Transformation in healthcare needs to occur within a complex dynamic system (i.e. a chaotic mess). Clear communication, shared goals and problem solving are especially challenging in healthcare environments. There are multiple and sometimes conflicting missions. The socialization of healthcare professionals is fragmented and often exists outside the organization and pre-employment. Our organizational structures further strengthen these silos. There are incredibly strong external pressures, constraints and influences from multiple stakeholders (payers, consumers, government agencies, etc.). The core tasks in healthcare often occur locally in complex, dynamic, and ambiguous situations and settings. Patient-driven variability is often a necessity and yet there is a good amount of unnecessary variability. Healthcare is pluralistic. It’s a conglomerate of missions, values, stakeholders, professionals, regulations, processes and practices.

Here are some transformational changes we’ve all been considering with my assessments of where we are:

Team-based care –We’ve been talking about it so much it’s become a cliché, yet we’re not so good at it.  If we actually did it, it would be transformational.

Deeper and expanded competencies – Lot’s of problems get in the way of this, and we’re dreadful at solving problems in healthcare.  This tactic is necessary for reducing costs.  All stakeholders (internal and external) need to get on board.

Explicit goal setting incentivized using internal and external motivators – we think we’re good at this, and we’ve gotten better, but we’ve not transformed how we do this. Why? Because we think we can set goals at the highest level and have them make sense at the local level. Hello? McFly? It doesn’t work.

Local change with targeted centralized support – uh… what we ask for too often is local support for centralized change. Is that you again McFly?

Feedback and redesign with front-line workers and patients at the center of the work. – Who has time for that?  We can do this, but only if we integrate it into our daily workflows and practice.

Use systems, process and team-based thinking. – ugh.  Clinical pathways help change the paradigm and demonstrate the benefit of doing this, but one problem is that professionals don’t know how to do this kind of work without a lot of coaching.

Agile engaging high-performance management systems – Does anyone in healthcare even know what this means?

One last thought…Many of us have been on a journey to point out what we consider to be a cancer in healthcare – variability.  Could variability be the malady of all maladies for healthcare?  Yet variability is often necessary as is cell growth and tissue regeneration; variability at the right time applied to the right patient is the right thing to do.  Also, attacking variability with blunt tools has negative consequences, much like using radiation and cytotoxic chemotherapy to fight cancer.   A better way to frame variability: there is good variability, acceptable variability and bad variability (normal, benign and malignant). We need to address the malignant variabilities with targeted and intelligent tools.

Transformation starts with asking the right questions. My favorite first question is, “what problem are we trying to solve?” Followed by “why?” If you’re in the service industry and the problem you’re trying to solve is a financial one, that’s not transformational, it’s operational. If the problem isn’t about those you’re serving, then it’s the wrong problem. Loss of focus on true north goals often sends problem solvers down the wrong path; be sure staff define the right problem and stick to it.  And don’t let operational problems get in the way of solving the real big ones.

Common customer oriented problems are cost, convenience and experience. When considering these, it’s important to not forget the most important problem, “Why they’re coming to you or want to come to you in the first place.” – forget that fundamental, and you’ll go out of business.  Perhaps one question for transformation could be, “How can we solve patients’ problems quicker, cheaper and where they are?”

Transformation also starts with realizing what we shouldn’t tolerate, and generating paradigm shifts.  The  patient safety movement is an example of transformation. It started 20 years ago with Dr. Leape using data, and asking the right question, “why are we tolerating this?” We look back now and we can’t believe the things we tolerated. Another example is the patient- and family-centered care approach to delivering care, and designing that delivery. This movement brought about a paradigm shift in how people think about healthcare.

Perhaps another question to ask, “Is what we’re doing and how we’re doing it the best way when you consider the value it brings to the consumer assuming they have to pay every cent of the cost plus a margin?” People are willing to pay a lot to get their cancer cured. They aren’t willing to pay a lot to get a sore throat looked at and cared for.  To think about this try the “miss work” or “miss school” test (e.g. if a family that values their child’s education is willing to take their child out of class to go to the doctor, that service is of value. If it’s not then they will either not go, or they’ll go somewhere after school that is quick and convenient– i.e. CVS minute clinic).

