Health care costs too much and achieves too little for one profound reason—it is tremendously inefficient. And because of that inefficiency, quality issues abound.
Some view improving efficiency in health care as simply getting doctors to see more patients each hour. Our view is different. In these pages, we present the stories of ingenious people and organizations, large and small, that have found ways to do the job better. They have reduced tensions and improved communication among medical team members, enormously improving performance. They have reprioritized the physician's day, leaving more time for patients. They have engaged patients along a continuum of care across a fragmented system. And they have made the delivery of care safer.
What these pioneers also have in common is an approach to their work known as reengineering, a term that entered the business lexicon after Reengineering the Corporation was published in 1993. It ignited a widespread movement to improve the way work is performed by businesses. In essence, reengineering sees work not as a series of separate tasks to be individually optimized, but as groupings of interconnected processes to be reassessed and reinvented in toto.
The book formally defined reengineering as "the fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical, contemporary measures of performance, such as cost, quality, service, and speed." Four words—fundamental, radical, dramatic, and process—are the keys to reengineering.
Fundamental refers to how work is performed and the basic questions that need to be asked: Are the underlying assumptions about the design of work still valid? Have advances in science and technology enabled work to be performed in new, more effective ways?
Radical means going beyond superficial changes in the way things are being done. You need to ask whether old structures and operating assumptions are diminishing the quality and service being delivered by your enterprise. Do you need to go back to your original roots to rethink how work should be done?
Dramatic tells you that reengineering isn't about marginal or incremental improvements. Sometimes an enterprise—or an entire industry—requires something more than piecemeal change. Has your organization reached a point where it's survival or efficacy is threatened in a way that only wholesale change can fix?
Finally, process refers to a group of activities that uses one or more kinds of input to create an output a customer values. In health care, the customer might be a patient, a clinician, or the entity paying for the care.
For the past 20 years, enterprises have relied on reengineering, or reengineering-like thinking, to achieve success. Companies as diverse as Texas Instruments, Campbell Soup, and Wal-Mart have successfully reengineered. The methodologies and techniques may vary in name, but they all share the same ambition for dramatic improvement in the performance of work by focusing on process.
Observers of health care agree that a compelling case exists for radical improvement and dramatic change in care delivery. So for the purposes of this book, we suggest a more appropriate definition of reengineering: The radical improvement of health care delivery processes to enhance quality and dramatically lower costs, while also greatly expanding patient accessibility to that improved care.
Implicit in this definition is our belief that more efficient and safer delivery will automatically lead to sharply reduced costs. More to the point, without reengineering, we don't see how any economy will ever be able to afford health care for all of its citizens.
Reengineering must be done, and it must be done by clinicians. No angel of government, even under the auspices of "national health care reform," can reduce the cost and improve the quality of health care without the work and leadership of clinicians. It's time for all clinicians—physicians, nurses, technicians, physician assistants, and pharmacists—to assume their rightful role in directing change.
By and large, health care has evaded both the rigors and rewards of reengineering. But there is no reason why that state of affairs should continue. Health care is ripe for reengineering, and signs point to adoption of those principles in certain segments of medical practice.
Dramatic Change is Possible
Meet Geisinger Health System, a 93-year-old network of three hospitals and an insurance company based in Danville, Pennsylvania. Geisinger recruited its CEO, Dr. Glenn Steele, a surgeon and oncologist, from the University of Chicago medical faculty in 2003. Ahead of many health care institutions, Geisinger was open to change, and having its own hospitals and health-insurance plan made it ideal for controlled experiments with a reengineering concept now known as ProvenCare.
The problem at hand was the huge variation in care that comes with dividing patient responsibility among multiple specialists. Since doctors use different protocols and possess different communication skills, patient outcomes were unpredictable. The variations increased relapses, which, in turn, caused more readmissions and drove up patient costs.
Starting with coronary-artery bypass surgery, a common, well-studied procedure with repeatable, refineable processes, Steele and seven cardiothoracic surgeons focused on how to solve the care-variation problem. They first decided to consider the work of a bypass as a process, then they developed a master list of 40 essential steps in patient treatment, ranging from initial visit to discharge. The individual treatment steps were well-known, of course; the new wrinkle was the innovative way in which Steele and his team chose to consider each step as part of a larger process, and to make sure that all steps got done every time.
To make this happen, ProvenCare provides bonuses for doctors who follow the established, written protocol. Those who see good reason to skip a step (very few have) must explain why in the patient's record. The ultimate goal is to confirm that no step has been forgotten, whether applied or not.
Preliminary studies show that ProvenCare's coronary bypass program significantly reduces hospital stays, patient bills, and readmission rates. Geisinger has now applied the approach to other procedures, including hip replacement, cataract surgery, and diabetes management.
But while there's no doubt that meticulous use of well-designed checklists can and does improve health care delivery, that's only one facet of what's needed to reengineer care as a whole. The breakthroughs we cite in the pages ahead, coupled with our analyses and comments, are organized to illustrate the three main pillars of our approach: technology, process, and people. Let's take each in turn.
- Technology. In any science-based enterprise, technological developments offer daily opportunities for redesigning work. Do you automatically consider technological solutions to the problems you find in delivering health care? Are you monitoring new technology for developments that might enhance performance in your hospital or practice? How do you find new technology that will mesh with your total system to work efficiently? Are you doing enough to reduce risks? Are you prepared to install the best available systems for fast, reliable communication among doctors, nurses, and administrators—and to make sure that they fit with the redesigned work of your organization? How far along are you in developing electronic health care records?
- Process. Whether or not new technology is applied, an organization's work is best understood as a collection of processes. What's the best technique for determining which processes need improvement? Once identified, how do you develop a strategy for getting the results you desire? How should work be reordered? Which frontline employees—nurses, administrative staff, doctors—should play what roles? How and to whom should changes be introduced, and should they be carried out sequentially or simultaneously?
- People. No process can work properly without people trained as a team to execute. Are existing relationships within your organization helpful or harmful to high performance? What programs are needed to prepare doctors and nurses for change? Are you open to listening to your people's criticisms of new methods and to support innovations designed to adapt to the real world? How do you develop leaders in hospitals or practices who will accept, strengthen, and maintain new standards?
Of course, people, process, and technology do not exist in isolation. The interfaces among them can either enhance or detract from the overall performance of an organization and the ultimate outcome and experience of the patient.
But before we begin detailed descriptions of pioneering programs focused on technology, processes, and people, let's meet a health care reformer whose reengineering achievements integrate all three approaches. Chapter 2 tells the story of Zeev Neuwirth, one of this country's most persistent and productive innovators in health care delivery.