The Mess in Healthcare - Paul Holmstrom

Speaker A I come here from two directions. One has to do with organizational development in healthcare. I've been involved in quite a lot of organizational reviews and audits, mainly in hospitals. The other direction I come from is from the field of system dynamics where I use system dynamics modeling to explore the effect of possible policies over time. And in that field I also meet a lot of practitioners and academics that work in healthcare settings. Interestingly, healthcare is usually very often seen from a national perspective. Health care system in Sweden is unique healthcare system in the states, wherever it's unique. And what I realized when I talked to my colleagues in the field of system dynamics is that the problems are exactly the same everywhere. So coming here today then I explored with two different titles. I decided to show you both of them. One title is one I've been playing around with for quite a long time. I call the mess in health care. And when we were on the preparation for this panel, I also realized that my perspective is very much micro perspective. It's something that is going on in the hospital. When I talk about the Mess, what is it I think about then going into particularly into a clinic, I often hear things that indicate that what is going on there is very fragmented. One indication of that is that one of the popular things in hospitals nowadays talking about lean and lean is all about reducing variation. But what goes on in a hospital is absolutely the maximum on variation. So it is fragmented. People do tend to get ill in a very different way. One thing that I very often hear is that staff say they only talk about money nowadays. It's very much cost oriented. There's the issues of the multi professionality which touches on what you said, the thing about the association versus the organisation and there's the flavor of the month. There's a researcher in Sweden who a number of years ago drew a map over all the various policies that had been a national level trying to sort out health care. The really most interesting question I keep asking people is what use do you have our manager? What value is the manager adding? And say well, I don't really need a manager. The manager there is really to make sure I'm getting paid and that I'm scheduled and I have my yearly discussion about my professional developments. Now, the other year, two years ago, I got a whack on the head and this whack came from a very interesting study published by the two National Academies of Science in the States, the National Academy of Engineering and the Institute of Medicine. They were exploring how can the healthcare sector utilize the knowledge within the engineering sector has to do with quality, process development and whatever. And the really interesting thing was that when they listed the causes of the healthcare crisis, they had a list of six points. And the second point was what they call the cottage industry structure of healthcare in the States. But 50% of all American doctors are self employed. 80% of all American doctors work within an organization with ten employees or less. And I thought to myself, well, what they're writing about the cottage industry is exactly what we've got in the Swedish Health Service, even though they're all employed in an employment hierarchy, because they're working as if they were independent. And very often when I go into healthcare organisation, I use Minsberg's archetypes to help me to understand what is going on. And at least in Sweden, I usually see that there's four of these archetypes present. At the top we've got the political archetype and under that we get a divisionalized structure where you've got hospitals with a geographical area. They're doing the same sort of thing, or it might be primary care units. And then within the hospital we've got the professional bureaucracy. And then it comes a really interesting thing. And that has to do with the answer, the question, what added value do is the boss gave? Well, not really. And that is that the real work in the hospital is done in this simple structure where the doctor meets the patient and tells the nurse what interventions should be done. It's as if they're running their own little business there. In Minsberg's book he's got this chart, he uses this picture where he compares the different archetypes. And this picture is particularly interesting because what he looks at is the difference between the formal organization and where work really is done. And what it says is typical in the professional bureaucracy is that the core of the organization is the work that is done by the professionals, but the bulk of people are actually employed in the service supporting them. And here you find all the nurses and auxiliary nurses and wards and whatever. And this is a paradox. Now I'm beginning to talk about it as the bifurcation on level three, where I've been looking at an organization clinical manager. So looking at it there's, what levels of work do we have? The type of hospitals that I work with? Anyway, I would say that the manager of the hospital, hospital director, needs to do a level four work. The manager of the clinic is organizing the work of the clinic as a level three job. The ward manager real job is a level two jobs. And you've got secretaries doing some sort of stuff there, looking at the work of doctors. You've got a lead specialist who writes instructions. This is what we do in the field of urology when we get in patients that everybody has to follow. You've got senior doctors who are capable on level three, and you've got junior doctors probably capable on level two when they join the hospital. And we've got senior nurses who ideally should be capable on level two. We've got junior nurses at that lower level who go auxiliary nurses at that lower level. So we've got the point of the mess. We've got here because you've got a clinical manager supposed to organize the clinic and the work. And you've got the senior doctors who have got exactly the same capabilities and knows what they could do there if they had the values and preferences to do the job. And they're not letting manager do the job of the organization. So you get a bit of a mess there. And I think that one of the points that we need to handle is to recognize the fact that there are different domains of work instead of seeing it as traditional employment hierarchy, there are in a professional organization, there are distinct domains. There's the domain of organizing stuff, there's the domain of the medical work and there's the domain of the nursing work. And in some countries, like in Britain, understand that nursing work is much more recognized because you talk about having a head nurse in a hospital while see in Swedish structure there's two jobs missing. I'm missing the job of a chief nursing officer in the hospital who develops the work of nursing and thus recognizing the domain of nursing. In Sweden, hospitals do have a chief medical officer but their role is only to handle when mistakes are done. So they've got formal legal instructions, they don't do any chief medical officer work. So I think we wouldn't need to handle the fact that work is done in different domains so as to allow the organizational people to do their thing. We've got this sticky issue of the organization and the association, using Elliot's wordings, when the doctors can be seen as an association and that gives us this sense of collegiality. We're not allowed to have opinions about what other doctors do. So what can the clinical manager do? So somehow that has to do with accountability. So this is my last slide and I think this is I'm realizing that accountability is the really tricky thing maybe in this apart from allowing the manager to clinic to do his or her job, accepting that fact, what accountabilities do we have in place? Of course what everybody really talks about or really accept is that the Bain accountability has to do with the license to practice, that there's a national licensing authority and we've got this systems then of complaints or having something where you file when somebody's either about practicing or doing something wrong. There is some sort of vaguer professional accountability to my colleagues within the same field. If I'm a urologist, other urologists have opinions about me and I want them to approve of me and my work. And on the organizational domain there's accountability for financials and efficiencies, usually in a top down pressure. I have yet to see anybody in a Swedish hospital to take a clinic at a clinic at a lower level, to take an initiative to cut costs themselves, although they're quite capable of doing it once they've been put under pressure. Now, interestingly, this year we have the second, I think it was Swedish National Conference on Patient Health Quality issues and there's quite a lot of discussion using statistics from the US where I think you say there's about 100,000 deaths a year due to errors in the system, equivalent to a jumbo jet crashing every second day. In Sweden this is estimated to be about 3000 deaths. And the people working with the system of handling discrepancies or issues or incidents in the system, they're beginning to say now on a national level that we don't have a problem really with individual practitioners, individual licensees doing their job right or wrong. That's not where the issue is. The issue lies with the system. So there's beginning to become a natural focus on system and that has to do then with holding the hospital accountable for something. And somewhere on my periphery then comes Michael Porter's book about lost the title Health. Michael Porter on strategy? No, Michael Porter on health care? Yeah, he's written an excellent book on health care where he says that we need to have the competition on patient outcomes and seeing the value chain as a whole, which is an interesting point of putting the pressure on the system rather than the individual relation between the patient and the doctor. So I think that from our point of view the reason I wanted to talk about this is that I think there is a mess here and who can sort it out. And I think that Requisite organization has theories in place as it is when we're looking at bias material from Seventy S and Hospital Organization by Ralph Robot, material that Rafe has done together for Warren, what I call the simple structure. It's explained by using a task initializing role relationship. The doctor has that role towards the nurses, but we need to understand this and explain the domains and wherever and I think the use for doing this can be the move that I perceive from individual accountability to system accountability.