CHAPTER 32.

TOC for Large-Scale Healthcare Systems

Julie Wright A patient opens a consultation with a doctor by saying "Doctor, it hurts when I do this."

The doctor asks "Why do you have to do 'this'?" mimicking the patient.

"Because I have to achieve that," replies the patient moving around the room.

"OK, but what if you could achieve 'that' by doing 'this' differently?"

"That would work," said the patient excitedly.

"So you agree.... If 'this' hurts it's best to stop doing it? You'll have time to heal and you will still get the results you need?"

"Of course.... Thanks doc!"

Introduction.

Unlike the practice of medicine by individual physicians, the practice of medicine within large-scale healthcare systems is a relatively new phenomenon. As industrialization concentrated populations in urban areas, medicine followed suit and began to be practiced by groups of physicians. As the collective provision of medical services flourished, exponential advances in the diagnosis and treatment of patients caused the medical profession to divide into specialties. Now it is often the case that a patient's care episode is dependent on the services of more than one specialist to reach a successful conclusion. Because of the division of specialties, patients are often forced to interact with many different people and services to secure the holistic treatment their conditions dictate.

While the delivery of healthcare is moving toward a more holistic model, the infrastructures within which is it delivered is still, for the most part, segmented with patients often being required to tolerate unnecessary waiting times between the receipt of separate services.

This chapter aims to show what needs to be changed, what the systems need to strive to achieve, and how to begin to identify the causes of these delays and to eradicate them, eventually redesigning the delivery of services to fit the ability of patients to absorb treatments, not their tolerance to waiting.

By successfully melding the many diverse services with a systemic approach, it is possible to increase the capacity of existing systems, reduce overall costs, and improve the quality of patient care along with the working environment of the people dedicated to the profession. How to stop doing what hurts and replace the current actions and behaviors with better and more effective practices that will benefit all is the goal.

Copyright 2010 by Julie Wright.

Why Change

Why Healthcare Systems Need to Improve

If you look hard enough, it is possible to find large-scale healthcare organizations in almost every shape, size, and form imaginable. To be considered a large-scale healthcare provider, an organization should be able to treat a wide spectrum of human conditions ranging between prevention, disease, and accidental trauma and almost all conditions in-between. Some patients' conditions need immediate urgent care, others longer term treatments. Some systems may also provide additional specialist services from assisted conception to palliative care and from rectifying congenital defects to, perhaps, the genetic engineering of zygotes.

The locations for the delivery of care can vary widely as well; from urban based, high-tech, tertiary, multispecialist facilities to rural lone practitioner family physicians, they all contribute to the larger scale healthcare systems that we will all find ourselves entering and using during our lives.

Some hospitals have Emergency Rooms (ERs) and some do not. They come in different sizes to suit the needs of the population being served; and some are even licensed to perform different functions for different levels of trauma. Some Emergency Rooms are the front door to the only healthcare facility for miles around and in others the local physician is the Emergency Room surgeon and general practitioner. In some, the general practitioner is the gate-keeper to the hospital's services even though they do not practice there.

There are facilities that focus on providing care for a very narrow range of conditions, such as standalone diagnostic centers and clinics that provide services for non-life threatening, elective surgery.

Around the perimeters, the large-scale healthcare organizations are providers of alternative therapies, some of which are gaining credibility and are being absorbed into the practice of scientific based Western medicine.

A large-scale healthcare organization can be a huge group comprised of hospitals, clinics, pharmacies, transport services, nursing homes, rehab facilities, and diagnostic centers, with large administrative offices that are remote from clinical areas, and some have international operations that are unbounded by international borders or politics. Alternatively, they can be a loose association of any type of clinic or surgery bound by a cooperative willing to support each other and their patients.

They can be not-for-profits organizations run by governments such as military services, charitable bodies, or socialized medicine, or as profit-oriented businesses, or as a variation of every shade of business model between the two ends of the spectrum. Blends of for-profit and not-for-profit can exist and function side by side within a large-scale healthcare organization.

These organizations can have another dimension-some are religious and others are secular; many have educational affiliations, as in teaching hospitals attached to medical schools, or are entirely privately owned and operated.

