Managers and administrators can have a strong influence on
organizational culture and directing change. Consider the case study presented
in Exercise 6.1 (p. 97) to discuss the following questions:
·
How did management demonstrate the principles of
teamwork and continuous improvement?
·
How did this lead to improvements in the
patient’s experience (service quality) and the quality of the clinical service
(content quality)?
·
What are some of the “below the waterline” issues in
organizational culture (see Exercise 4.1, p. 68) and mental models (CH. 6) in
this case study? Use examples to support your observations.
Conduct additional research on how managers can support the
identification of mental models and best practices to develop capable teams and
support quality improvement. To complete your assignment, bring your analysis
of the case study and current research together in an analytical paper
discussing the healthcare manager’s role and responsibilities to foster
collaboration and teamwork.
Be sure to utilize the textbook and integrate at least three
peer-reviewed sources along with their citations and references. Your paper
must be APA formatted and include at least 1500 words. Please use the APA 7th Essay
Template available in the Supplementary Course Resources>>APA 7th Edition
Resources section.
REFERENCE MATERIALS
Exercise
6.1 Case Study:
The following section
is reprinted with slight changes with the permission of Simon & Schuster
Adult Publishing Group from The New Pioneers: The Men and Women Who Are
Transforming the Workplace and Marketplace by Thomas Petzinger Jr. Copyright ©
1999 by Thomas Petzinger Jr.
While many companies are getting better at customer service,
one industry has gotten a lot worse lately. That industry is medicine. The
onslaught of managed care has commoditized what was once the most delicate
relationship in all of commerce, that of doctor and patient. Accounting for the
payment of services most delicate relationship in all of commerce, that of
doctor and patient. Accounting for the payment of services has overwhelmed the
rendering of the services themselves. Yet a few islands of people have thrown
off their Newtonian blinders and recognized that putting the customer first can
redound to the benefit of the provider as well. With so many competing claims
on every dollar, every process, and every hour of time and attention, the
interests of the customer—the patient—serve as a common ground for making the
entire system more efficient. One hospital is such a place: a 520-bed teaching
hospital and so-called trauma-one center with a stellar clinical reputation.
Within the hospital, an outpatient surgery clinic was opened long ago, in which
an ever-larger per-centage of procedures were being conducted. And although the
surgical staff was acclaimed, management recognized that the overall patient
experience left something to be desired.
The main problem was delay. The surgery line was jam-packed
as early as 5:30 every morning. Some patients spent the entire day lurching
from check-in to pre-op to anesthesia to surgery to recovery to post-op, with
too much of the time spent simply waiting. As much as some people may wish to
convalesce at length as admitted hospital patients, no one wants to turn a four-hour
out-patient experience into a nine-hour ordeal. If the hospital wanted to
maintain (much less extend) its position in the marketplace, it had to figure
out how to get patients through faster without degrading clinical results.
The job of facilitating the planning process went to an
internal quality
consultant who had worked for 15 years as a registered
nurse, mostly in neonatal intensive care, before earning her MBA and fulfilling
this new organizational role. In her years in intensive care, she was often
perplexed by the priorities that families exhibited in the direst medical
situations. “I’m working like crazy to save a baby, but the parents get upset
because the grandparents didn’t get to see the baby!” she recalls. In time she
could see that medicine was only part of healthcare. “Healthcare providers hold
people’s lives in their hands at a very vulnerable time,” she says. “Healthcare
is about a personal encounter.” Most of the people on the business side of
healthcare have little intellectual grasp and less emotional grasp of this
concept. Indeed, after moving to the business side herself, she became
convinced that some of the most intractable problems of the industry could be
solved only by people who, like her, combined far-flung disciplines. “Innovation
will come from people who have crossed the boundaries from other disciplines,”
she says—from business to medicine, from medicine to law, and so on.The
facilitator insisted on involving the maximum number of nurses—people who knew
the whole patient as well as the individual surgeries they variously received.
The new administrator over the area requested that the members of the
improvement committee visit as many other hospitals as possible within their
large hospital system to explore which outpatient surgical practices could be
employed at their own site. And throughout the study process, the administrator
continually harped on the “vision statement” of the initiative, which put as
its first priority “to provide a patient/family focused quality culture.”
This new
administrator in the surgery service, a nurse herself, was a
powerful force in leading the improvement effort. Under the
previous leader-ship, the policy for change was simply “give the surgeons
whatever they want,” as she put it. The administrator acknowledged that the
surgeon must call the shots on procedures—but not necessarily on process. In
that respect she, too, insisted on using the patient as the point of departure.
“If you’re guided by only one phrase—what is best for the patient—you will
always come up with the right answer,” the administrator insists. (Hearing the
administrator and facilitator say this over and over began to remind me of the
best editors I have worked for. When in doubt, they would often say, do only
what’s right for the reader. Everything else will fall into place.)
Studying the surgery line from the patients’ point of view
was disturb-ingly illuminating. Surgeons showing up late for the first round of
surgeries at 7:30 a.m. threw off the schedule for the entire day. The various
hospital departments—admitting, financing, lab, surgery—all conducted their own
separate interaction with the patient on each of their individual schedules. A
poor physical layout, including a long corridor separating the operating rooms
from pre-op, compounded the inefficiencies. Once a patient was called to
surgery, he spent 40 minutes waiting for an orderly to arrive with a wheelchair
or gurney. And, because this was an outpatient surgery center located inside a
hospital, the anesthesiologists were accustomed to administering heavy
sedation, often slowing the patient’s recovery from otherwise minor surgery and
further clog-ging the entire line. The operation was a success, but the patient
was pissed.
