Publishing. All rights reserved. 1 HBR / Digital Article / To Improve Health Care, Focus on Fixing Systems — Not People cited: leadership and culture. Leadership because it has failed to create conditions that would lead to the improvement succeeding; and culture because it has failed to be the fertile soil in which the improvement could take root. We and many other health care delivery leaders and experts have spent the past several decades wrestling with these two problems — regularly citing them and describing them in publications that contain recipes for how to change leadership or culture. To ensure our improvement programs will succeed, we exhort each other to set bolder goals, better enable our people to do their best work, and respond to feedback. At the same time, we urge our health care workers to adopt behaviors that will shift mindsets that, over time, will reset culture. These are not bad ideas, but they contain a flaw: Instead of focusing attention on the systems in which people work, they focus on fixing the people. The systems need fixing far more than the people. In fact, we owe it to our frontline clinicians who have shouldered the weight of poorly designed and unoptimized systems to shift our focus to designing systems that facilitate delivery of the highest-quality care. Well into the 20th century, health care across the globe functioned as a craft industry with a hyperlocal and individual identity. Systems of care delivery did not exist in the sense that we currently understand them. With substantial population growth in the modern era, scalability and standardization of clinical care practices have defined the shift of health care to a production industry, now influenced by the practices of manufacturers such as automakers and high-risk industries such as nuclear energy, chemical manufacturing, commercial aviation, and high-speed railroads. Copyright © 2024 Harvard Business School Publishing. All rights reserved. 2 HBR / Digital Article / To Improve Health Care, Focus on Fixing Systems — Not People Toyota Production System, Lean/Six Sigma, and High Reliability Organizing have figured prominently as management strategies to guide this shift to a production industry in health care. And while not inappropriate or misguided for health care, they have largely met with ephemeral success and most often only incremental improvements. Wondering why these approaches have not broadly led to large-scale and sustainable operational excellence in health care, we have studied industries that seem to have built better systems — not just high- reliability organizations mentioned previously but also firms such as Amazon, Ritz Carlton, and restaurants like the Cheesecake Factory. These companies have built reliable production systems that engage workers and customers to drive daily learning and continually optimize system performance. Essentially, the people working to improve these organizations’ performance have focused less on trying to get more from their workforce and more on trying to maximize what they can get from the system. This is a critical concept when considering the health care industry’s challenge of overwhelming burnout and global shortages of physicians and nurses. One of the most important aspects of systems-focused industries is they don’t regularly spend time with frontline workers talking about abstract methods, principles, or theories for how they can improve their work. Instead, they spend time seeking feedback and understanding challenges so they can (re)design daily operations to make frontline workers’ jobs easier and simultaneously improve the output of the system. If quality and safety are important to the work product of the organization, they can’t be ancillary concerns. They must be embedded in the work itself. As our health care industry considers the path forward, we health care leaders must account for the strains on our workforce — catalyzed by Copyright © 2024 Harvard Business School Publishing. All rights reserved. 3 HBR / Digital Article / To Improve Health Care, Focus on Fixing Systems — Not People both the pandemic and the great resignation — and recognize that there is no greater generator of dissatisfaction than working in a system not intentionally and carefully designed for success. It is simply not right to add the weight of improving health care’s outcomes — quality, safety, experience, and costs — to the daily challenges of working in poorly designed systems. A significant change in how we health care leaders approach this work and how we talk about it is necessary. Quality and safety are the primary work product of health care. Maureen Bisognano, a senior fellow at the Institute for Healthcare Improvement, has said everyone in health care has two jobs: the job they were hired to do and the job of making it better. We would argue that those are the same job: participating in the effort to continually improve the care provided to our patients and families. But how do we actually do that? Have any health systems managed to make this kind of change and created a systems-focused improvement program that everyone owns together? The answer is yes…but they look different from the traditional health system. Places like Jefferson Health, which serves eastern Pennsylvania and southern New Jersey; Prisma Health, the largest health care organization in South Carolina; and Greater Baltimore Medical Center have all built dynamic operating models that support continuous learning and continuous improvement via system redesign. And there are many other health care providers that have built aspects of the same. We call these successful, operationally integrated, and technology-enabled approaches care operating systems. Organizations that have taken this approach consistently weave disparate information and improvement initiatives together into a practical, technology-enabled management system that improves care Copyright © 2024 Harvard Business School Publishing. All rights reserved. 4 HBR / Digital Article / To Improve Health Care, Focus on Fixing Systems — Not People for patients and reconnects clinicians to their purpose, leading to sustained improvements in many outcomes. There is also evidence that focusing on the care operating system leads to an improved organizational learning culture and a highly engaged staff which can serve as antidotes to the current crisis of burnout in the health workforce. The administrative and clinical leadership of exemplars has typically customized the care operating system of their organization to the identified needs of its patients and workforce. But all their operating systems share common characteristics, behaviors, and principles. This is what they look like: They deeply value and appreciate the commitment and passion of their people. Systems that embed care operating systems into daily operations understand that they must harness the brilliance of their people at massive scale and celebrate them for their incredible resilience and commitment to excellent care. At Jefferson Health, during quarterly enterprise-wide meetings, leaders regularly celebrate individual staff and teams who make a “great catch” — e.g., identifying a potential safety risk that leads to large scale organizational improvement and risk mitigation. They appreciate that health care is complex, and that complexity needs strong default systems. There was a time when health care was a relatively simple system. With few medicines and few team members, the clinicians of a century ago had fewer opportunities for error and miscommunication. But in health care today dozens of people typically work together in ever-changing teams, delivering an expanding array of life-saving interventions. Copyright © 2024 Harvard Business School Publishing. All rights reserved. 