We think patients and families value all healthcare equally, but their behavior suggests they don’t.  We need to provide value starting with thinking a little differently about what value means to those we serve: “if the patient had to pay every cent of the cost of their healthcare, how would we do it differently?”

In some cases we may need to be explicit about the value.  For example if a family takes their child to the doctor primarily to get vaccines, what would happen if they were to become solely responsible for the cost?   They would start going to CVS to get them.  Just walk in, get the shot and leave whenever at a cheap cost, no doctor involved (and by the way stop at the do-it-yourself height and weight station on your way out). Yet, there is value in going to and paying for the doctor visit that may not be entirely understood.

Recently in the New York Times I saw an invited editorial by Pamela Hartzband (a Boston Physician) and her husband Jerome Groopman (a Boston physician who wrote How Doctors Think). The editorial was entitled How Medical Care is Being Corrupted (http://www.nytimes.com/2014/11/19/opinion/how-medical-care-is-being-corrupted.html?_r=1).

Drs. Hartzband and Groopman assert that pay for performance is not good for health care because it will incentivize physicians not to do what’s in the best interest of their patients.  Of course, incentivizing can lead to unintended consequences, but I would assert that our current fee-for-service system has more damaging consequences.

A few days later my former health care policy teacher wrote about this op-ed in his blog (http://www.managinghealthcarecosts.blogspot.com). He wasn’t impressed either.  He felt that the perfect way to compensate physicians doesn’t exist, and not holding physicians accountable for providing evidence-based care isn’t a good idea.  In addition we need to hold systems accountable for not causing unnecessary harm.

Are they suggesting that fee for service is better? And hasn’t created corruption?   Mmmm…

Current pay for performance formulas and strategies are far from perfect. The triple aim in its simplified version contains a paradox for sure – better population health and better care for the individual patient? What? And add better cost to that and you get a triple paradox, especially when you consider that no one in health care wants to be paid less.

Could pay for performance lead to gaming of the system and undesirable behaviors? Probably. Would it be worse than what we have now? Probably not.

Hasn’t the current reimbursement system led to poor quality, unreliable safety, overuse, misuse and underuse? Haven’t physicians made decisions about what kind of medicine to practice, where to practice, what kind of patients to care for and what to do for those patients based on our current fee for service reimbursement? Don’t we essentially have a corrupt health care system now?  Perhaps I’m being too negative, but the Hartzband-Groopman op-ed by not addressing these questions at least a little lacks some credibility.

Physicians have often elevated themselves to a mystical high road, creating a façade of selflessness and high morality. Drs Groopman and Hartzband have only repeated this cliché in their op-ed. The reality is that physicians have repeatedly demonstrated that they are merely human and their motivations are prone to selfishness.  In fact, their op-ed suggests this.  Physicians’ decisions ought to be centered on the needs and goals of the patient and evidence-based.  We could add the needs of the community and population as well.  They need to be fairly rewarded for doing their job well and for the quantity at which they do it.  Balance is the key.

I recently wrote down some guiding principles for redesigning patient-centered care delivery.  These patient-centered directives are taken from years of reading, hearing and seeing best practices and principles.  I’ve especially been influenced by the speeches and writings of Don Berwick and Bev Johnson.

Here they are:

• “Don’t harm me”
• “Don’t unnecessarily disrupt my time, my place, my money, my dignity, my privacy”
• “Do comfort me and care about me while you care for me”
• “Do keep me informed in real-time”
• “Do include me in decision-making”
• “Do help me manage my illness so I can be and feel healthier”
• “Nothing for me without me”

Here are some systems-thinking principles to keep in mind:

• Value streams are mapped through the eyes of the patient and family.
• Processes are designed to maximize value for the patient and family (and community).
• What we do is for the patient and family, and how we do it is also for the patient and family.
• The system is designed with the patient and family as well as for the patient and family
• The system anticipates the needs of the patient and family
• The system is flexible and predictable in the eyes of the patient and family
• The Voice of the Customer is used in every process improvement and redesign

You might recognize that there are 14 points here.  You also might recognize that half of them are directly from the voice of the patient (a lucky seven).  These are powerful and transformative principles when followed relentlessly and deliberately.  I’ve followed these principles to the best of my ability as a physician and a leader and they work.

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 (http://thehealthcareblog.com/blog/2014/05/07/a-declaration-of-independence-is-only-the-beginning/).  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.

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.