The Smart Cogs of Health Care

Health care is at a cross roads.  Are physicians the problem or the solution?  I’m not sure how much of the problem they are, but I’m certain they are part of the solution.  Physician behavior is the result of the system within which they work.

Truthfully physicians are the “smart cogs” of health care.  And we need to design a system that optimally leverages this strength.  Deming referred to those front line workers who most understand the processes as the smart cogs.   In health care smart cogs serve two purposes: 1) applying, adjusting and adapting standard processes to individual patients, and 2) leading the creation and continuous improvement of those standard processes.

However, our system of health care hasn’t empowered or enabled physicians to be effective smart cogs.   First, the fee for service model has driven the idea that every thing must be related to the generation of RVUs.  Thus, physicians don’t have the time to do job #2 of the smart cog, and they spend less time doing job #1 simply because it takes time.  Second, the capacity for physician to understand the processes of care is decreasing.  With increasing complexity, even the smartest physicians are finding it hard to be experts in care delivery.  Third, applying the science of quality improvement generates data, and that data needs to be analyzed, which takes time as well as expert knowledge of the science of improvement.  Physicians lack the time and often the skills.   Fourth, medical science knowledge and evidence is expanding at a pace the individual isn’t capable of processing, especially the busy clinician.

So, what to do?  Consolidate, collaborate and commit.  Consolidate into integrated networks where scale can allow for physicians to organize in such a way to allow for proactive process and pathway development and maintaining.  Collaborate across disciplines, departments and care settings to create more patient-centered, effective, efficient and coordinated care processes and clinical pathways that breakdown traditional provider and setting-centric boundaries.  Commit to a new way of managing care and changing the current system with its poorly aligned incentives and poorly coordinated components.

John Haughom, MD, wrote a blog that discusses this issue as well (  He mentions two organizations who have figured out how to empower and enable the smart cogs (Intermountain Health and Virginia Mason).   Dr. Haughom also mentions the importance of having the will to change despite the barriers we face.  Many physicians want to see change, yet they aren’t driving change.  Many managers of health care systems want to see change, yet they can’t make it happen fast enough.  We seem to be caught in the hamster wheel of the current system.  We need to figure out how to allow enough breaks from the current wheel to improve the efficiency of the system, so that more resource and time can be freed up to allow for more proactive process improvement.

Ode to Deming, Part I

W. Edwards Deming is a bit of a hero to me.  His theory of profound knowledge is a thing of grace.  He understood the interdependency of people and systems and the importance of purpose and knowledge.  His 14 points are full of wisdom (to get the full breadth of his wisdom, one needs to read his books).

 Systems thinking and engineering is not new, even in healthcare.  Yet, it remains on the fringe.  Why is this?  One reason may be the failure of enough physicians to realize the utility of seeing care delivery in the context of systems.  They are leaders of care teams, and most are either not fond of systems thinking or know little about it.  Another reason may be administrators lack of first hand knowledge of care delivery, despite grasping the importance of systems thinking .  Administrators are good business people who have devoted their careers to health care (God Bless them), however they don’t often have broad bedside, and across the care continuum experience in delivering care.   Another reason: health care has been a successful industry and good to most working in it, thus there is little sense of urgency for change.

Perhaps another reason why systems thinking isn’t top of mind in health care is organizational culture.  Organizational cultures in health care tend to encourage autonomy and independence, and trust tends to be low.  This results in those directly involved in health care delivery (physicians, advanced practitioners, nurses, technicians, medical assistants and receptionists) lacking empowerment and capacity for change and spending time on systems redesign.

 When I was taking care of patients full-time, I loved it.  Yet, there was a voice inside my head that kept nudging me: “The system is broken and can’t continue on its current path. You can help fix it.”  My concern for health care had nothing to do with its economics.  As a pediatric hematologist-oncologist the only opinion I had on economics was how little I was paid relative to many other medical and surgical specialists. 

So, what were the reasons I had this voice in my head?  What we were doing in health care back then wasn’t consistently patient or family-centered, it wasn’t really efficient or timely, the quality, experience and components of care were variable and often unpredictable.  Substandard care was delivered too often, staff were unhappy and many felt powerless and/or burnt-out, and trust and respect among different disciplines and departments was too low.  And I saw all of these short-comings as problems related to systems design, not people.  There was a lack of awareness for the interdependencies of the processes of care leading to a lack of true teamwork and collaboration, which is needed in such interdependent systems.  Finally, the knowledge, will and resources for driving systems redesign were and still are hard to come by.

So, Deming became my hero.  His writings spoke to me.  My impressions and instincts were validated and expanded by his writings.  His profound theory of knowledge states that performance can be improved if leadership 1) adopts a systems way of thinking, 2) respects the importance of understanding variation, 3) uses the power of knowledge correctly, and 4) applies the psychology of change to their actions.  

Effective leaders change systems with the purpose of continuously improving performance towards a shared purpose.  In health care we need more systems thinking.  We need to keep going back to the basics that Deming eloquently laid out and improve the performance of our systems. 

At the same time, system changes can’t be so disruptive that the care we are delivering today declines in quality or access, and the financial viability of our health care institutions is threatened.