But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Wednesday, February 7, 2007

Change must come from within

A personal observation after five years on the job and in this field:

The biggest managerial conundrum facing hospital administrators is how to bring about constructive and lasting change in these large, complex organizations that are known as academic medical centers. People often say that AMCs are behind the times with the application of managerial techniques that are in wide use in other kinds of organizations. That may be so, but I do not think it is an accident or for lack of trying. I think there is something fundamentally different about these hospitals that requires a different point of view and approach.

The first difference is that we do not produce a single product or service. Every patient is different, and every patient expects and deserves personalized service and individualized attention. Not so different, you might argue. There are plenty of businesses that offer service tailored to the individual, and they have learned how to provide that service consistently and efficiently. And it is true that, in medicine, there are general rules and appropriate clinical responses for many patients with one or another disease. For example, I have discussed below the use of clinical pathways to make care decisions more routine, and I have discussed protocols that can be used to avoid ventilator-associated pneumonia, central line infections, and other harm. But, at its core, effective treatment really does require due attention to the individual biology of the patient, his or her state at the exact time of treatment, as well as related factors like family and home situations. It is as much art as science.

The second difference is that the key players in the delivery of medical care -- the doctors -- are not employees of the hospital. They are essentially independent contractors who have chosen one or another AMC for a particular mix of clinical care, research, and teaching that gives them personal satisfaction. Further, they have been taught through medical school, residency training, and their history of academic professional advancement that they will ultimately judged by the results of their personal efforts, not by the progress of the institution within which they work. In baseball parlance, they are all free agents. I do not say this with any inclination to diminish the dedication, expertise, or integrity of these doctors. I offer it, though, as a sociological context for their perspective on the world. (And please, I recognize that I am generalizing a bit here, so I am shortening the description of what is a broad continuum of individuals.)

Red Sox fans know what I mean when I say, "That's Manny being Manny." Our left-fielder is a brilliant baseball player who sometimes lets his individual inclinations interfere with the well-being of the team, but who is admired, respected, and even beloved for his overall contributions on the field. Even when his actions confuse and confound and annoy us, we put up with him because he is a hard-working person usually devoted to doing the best he can -- and because his results in the batter's box can be stunning and change the course of a game or even a season.

Doctors in AMCs are not all "Manny being Manny", but they are thoroughbreds in their own way. Sometimes their behavior can be confusing and even infuriating to hospital administrators. But let us remember: Even those doctors who truly care about the interests of the hospital must make individual decisions in the batter's box when seeing a patient. They know they will ultimately be judged by others -- and by themselves -- for their specific performance in an exam room, an operating room, or on a patient floor. The same holds true for their performance in the research lab and in instructional sessions with medical students or residents.

The rest of us in other jobs think we are being judged as acutely for our own performance, but our performance is often measured in terms of our effectiveness as team members or by our interpersonal skills or by the overall progress of our organization. But now think of how we expect our own doctors to get results. How often have you heard, "Well his bedside manner isn't very good, but he is a great surgeon. If I have to choose, I want a great surgeon." It is not that we intentionally are enablers of bad behavior: It is that we selfishly want good results for ourselves or our loved ones -- and we expect the doctor to deliver it notwithstanding the economics of the health care system, the productivity of the hospital, or any other ancillary concerns.

Here at BIDMC, we are engaged in an experiment, trying to mold the hospital to your expectation of a great hospital experience. As one of my folks put it yesterday, we are trying to be "aggressively patient centered" so that every person is treated as though he or she were a member of our own family. How can we do that, you might ask, if what I say above is true? The answer lies in part in our own history as an organization, a legacy of the underlying values of both the New England Deaconess Hospital and the Beth Israel Hospital. But there was another factor.

Because our hospital went through an exceptionally bad period after the merger that created BIDMC and then almost literally rose from the ashes, those doctors, nurses, and others who stayed with us and have since joined us have an extraordinary degree of loyalty, optimism, and enthusiasm about our ability to work together to deliver the kind of care I describe above. They are collaborative to an outstanding degree. Yes, the doctors are still free agents, but they recognize that even their individual advancement can be enhanced by teamwork and cooperation.

In the postings below entitled "What Works", I have given some examples of their attempts and accomplishments. But here is the key message: Not one of those initiatives was driven by me or other members of the senior management team. The desire for change and improvement came from within, from those very free agents who are viewed by some industry observers as so troublesome.

So here is the five-year takeaway. My management philosophy is remarkably simple. My job as CEO is to help create an environment and provide the resources within which the native creativity of our doctors and other staff can flourish. I don't practice an iota of medicine, but when I do my job right, they are better able to do theirs right.

There is a joke that, "You've seen one AMC, you've seen one AMC." Maybe what I say would not apply elsewhere. We will also get to see if it works even here for the next five years! The jury is still out, but so far, we appear to be headed in the right direction.

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