Whatever mix of services and provisions an individual healthcare service system possesses they all have a common need, that of being able to generate or acquire sufficient cash to operate. Even highly motivated not-for-profit providers have no mission if they do not have an operating margin. For-profit and not-for-profit organizations cannot operate at a financial loss no matter what their source of income: fees, donations, endowments, etc. In many countries, not-for-profit organizations qualify for favorable tax breaks. The other main difference between for-profit and not-for-profit operations is that the profit generated by not-for-profits is not paid out to shareholders as a dividend, as for-profits are obliged to do, but the profit or margin is used to sustain and grow the organization. Therefore, a not-for-profit organization, or perhaps "not-for-dividend" would be a more accurate description, will be unable to fulfill its mission if it is unable to generate a profit, or a margin.

Therefore, no matter what the size, shape, location, mission, or orientation of large-scale healthcare organization, they are all facing all or a mix of the same problems: Growing and aging populations-this translates to more patients and a growing demand from the same population.

Less money-as demands for better value, quality, and quantity increase for the same or lesser amount of healthcare spending.

More technology-to keep pace with advances in the field of medicine and its administration.

Higher expectations-of a continuingly better-educated consumer in most part due to access to medical information via the Internet.

Increasing competition-especially in more developed societies.

A need to provide new medical services to currently underserved populations.

An insufficient supply of clinicians-both physicians and nurses are in short supply globally.

A more mobile population capable of spreading disease faster than ever before.

Healthcare is an industry that will never lose its client base as long as our race survives and it is one of the most regulated, if not the most regulated, industry in the world. It employs the best-educated workforce in the world and in some cases offers the highest and lowest salaries of any profession.

In short, large-scale healthcare organizations can be as difficult to categorize as we are ourselves and their problems can be as diverse as diseases we can suffer from.

Given the huge range of diversity present in healthcare systems, the only accurate model that can be drawn of large-scale healthcare systems is that of a black box into which people enter as patients and from which they leave, with a wide degree of altered states of being from a clean bill of health to dead.

The Goal of Healthcare

The human race has an insatiable appetite for healthcare. This appetite reaches beyond treatment well into the realms of prevention. It is commonly acknowledged that "prevention is better than cure"-when it can be achieved. Inoculation and healthy living practices improve life expectancy, but thus far rarely in enough numbers to release the clinical capacity to treat all of those who need care. No matter what the mode of delivery, socialized or private, there are still sectors of every population that can benefit from additional professional healthcare globally. Therefore, every large-scale healthcare system needs additional capacity to treat more patients.

Medical technology continues to advance, in many cases, quicker than the delivery system can bring the advances to the patients. The advent of the Internet has given the public unprecedented access to news about new treatments and online diagnostic tools and medical Websites are educating patients far more than ever before. The expectations being placed on the medical profession are the highest they have ever experienced and will be unlikely to decelerate in the near future. The healthcare industry is under tremendous pressure to treat patients better to achieve more effective results than in the past.

In the practice of medicine, time is often of the essence. The need for the immediate treatment of trauma is often well provisioned, but even in the most developed of societies ERs get backed up as the not always predictable ebb and flow of patients present themselves for treatment. In contrast to this, the advances made in early detection, more accurate diagnoses, and more effective treatments of less acute but more long-term, chronic conditions has, in some cases, exponentially increased the numbers of people needing lifelong treatment, support, and medication. With the rise in expectations, there is a reduction in the tolerance of the time people are prepared to wait for a medical consultation. There is a pressing need to treat patients sooner than in the past.

The Internet has also given the public access to healthcare performance data. Through measurement and benchmarking, many areas of medicine today are open to scrutiny by their consumers. Choice, even in some socialized healthcare systems, is fast becoming a perceived right of the healthcare consumer around the world. In some countries, health-care is considered to be a basic human right that carries with it statutory legal rights for the individual.

With good physicians and a high proportion of facilities experiencing increases in demand and with some poorly performing services struggling to attract patients, it is an imperative of healthcare providers to keep improving both now and in the future.

Therefore, the global goal of healthcare is to be able to treat more patients, better, sooner, now and in the future.

What to Change

Where to Start: Government or Facility?

There are many opinions on how healthcare should be funded and who should be responsible for its delivery.

Socialized healthcare has much to commend it as well as to condemn it. The exact same thing can be said of privatized medicine. The only census that can be reasonably reached about the best mechanism for managing the funding and management of healthcare is that there is currently no one best way and each of the methods used thus far appear to fail any given measure of "value for money."