5 HBR / Digital Article / To Improve Health Care, Focus on Fixing Systems — Not People Exemplars understand that this complexity requires a system to support those people. At Jefferson Health’s Abington Hospital in Abington, Pennsylvania, unit-level leaders have an electronic, real-time dashboard that orients the entire care team to the unit-based and system-level priorities that matter during that shift that day. Complex industries have a maxim (borrowed from James Clear’s book Atomic Habits) that leaders of health care organizations need to learn: “You do not rise to the level of your goals. You fall to the level of your systems.” They recognize that organizational efforts to “improve culture” without strong systems rarely lead to sustainable performance improvement. For systems to continuously improve, they must have a culture of learning and improvement. But seeking a transformed culture, without building the systems that enable it, is like trying to create music without instruments. They do not see safety, equity, and experience as silos. At the point of care, where all value is actually created, it is essential that health care organizations integrate the management systems for safety, quality, equity, experience, and efficiency into a single high- functioning operating system. Managing these domains separately suboptimizes the management of them all. Toward that end, leaders of operations, quality, and information systems at Greater Baltimore Medical Center have created unit-based dashboards to understand the experience of pain in maternity care, potentially avoidable Cesarean sections, and other maternity-related complications and then use clinical process improvement to reduce those complications systematically. Copyright © 2024 Harvard Business School Publishing. All rights reserved. 6 HBR / Digital Article / To Improve Health Care, Focus on Fixing Systems — Not People Their quality and safety teams are obsessed with improving the system. At the heart of these operating systems are daily workflows in which methods to obtain feedback about how the system is performing lead to daily identification, triage, and resolution of real-time operational challenges. In these organizations, the quality team is not seen as reactive, policing, or scorekeeping; it is viewed as frontline clinicians’ greatest advocates. Their clinicians receive information and guidance about the system in their native language. For too long, our health care organizations have created a divide within frontline staff by forcing them to use and understand quality language that feels esoteric and has little similarity to daily clinical language. At Jefferson Health, teams employ an “onstage” and “offstage” approach where highly technical language is reserved for “offstage” where specialist workflow engineers focus on redesigning the care processes to allow frontline clinicians to deliver best in class care. This is then communicated to clinicians with “onstage” information that is designed to fit with clinician lingo and culture under a single identity called the “OnPoint Program,” which is Jefferson Health’s care operating system. Frontline staff engage daily with the OnPoint Program and team to improve their daily work in a language that is clear, concise, and easy to digest. They believe in real transparency. Many health care organizations have constructed false narratives around not being transparent with patients — contending that “they won’t understand, they will call us constantly, they will sue us.” None of this is true. In contrast, at organizations where the quality of care is the priority, the staff regularly reflects on and publishes information on outcome data that matters to patients and caregivers. Copyright © 2024 Harvard Business School Publishing. All rights reserved. 7 HBR / Digital Article / To Improve Health Care, Focus on Fixing Systems — Not People Meaningful performance data is easily accessible to their frontline care teams, leaders, and patients. At Medstar Health, a health system that serves Maryland, Virginia, and Washington, D.C., the results of its Communication and Resolution Program (CANDOR) have shown that disclosing a harmful care event when it happens, apologizing for it, and being transparent with patients following an unexpected outcome can increase trust, decrease liability claims, and lead to ultimately safer care. As health system leaders, we are often pursuing ambitious goals, including achieving better health for our patients, providing our patients and workforce a better experience, and improving our bottom lines. Operating systems like the ones described above deliver these results and do so in ways that become habitual. The operating system fades into the background, and what moves to the foreground is the elegant, simple, refreshingly obvious human-to-human interaction that is at the heart of what all of us hope our teams will accomplish: delivering and receiving the best possible care. This has always been health care’s original and highest purpose — what we who work in these organizations are good at, what we love to do, and what the world needs. This article was originally published online on July 12, 2024. Kedar S. Mate, MD, is president and chief executive officer of the Institute for Healthcare Improvement and a member of the faculty of Weill Cornell Medical College. Josh Clark is a vice president at the Institute of Healthcare Improvement. Prior to joining IHI, Josh served as the senior vice president of quality and safety operations at Jefferson Health, an 18-hospital system covering the greater Philadelphia region and southern New Jersey, and senior director of quality and safety at Carilion Clinic, a health system based in Roanoke, Virginia. Copyright © 2024 Harvard Business School Publishing. All rights reserved. 8 HBR / Digital Article / To Improve Health Care, Focus on Fixing Systems — Not People Jeff Salvon-Harman, MD, is vice president of safety at the Institute for Healthcare Improvement. Copyright © 2024 Harvard Business School Publishing. All rights reserved. 9 Copyright 2024 Harvard Business Publishing. All Rights Reserved. Additional restrictions may apply including the use of this content as assigned course material. Please consult your institution's librarian about any restrictions that might apply under the license with your institution. For more information and teaching resources from Harvard Business Publishing including Harvard Business School Cases, eLearning products, and business simulations please visit hbsp.harvard.edu.