Over the years, industry has been able to automate many processes and, in doing so, increase the accuracy and therefore the constancy and quality of the products it produces. We can now enjoy the exact same products on every continent of the world safe in the knowledge that they will not vary in quality.

While many of the support services utilized within healthcare have benefitted from, and will continue to benefit from, advancing technology, the interaction between a patient and a physician is one area of healthcare where it will not be possible to replace with automated services.

Telemedicine and remote consultations have their place, but these are compromise solutions to provide patients and their caregivers access to a wider community of clinicians. These technological advances are not a substitute for face-to-face consultations that can provide the clinician with a much greater depth of understanding of the patient's condition and therefore their subsequent diagnosis and treatment needs.

Many attempts have been made to standardize the processes that form the interaction between a patient and clinician and while the outcomes of these interactions can share a commonality, the route through different levels of understanding and modes of communication are rarely the same from patient to patient.

The need for effective clinician/patient communication is gaining recognition with medical and nursing schools to the extent that many, if not all, now provide training in patient/clinician communication. In some schools, these programs carry a required pass mark for progression to qualification.

These programs offer evidence of healthcare systems' reliance on the people working within it to provide the people working with patients, and each other, effective means of communication and the ability to adapt the required communication to a form that will contribute to the most effective clinical outcomes.

In short, successful outcomes associated with healthcare improvement initiatives are much more likely to occur when the "process units" (people responsible for delivering the service) are able to recognize, understand, and resolve relatively simple local problems through the use of standardized critical thinking processes, communication skills, and working practices.

By teaching the staff how to resolve problems effectively and by providing them with commonly understood management taxonomy and subsequent language that can be used on larger, systemic problems, it is possible to achieve greater success than the application of systemic solutions to standardize or improve operational process alone.

The Constantly Evolving Workforce

Being so people-dependent, healthcare has the never-ending task of providing service with a constantly evolving and changing workforce. It is a profession with clearly defined career paths and it has a culture of life-long learning. As additional patient needs are recognized, the necessary scope and depth of learning keeps growing. It is the ability to keep learning that underlies the adaptive nature of healthcare givers and provides the service with its greatest strength.

No matter what the configuration of a hospital, the people working within it can very quickly change the services conducted within its physical confines to meet the needs of their patients. Although this happens unnoticed each day in each facility, this adaptive behavior is most evident in times of large-scale disasters; a facility designed to treat patients with long-term chronic conditions can be transformed into a triage center for victims; a unit designated to treat children can provide care for adults; a dental hospital can house wounded military personnel. The function of a facility is more dependent on the skills of the people working within it than the physical plant in which they work.

In addition, the ability of staff to adapt to meet the challenges of prevailing circumstances provides the biggest managerial challenge in healthcare today.

As large-scale healthcare systems prepare to treat more patients, better, sooner, now and in the future, they face the task of aligning a workforce that possesses a very wide range of evolving clinical and interpersonal skills to move their organizations forward.

The Reality of Healthcare

In management terms, healthcare is a blend of two types of project management; that of individual patients being "processed" through the system-each patient can be classified as a project because rarely are concurrent patients' treatment needs identical-and that of operational improvement projects, such as the introduction of electronic patient records, reducing patient waiting times, etc.

The effect of any improvement initiatives, on both of the project management based work streams, should be to generate an overall increase in effectiveness to achieve one or ideally more of the following objectives: Generate more income, which will provide a facility with more resources to enable it to Take care of more patients.

Offer improved services.

Reduce patients' waiting times.

Continually improve.

When people who spend the majority of their time involved with direct patient care are charged with tasks from the operational improvement projects, they are often being asked to perform what can loosely be described as "extracurricular" activities as often they have to carve time out of their patient care commitments to perform them. When individuals are charged with participating in both types of "project," they are often placed under tremendous pressure. They feel a loyalty to their patients at the same time as recognizing the need to improve the system that will eventually help them to deliver better or quicker services to their future patients.

Unlike the production environment, the service sector is far more dependent on the people to deliver the desired outcomes needed to succeed. In services like banking, insurance, leisure, and the like, it is possible to standardize many of the processes along the lines of a production environment, a trait that many departments in healthcare facilities mimic. However, the resulting finished "product" is, say, an insurance policy or a vacation; there are inherent mechanisms that can be tweaked or adjusted to meet the consumers' needs. However, in healthcare the finished product is far less predictable and the producers are far less able to gauge the effectiveness of their efforts as they are often as dependent on the emotive and experiential issues of their patients' care episode as the science and technology used to satisfy the health needs of their "clients." It is this human element of both the "production units" and the "raw material" that introduces huge amounts of potential variation into the management of healthcare and which generate core problems3 that can be difficult to predict and even more difficult to generalize without the use of effective analytical tools.

