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The
significant problems we face cannot be resolved at the same level
of thinking we were at when we created them. --attributed
to Albert Einstein1
"...
the purpose of bureaucracy is to compensate for incompetence and
lack of discipline--a problem that largely goes away if you have
the right people in the first place." --James C Collins,
Good to Great2
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Presented at
Kaiser Permanente Spring Primary Care, April 18-23, 2003, The Orchid
at Mauna Lani, Kohala Coast, Hawaii, as: Pfeiffer B, Agpaoa C, Carvalho
S, Copp C. Honolulu Pediatrics: learnings in retrospect.
Introduction
American
medicine has produced dramatic and miraculous advances in care over
the past several decades, and Kaiser Permanente (KP) has often been
at the forefront of innovations in delivering this care. Nonetheless--and
although advances in technology and quality have produced major benefits
to the American populace--the medical industry nationwide has never
been noted for excellence in customer service. While many industries
became accustomed to the pressures of competition, this concept remained
foreign to medicine. Now, however, times have changed.
The Past--A Problem to
be Solved
In the
past, the Pediatrics Department at KP Honolulu consistently adhered
to standards of efficiency, effectiveness, and customer service that
had become common nationally in medicine: Phones often went unanswered;
access was often difficult to obtain; systematic approaches to operations
either didn't exist or were obtuse and dysfunctional; and customer service
was congruent with these supporting structures. An evident fact was
that delivering this level of service to our members was no longer viable--and
that neither would we be if we continued in the same way.
We approached
this challenge by focusing on three essential needs: well-functioning
operations, empowered employees to run these systems, and supportive
leaders to help build the systems and facilitate the employees' performance.
This article discusses our approach to changing the systems to work
for the end result: serving our patients.
The Diagnostic Approach
Many of
our operations did work quite well--just not for our patients. Dysfunction
often existed because the system was designed to be effective for someone
along the process path; for example, sometimes systems were designed
for the ease of employees working at the beginning of the process. Some
systems were designed to protect a "weak link"--real or perceived--or
to appease a certain interest group or hardened silo. Honest introspection
into many of our paradigms revealed uncomfortable patterns that nonetheless
needed to be addressed.
Closer
inspection showed that most operations were failing because they were
designed "backwards": Focus was placed not on what was needed
but on what we thought we could provide. Operations often reflected
the bureaucratic hierarchy, not the abilities of employees or the needs
of Health Plan members. Systems often evolved from a series of compromises.
Although compromise may be politically expedient, systems that result
from compromise are usually compromised systems.
In this
way, the end result was often a set of dysfunctional systems, disempowered
employees, and poor customer service. This structural and cultural paradigm
had to change so that a more functional operation could flourish.
The Reconstruction
The first
step in any improvement program is to realize that you can't do it alone.
Nonetheless, our clinical systems were designed and managed predominantly
by doctors and nurses--none of whom traditionally are trained in operational
processes. We therefore needed to add to the management team a business
consultant, an industrial engineer, or sometimes, a referee. We needed
professionals to assist us with duties that were outside of our profession.
During
our clinical redesign, we developed a structure that can be applied
to a variety of settings. In this structure, the hierarchical pyramid
is inverted so that the leadership supports the staff with principles,
tools, and empowerment, thus allowing them to function at their highest
capacity.
We call
this approach "gyroscopic operations." A gyroscope provides
stability and maintains direction by using momentum created by rapid
rotation of a wheel. Despite outside forces placed upon it, a smoothly
operating gyroscope resists movement from its core direction. We wanted
our systems to operate in the same manner.
We believe
that this approach is one key to our success and can be useful for other
clinics. A schematic of this approach is shown in Figure 1.
Figure
1. Schematic illustration likens operational structure of KP Honolulu
Pediatrics Department to a gyroscope in which functional processes of
the clinic are directed toward a guiding principle and are kept in balance
by clinical peers. These functional processes operate within a structure
of systems and measures and are based on clinic and organizational leadership.
In this
approach, employees are given principles, guidelines, and tools to do
their job well. They then perform independently with these principles
for guidance and with leadership for support. The support structure
is completed by systems (created to allow consistent realization of
each goal) and measures (delivered for redirection or fine tuning directly
to the employees whose performance is being measured).
Construction
of this structure must be accomplished in stages. First, principles
and goals are determined. For example, the primary care leadership determined
that all patients should have a primary care physician and should see
their personal care provider (PCP). Patients should also be seen on
the day that they call about an illness. Each of these principles is
a universal, intuitive truth that few would challenge.
Once these
principles were set forth, a system was designed to achieve each goal.
To be effective, the system was set up so that the path of least resistance
was to provide the desired service; if employees must "swim upstream"
against the system or if they have no tools enabling them to easily
perform duties consistent with the guiding principle, then that goal
will not be realized fully or consistently. If receptionists are assigned
to give patients same-day access, then appointments must be available
on that day. If receptionists are assigned to match patients with their
PCP, then a functional mechanism must exist by which this assignment
can be consistently achieved. Employees need tools that serve them and
make it easy to do the work the right way.