In talking to patients, the researchers discovered a subtext
in the com-plaints about delays: resentment over the loss of personal control.
Patients spent the day in God-awful gauze gowns, stripped of their underwear,
their backsides exposed to the world. Partly this reflected a medical culture
that considered the procedure, not the patient, as the customer. As the
administrator put it to me, “If you’re naked on a stretcher on your back,
you’re pretty subservient.” Family members, meanwhile, had to roam the hospital
in search of change so they could coax a cup of coffee from a vending machine.
She marveled at the arrogance of it. “You’re spending $3,000 on a loved one,
but you’d better bring correct change.”
Fortunately, this administrator had the political standing
to push through big changes, and although the staff surgeons effectively had
veto power, most were too busy to get deeply involved in the improvement
process. Because few patients enjoy getting stuck with needles, the nurses
created a process for capturing the blood from the insertion of each patient’s
intra-venous needle and sending it to the lab for whatever tests were
necessary. This cut down not only on discomfort, but on time, money, and
scheduling complexity. The unremitting bureaucratic questions and paperwork were
all replaced with a single registration packet that patients picked up in their
doctors’ offices and completed days before ever setting foot in the hospital;
last-minute administrative details were attended to in a single phone call the
day before surgery. The nurses set up a check-in system for the coats and
valuables of patients and family members, which eliminated the need for every
family to encamp with their belongings in a pre-op room for the entire day. A
family-friendly waiting area was created, stocked with free snacks and drinks.
There would be no more desperate searches for correct change. That was only the
beginning. Patients had always resented having to purchase their post-op
medications from the hospital pharmacy; simply freeing them to use their
neighborhood drugstore got them out of the surgery line sooner, further
relieving the congestion. Also in the interest of saving time, the nurses made
a heretical proposal to allow healthy outpatients to walk into surgery under
their own power, accompanied by their family members, rather than waiting 40
minutes for a wheelchair or gurney. That idea got the attention of the
surgeons, who after years of paying ghastly malpractice premiums vowed that the
administrator, not they, would suffer the personal liability on that one. The
risk-management department went “eek” at the idea. Yet as the improvement
committee pointed out, the hospital permitted outpatients to traverse any other
distance in the building by foot. Why should the march into surgery be any
different?
In a similar vein, the nurses suggested allowing patients to
wear under-wear beneath their hospital gowns. The administrators could scarcely
believe their ears: “Show me one place in the literature where patients wear
under-wear to surgery!” one top administrator demanded. (The nurses noted that
restricting change to what had been attempted elsewhere would automatically
eliminate the possibility of any breakthrough in performance.) And why stop at
underwear, the nurses asked. The hospital was conducting more and more
outpatient cataract operations; why not let these patients wear their clothes
into surgery? “Contamination!” the purists cried. But clothing is no dirtier
than the skin beneath it, the nurses answered. This change eliminated a major
post-op bottleneck caused by elderly patients who could not dress themselves or
tie their shoes with their heads clouded by anesthesia and their depth
perception altered by the removal of their cataracts.
As the changes took effect, the nurses observed another
unintended effect. Patients were reducing their recovery times! People were no
longer looking at ceiling tiles on their way into surgery like characters in an
episode of Dr. Kildare. They went into surgery feeling better and came out of
it feeling better. In case after case they were ready to leave the joint faster;
this in turn freed up more space for other patients. Because they had studied
practices at a number of stand-alone clinics, the nurses even suggested to the
physicians that the outpatients would be better off with less anesthesia,
hastening their recoveries, speeding their exit, and freeing up still more
capacity.
Within a year, the volume at the outpatient surgery unit had
surged 50 percent with no increase in square footage and no increase in staff.
Customer-service surveys were positive, and costs were under control. And it
dawned on the facilitator that the nurses’ intuitive conviction that the
patient should come first benefited the surgery line itself at every single
step. Everyone and everything connected to the process—surgeon, staff, insurers,
time, cost, and quality—seemed to come out ahead when the patients’ interests
came first.
What was really happening, of course, was that the change
teams simply put common sense first. In a complex process of many players, the
interest of the patient was the one unifying characteristic—the best baseline
for calibration—because the patient was the only person touched by every step.
Exercise
4.1
Berwick, D. 2003. “Improvement, Trust, and the Healthcare
Workforce.” Quality & Safety in Health Care 12 (supplement 1): i2–i6.
www.ncbi.nlm.nih. gov/pmc/articles/PMC1765768/pdf/.
In this article, Dr. Berwick describes several historical
and present-day “below the waterline” factors that inhibit healthcare quality
improvement. For example, he observes that improvement is limited when the
workforce is not encouraged to actively participate in reinventing the system.
• Identify three factors described
by Dr. Berwick that are the most difficult for healthcare organizations to
overcome and explain why.
• For the three factors you select,
describe actions that managers can take to eliminate or minimize the factor so
it no longer inhibits operations improvement.
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