Tackling the problems facing healthcare at the governmental level of any country is a long, laborious procedure that all too often results in unsatisfactory compromises.1 Very few people or organizations work within a sphere of influence large enough to be able to have a meaningful impact on a national or legislative level on the delivery of healthcare. If we, as individuals or organizations, strive to change healthcare from the very top down, through the representatives of our respective governments, we will have a mammoth task on our hands with very little chance of success.

However, those of us working within or consulting with healthcare facilities do have a chance of making a difference. Therefore, we need to recognize the limitations of our sphere of influence and be prepared to work within it.

Unlike industry, healthcare is an industry sector that is, for the most part, prepared to share best practices and ideas and processes for improvement because it recognizes the need, even between competing facilities, to contribute to the common goal of trying to treat more patients, better, sooner, now and in the future. This openness supports the numerous journals and publications covering medical advances and the management of healthcare. Healthcare openly admits its need to improve and it is prepared to consider and share ideas and processes that will help it to improve. However, there are far too many instances when the "silver bullet" for one system or facility is adopted by another facility without fully understanding why it was able to be so successful in the first place. Because of the driving need of healthcare managers and administrators to improve the performance of their facilities, many of them have fallen prey to consultancies and methodologies that: Do not address their core problem and therefore fail to achieve the operational improvements achieved in other facilities.

Fail to yield an effective return on investment.

Are strangely familiar to longer serving staff who claim to have "seen it all before."

Fail to take into consideration the concerns and reservations of the people who are expected to implement the changes.

However, these experiences have failed to quell the intuition of the industry that there must be a better way to manage these systems and produce better results.

That intuition provides the imperative for facilities and systems to continue to seek out, adapt, and adopt new improvement methodologies.

As with all purchases, the caveat needs to be "buyers beware," unless the facility or system is able to prove to itself that it knows what its core problem is, the underlying reason that most (around 70 percent) of its symptoms exist, and that the proposed solution will address them, they will be introducing a fix that will only improve a small proportion of the system and quite possibly an area where improvements will generate more problems in other areas. Some typical examples of these behaviors are: Deciding to improve the ability of an operating room (OR) suite to process more patients in a facility that does not have sufficient ICU staff to take care of the patients postoperatively. This results in unsafe staffing levels and additional staff being called in to work at short notice, at additional expenses to the facility.

Deciding to improve Throughput in the emergency room while ignoring the needs of the discharge process. This in turn results in extended boarding (patients waiting on gurneys) in the department because there are no vacant beds to move them into.

The decision by an entire board to adopt a method to manage waiting lists that proved effective in reducing waiting times in a facility that was operating at 65 percent capacity and in a facility that was already working at 95 percent of its capacity. The result was a very costly program that was unable to deliver the improvements needed because of a lack of capacity, and a group of disgruntled staff who had to find alternate work when the unit downsized.

This propensity to adopt improvement programs with little or no understanding of the systemic effects is not uncommon. However, when systemic improvements that are able to incorporate the differentiated needs of individual facilities are adopted they can produce astounding results; improvements such as increased patient Throughput at levels that far exceed expectations, with little or no increase in resources.

By working at the facility level with the TOC suite of tools, it is possible to differentiate between the core problems of each individual facility, align the staff to be ready to take an active role in systemic improvements and take full advantage of the industry's inherent propensity to spread best practices to other facilities.

The Organic Nature of Healthcare Facilities

Healthcare facilities grow, and sometimes contract, over time in response to local needs and the availability of clinicians.2 As facilities secure the services of medical specialists, their infrastructures develop to accommodate the specialists' and their patients' needs. These needs can also change over time as treatment regimes develop and morph clinical offerings to patients.

A good way to demonstrate the organic nature of large healthcare systems is to view them from above the facilities. Hospitals, even new ones, undergo ongoing physical development with wings, towers, and additional buildings being added to house evolving services. Unlike production plants, few hospitals can afford the luxury of suspending services while these additions or renovations are constructed because of the need to provide around-the-clock care.

The need to work in a constantly changing environment poses problems for the staff and patients alike. As the physical plant of hospitals change over time, their operational systems also need to adapt and change to support the changing mix of clinical specialists and new treatment regimens. All too often the number of changes taking place in a single facility at any one time are too numerous to track effectively. This is especially true in facilities that possess a strong silo management culture; one where the predominant mode of management is departmental, vertical, and hierarchical. This form of management has evolved in most healthcare facilities and it is widely accepted that these organizations are too big to manage systemically.

The Human "Engine of Healthcare"