In order to understand fully the generic core problem of healthcare as an industry, it is necessary to dig deep enough to find a common cause that will take into account all of the wide range of variations presented by a service that delivers very personal care to people.

The core problem of healthcare has to encompass fully the problems experienced by the people as well as the operational processes used within the system.

To verify this statement, one only has to look at the improvement programs that are adopted by seemingly homogonous large-scale healthcare systems represented by countrywide socialized systems.

It is common for overarching socialized healthcare management entities to insist upon the adoption of certain management practices that have brought benefits to a few of their facilities, often through pilot projects.

What these projects almost inevitably overlook is the real current core problem of each facility4 and in doing so assumes that because project X worked so well on one facility, its repetition will yield the same results in all of their locations.

What is not established before these projects are initiated is the core problem of each facility and whether the proposed project will eliminate the core problem by rectifying the underlying conflict, or if it will only address lesser problems and symptoms (undesirable effects) being generated by the conflict.

Current Problem Solving Techniques

"Not everything that can be counted counts and not everything that counts can be counted."

-Albert Einstein Many healthcare facilities operate a variety of programs to try to gather and address the problems or undesirable effects5 (UDEs) the staff and patients experience, but few, if any, are able to effectively conclude this process to the satisfaction of all involved.

Often raising negatives in the form of problems to line managers can be done, but all too often the response from management takes the form of a survey or numeric analysis of data that attempts to quantify the extent of the raised problem and which often leaves the apparently lower ranking problems untouched in the subsequent improvement attempts.

What is often not recognized during these exercises is the degree of impact that some behavioral problems can have on a system. Even if such problems are raised, they are often accepted as being a "fact of life" that has to be tolerated rather than addressed.

Many facilities investigate "adverse events" and treatment effectiveness through the application of a form of cause-and-effect analysis, from which frequently operational changes are implemented based on the findings. This practice is inherent throughout healthcare, in both the medical and operations management fields. These analyses are often the basis of best practice models that are fast becoming the measurements for clinician performance and payment structures. However, the cause-and-effect analyses are all too often only used to analyze exceptional or isolated events and often fail to dig deeply enough to include otherwise unreported negative effects from such incidents-they fail to unearth the deepest root cause of the problem, as pictured in Fig. 32-1.

In addition to this, some facilities even lack an effective way to raise negatives. Some facilities possess cultures that place expectation on their staff to figure out solutions at a local level. Again, these solutions are far removed from the source of the problem.

These modes of problem solving result in the building of operational barriers between departments that serve to further isolate departments into operational silos and discourage systemic cooperation.

Adapting Industry's Solutions for Healthcare

In an effort to try to rationalize the delivery of healthcare, many providers are turning to industry for improvement models. They often view the variation they experience as being a problem that needs to be eradicated, using tools such as Six Sigma and Lean. In some cases, the use of these tools are wholly appropriate if the core problem of a facility is a type of constraint that can be effectively addressed using these tools and will contribute to the goal of enabling facilities to treat more patients, better, sooner, both now and in the future. However, if the use of a particular management tool is one that violates any of the conditions of the goal or if it demands a compromise solution, then it is not the tool the facility needs to use to improve systemically.

Given that healthcare is overwhelmingly people-driven, the majority of the problems that demand the attention of the staff are those generated by the interactions between people. This "noise" has to be greatly reduced before the people working in the system can begin to recognize and be confident enough to address the operational issues that need to be fixed. Until this is achieved, "people will be people" and they will revert to old ways of working of protectionism, watching their backs, and apportioning blame. To reduce the "interpersonal noise" of a system, it is necessary to diagnose why this noise is being generated.

FIGURE 32-1 Using TOC Logic Tools ( E. M. Goldratt used by permission, all rights reserved. Source: E. M. Goldratt 1999. Viewer Notebook 137.) Much as a physician uses the presenting symptoms of a patient to make a diagnosis, what is needed to find the core problem of a facility is a rigorous cause-and-effect analysis of the symptoms from which the system is suffering. The symptoms of a system are the UDEs being experienced by the people within the system.

Often the analysis of numerical data will not reveal behavioral symptoms; rather, it will provide a measure of the outcome of the effect of a combination of symptoms, whereas a collection of UDEs in a verbalized form offers insights into behavioral and operational issues that, analyzed with rigorous cause-and-effect methodologies, can be used to expose the core problem that causes them to exist.

