The front lines of medicine offer unique perspectives on patient care and the arcane American healthcare system, arguably unseen by policymakers and academic researchers. The daily observations of a practitioner, especially a newly minted intern, range from the subtle to the painfully obvious and are limited only by the capacity to remember anything amid the flurry of pages, lab results, procedures, phone calls, and admission notes.
What is encouraging is that a host of clever, well-intentioned people are trying to learn from these observations and propose improvements. Indeed, the momentum building around evidence-based and high-performance medicine is refreshing. But, without being a naysayer, I want to ask whether we are expending our resources most effectively. Are we making the impact we intended?
A favorite case study in business operations curricula is the Toyota Production System (TPS). In a nutshell, the focus is on identifying problems, addressing potential solutions, implementing changes, and then reiterating the process for continuous improvement.
Physician and nurse leaders are growing increasingly involved in operational enhancements, especially in the context of delivering higher quality care to patients. Healthcare organizations are tapping these providers to serve as officers with broad mandates. Much of the effort for meaningful change has therefore been invested within the hospital walls.
After just a short time on an inpatient ward, emergency department trauma unit, primary care provider’s office, or operating suite, the question is not What needs to be done? but rather Where do we start? Hundreds of ideas can spring to mind, whether formalizing communication hand-offs, cross-training team members, smoothing the ebb and flow of discharges, disseminating electronic health records, or reducing errors. The challenge is to prioritize. This problem is not unknown to corporations that undergo a strategy and budget review process every year. If the process were easy and the stakes low, there would not be an industry of consultants and business gurus offering advice. Selecting the key, game-changing initiatives is difficult, though, particularly in medicine, where the unpredictability of human health and disease is mirrored in the rather unpredictable workflow.
What seems to have occurred is that providers have chosen to tackle change incrementally, to catch as catch can, due in no small part to the fragmentation of clinical departments by specialty, but also because of dedication to patients in the face of time constraints. Physicians by and large choose the profession to heal patients and have an urge to fix things that get in the way of that goal.
In TPS, when the cord is pulled, the whole automotive line stops to troubleshoot a problem. Yet medicine lacks the prioritization, coordination, and knowledge-sharing seen in that system. The movement for healthcare reform is laudable, but the challenge is to shift from incremental to wholesale impact.
To move beyond incremental im-provements, healthcare leaders will have to tackle the inertia of a complex system rooted in uncertain science and contingent human behavior. An unfavorable reimbursement environment makes long-term vision statements, much less annual strategic initiatives, seem far-fetched. Some confluence of factors—such as financing, regulation, or technology—will have to be found to enable genuine overhauls, to rethink entrenched assumptions. Perhaps frustrated by ideas withering in committees or Congressional hearings, providers have resorted to the decentralized approach seen today. But this needs to change to achieve the results expected by our patients and society. Improvements must come from within, yes, but they must be home runs, not singles and doubles.
Jason Sanders, HMS ’08, is an intern in internal medicine at Massachusetts General Hospital.