The other
internal support implemented was measurement that reflects movement
toward the guiding principle. These measures are delivered to and reviewed
with the employees whose performance is being measured.
These
supports are linked to the staff by a local leader chosen from among
the employees themselves. This leadership position--an essential piece
of our approach--is not recognized officially in the organizational
hierarchy but is held by a person to whom the staff look for competence,
information, and direction. Moreover, by assuming this leadership role,
a staff member implies that all members have the potential to be leaders.
This message begins to diffuse sharp demarcations in the workplace hierarchy
and empowers the staff to think of themselves not only as empowered
but as responsible.
Employees
using these systems may be considered the flywheel of the gyroscope.
Allowed to perform in a low-friction environment, they provide the momentum
and stability that keep the system oriented in the direction of its
core principles.
We based
the new approach on the premise that all people come to work to do a
good job. Giving them principled goals, functional systems, and feedback
are generally sufficient incentive to create both improvement and satisfaction.
A gyroscope
thus provides a metaphor for this structure. The most important part
of this structure is the staff, who perform their duties in a functional
environment, provide momentum and stability, and maintain direction.
The leaders act as a supporting structure and provide a platform on
which the employees perform their jobs.
Application and Extrapolation
KP's Health
Care Team Leadership provided the principles for quality service and
care. A "gyroscopic" structure and new systems were applied
to each of these goals, and--when possible--systems were automated to
accomplish the goals. Examples of such principles and their operationalization
are shown in Figures 2 and 3.
Figure 2. Schematic illustration uses gyroscope analogy to depict operationalization
of three principles for high-quality service and care: creation and
maintenance of user-friendly processes, use of exit linking, and assignment
of all KP members to their own personal care providers (PCPs). MA =
medical assistant.
Figure 3. Schematic illustration uses gyroscope analogy to depict process
of ensuring that patients obtain appointments with their own PCPs.
The KP
Hawaii Region determined that linking members to their PCP would be
best attained after the first visit to a KP clinic. Medical assistants
were chosen as the best suited for performing this function, and systems
were designed and automated to accomplish it. Measures were delivered
and reviewed with a medical assistant who took an active interest and
led in the endeavor. The team and clinic leadership enabled the processes,
and the organizational leadership supplied measures and evidence-based
principles upon which to focus.
Figure
3 is an abbreviated schematic of operations involved in passage of a
patient through a routine clinic visit. As the patient moves through
the clinic, a variety of operations occur simultaneously. To be accomplished
consistently, goals must be intuitive as well as important to the staff
and to patients. Systems must work to achieve these goals easily; the
staff must be empowered to maintain and improve each operation; and
relevant, actionable measures must be delivered regularly. All these
tasks and objectives must be supported by the leadership, not imposed
by it. Figure 4 shows how this approach for monitoring and correcting
aspects of a medical encounter is analogous to the gyroscopic activity
of an airplane's navigational system.
In its
clinical redesign, KP's Honolulu Pediatric Department has focused on
several principles set forth by the Health Care Team leadership. By
applying the "gyroscopic operations" structure to these goals,
processes were automated for consistently achieving the objectives (Table
1) of the clinic's staff (Table 2).
Conclusion
Creating
a structure in which employees can perform professionally to the best
of their ability makes patients and employees--clinical as well as nonclinical--universally
happier. We have learned that if we empower people to do a job well,
they will do so. Give them the tools to do it, and they will use them.
Build systems that work for the end customer, and these systems will
work for everyone. Focus on doing the right things for patients, and
the resources already available will usually be sufficient.
Figure 4. Just as the three-dimensional orientation
of an airplane's flight path is maintained by a series of gyroscopes
that monitor and correct changes in altitude, pitch, and direction,
so are the dimensions of a medical encounter monitored and corrected
within a clinical setting.
We have
found that good service is beneficial to patients, physicians, and all
other employees. When patients have access to their primary care physician,
when receptionists are able to give appointments when patients need
them, when physicians are not backlogged or rushed, when flow through
the clinic is smooth and expedient, and when staff can perform interdependently
to their highest potential, all involved will find themselves much more
effective--and possibly, therefore, more contented.
Kaiser Permanente Honolulu Pediatric Health Care Team
Acknowledgments
Suzanne
Ivey, BS; Glenn Y Furuya, MA; and Chris Lutz, BS, MBA were consultants
on leadership and systems improvement.
References
- Calaprice
A, editor. The expanded quotable Einstein. Princeton (NJ): Princeton
University Press; 2000.
- Collins
JC. Good to great: why some companies make the leap--and others don't.
New York: HarperBusiness; 2001.
Additional
Reading
- Berwick
DM. Disseminating innovations in health care. JAMA 2003 Apr 16;289(15):1969-75.
- Berwick
DM. Escape fire: lessons for the future of health care. New York:
The Commonwealth Fund; 2002. Available from: http://cmwf.org/programs/quality/berwick_escapefire_563.pdf
(accessed August 6, 2003).
- Foster
MS. Henry J Kaiser: builder in the modern American West. Austin (TX):
University of Texas Press; 1989.
- O'Toole
J. Leading change: the argument for values-based leadership. New York:
Ballantine Books; 1996.