To collect sufficient verbalized UDEs to be able to deduce the core problem of a facility, there needs to be a safe environment for the people suffering from the UDEs to voice their concerns. They need guidelines to help them give accurate descriptions of the UDEs, ones that do not place blame onto colleagues, but rather give a clear description of the result of errant actions and processes, and which will not result in future recriminations.

Once a safe platform has been established, it is necessary to make sure that the concerns being raised are addressed in an effective manner.

If both a safe platform and an effective mechanism were in place to understand and address systemic negatives, then far less "interpersonal noise" and fewer operational problems would exist. Therefore, the underlying core problem of healthcare facilities is the lack of platform and mechanism by which negatives can be effectively raised and addressed (Wright and King, 2006).

Both a platform and a mechanism are needed because a platform without an effective mechanism to identify and rectify the causes of the UDEs will be ineffective, as is a mechanism that does not address the majority of negatives at a systemic level.

If both an effective platform and mechanism were present in a facility, the UDEs or symptoms being experienced would be of minimal concern and the facility would be able to improve with the following results: A minimum amount of disruption to patient care.

A cooperative workforce.

The facility working at optimum capacity, generating or securing the maximum possible income.

Clinical staff would be able to devote almost all of their workday to the treatment of patients.

Administrative services would be subordinate to clinical services, causing minimal disruption and waiting times for patient/clinician interaction.

A greatly reduced need for clinicians to participate in administrative improvement programs.

What to Change to

Where Should the Constraint Reside in Healthcare?

In an ideal healthcare system, there would be nothing to stop the constrained resource of clinicians from maximizing the time they spend with patients. In fact, the clinicians need to be the constraint.

This constraint will never be broken until there is enough clinical capacity to treat all of the community's patients, with the best available methods, as soon as they need it.

If a facility does have sufficient clinical staff, the constraint needs to be the recovery rate of the patients. Under these circumstances, the only factor that should impede a patient's progress through the caregivers' services should be the patient's ability to heal or recover, with no system or clinician imposed wait times.

These ambitious constraints are far from being onerous; they are the constraints health-care providers and their managers should be striving to establish within their individual facilities.

However, before these ambitious targets can be reached, it is necessary to address the underlying core problem.

Starting an Organization on a Process of Ongoing Improvement

In healthcare, the deepest problem of a lack of platform and mechanism by which negatives can be effectively raised and addressed is easier to understand in the form of the personal conflict or dilemma being experienced by the people who suffer from it. They are caught in the personal dilemma described in the following Evaporating Cloud6 in Fig. 32-2.

This Cloud reads: In order to [A] treat more patients better, sooner, now and in the future, I need to [B] contribute my expertise to the improvement of our facility; and in order to [B] contribute my expertise to the improvement of our facility, I want [D] to raise reservations about proposed changes.

On the other hand, in order to [A] treat more patients better, sooner, now and in the future, I need [C] not to waste my time (use my time as productively as possible) and in order to [C] use my time as productively as possible, I [D'] don't want to raise reservations about proposed changes.

FIGURE 32-2 Contributing expertise.

Obviously, D and D' are in direct conflict, a simple "do or don't do" dilemma.

Some of the assumptions behind some of the arrows of this cloud are as in Table 32-1.

Because this dilemma is so prevalent in healthcare, the people working in it are often unable to prioritize effectively between the demands on their time and they resolve this perpetual dilemma by accepting an ever-increasing administrative workload. This is a practice that, as it becomes more and more common among the workforce, is accepted as being a fact of life in healthcare.

As people feel obligated to accept this fact of life, they try to complete all of the work expected of them and are frequently forced into accepting a compromise solution by working more hours, and taking on more unrecognized and often unpaid tasks and responsibilities than they are contracted for, all too regularly to the detriment of their personal lives.

Conversely, the people who refuse to be put upon are often thought of as being obstructive and uncooperative.

In either case, the inability or unwillingness of these people to raise objections to the proposed change or to suggest alternate solutions is prevalent, and without the ability to resolve this dilemma in a way that does not compromise the essential needs of both B and C, it is not possible to effectively achieve the goal of healthcare to treat more patients, better, sooner, now and in the future.

TABLE 32-1 Assumptions for Raising or Not Raising Reservations about Proposed Change Initiative This dilemma is generated by the fact that staff is often unable to resolve many of the problems generated by any or a combination of the following: Interpersonal conflicts Conflicting schedules Insufficient resources Ineffective operational processes Erroneous policies These problems exist because of the deeper underlying problem of a lack of platform and mechanism by which negatives can be effectively raised and addressed.

Providing a Safe Platform and an Effective Mechanism