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A proven business remedy for ourailing healthcare industry

“Healthcare delivery systems work only when the people in them—line workers and leadership alike—are in highly functional, trustworthy, and productive relationships. High Performance Healthcare isboth theoretically sound and eminently practical—a rare combination!”
–Thomas S. Inui, ScM, MD, Relationship-Centered Care InitiativeCodirector and Professor of Medicine and Associate Dean for Health Care Research,Indiana University School of Medicine

“Dr. Gittell shows how a relatively small number of communication and relationship-building elementshave a direct relationship to successful performance in both healthcare and the airline industry.Her ultimate accomplishment in healthcare may be a simple tool that buildsthe individual reliability mandatory for safe patient care.”
–Robert S. Hendler, MD, Vice President, Clinical Quality, Tenet Healthcare Corporation

“Gittell’s book raises important issues and options that need to be addressedin any national healthcare reform effort.”
–Thomas P. Glynn, PhD, Chief Operating Officer, Partners HealthCare

“This is a must-read for improving organizational performance.”
—Earll M. Murman, PhD, MIT Ford Professor of Engineering Emeritusand coauthor of Lean Enterprise Value

“High Performance Healthcare points compellingly to a direction for change.”
—Christine Bishop, PhD, Atran Professor of Labor Economics,Heller School for Social Policy and Management, Brandeis University

“Every healthcare leader needs to read this book.”
—Gene Beyt, MD, MS, Senior Vice President of Medical Quality, Clarian Health

“This is an important work for clinicians, educators, and administrators.”
—John Wright, MD, Attending Orthopedic Surgeon,Brigham and Women’s Hospital, Harvard Medical School

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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...