Hospitals have made themselves so unwieldy as to be virtually unmanageable, yet the technological revolution and the transformation into a global village provide opportunities for alternative managerial paradigms that put the patients – and not the organization structure – at the center.
Throughout the world, the health system is in crisis. The intolerable crowding in hospital wards, the collapse of emergency rooms, the risks faced by anyone who actually needs hospital care, and staff burnout are all symptoms of basic systemic problems.
The illness is managerial. As we approach the end of the first quarter of the 21st century, medical systems are managed according to outdated managerial principles designed at the beginning of the 20th century by the father of mass production, Frederick Taylor. Paradoxically, the dramatic progress in the efficiency of health services in the past century has become the source of the inefficiency of the medical system in this century.
Efficiency and Specialization Have Turned into Root Problems
Increased efficiency of medical centers throughout the 20th century improved the quality of medical services; this contributed to the sharp increase in life span. Concentration of medical services in a large intense capital medical centres allows for efficient use of financial, technological and human professional resources. Management centralized decision making and reduction of employment discretion, which was viewed as a means to improve efficiency in use of resources, led to increased investments in construction, technological equipment, computer systems and personnel; but, in turn, medical centers have turned into complex organizations that are very difficult to manage.
Manufacturing and managerial engineers tried to solve the complication problem with by reducing the organizational structure of hospitals into professional departments (as is done in mass production); the departments gradually turned into fortresses (silos) controlled by department heads who focused inward on increasing the efficiency of their own departments. Their intentions were good, but they didn’t relate to the needs of the system as a whole. By dividing up into units, the organization became complex and clumsy, lost its ability to create systemic improvement and, above all, it no longer served the patient, who usually needs multi-disciplinary care that includes experts from several different departments. Incidentally, academia is going through a similar process.
The change in the medical system in the 21st century is dramatic. Due to the expanded life span, aging population, and growing numbers of the chronically ill (who now make up some 80% of those requiring medical services), the need for medical services is greater than ever before. Even the technological revolution in medicine has changed the character of the care. As a result of these trends, the medical system has changed from complicated into complexed chaotic. Along with the opportunities it presents, the change in the nature of the work environment has proven to be a breeding ground for autoimmune diseases (in which the immune system attacks the body’s own tissues.)
Adopting an integrated computerized, technological system of information without changing the managerial paradigm has made the organizational chaos even more unmanageable and has led to deterioration of the quality of service and personal relationships with patients. And so, we see, it was actually the search for efficiency that made hospitals inefficient and incapable of fulfilling the purpose of their existence.
A Different View of Management is Necessary
There can be no doubt that it is important to improve work processes in the professional units, but that alone will hardly provide effective solutions to the measures of quality, time and patient-experience and safety. Emergency rooms will not be able to provide quality care unless a managerial standard for integrating experts into emergency medicine and maintaining channels of communication and organizational culture of a multi-disciplinary teams is put in place.
Hospitals do not need a prescription to increase their efficiency; they need a change in their understanding of the management of the medical system. The journey towards this change begins with the development of a systemic process, which, first and foremost, must create an integrated staff (Team of Teams) that includes the local teams from inside and outside the medical center (such as community, technology, regulation and public policy).
Integrating Past and Future
Medicine of the past, in which the multidisciplinary doctor (at first, it was the pharmacist) provided integrative medical services in the community, could provide the inspiration for an advanced view of management of today’s medical system. The technological revolution and the transition to the global village create an opportunity for an alternative paradigm in which patients – and not the system – are at the center.
The vision of Lean Healthcare is based on a medical system that resembles a network made up of multi-disciplinary action committees with shared consciousness who engage in an integrated process with the community, representatives of the professional departments, imaging services, laboratories and the pharmacy. The process must be constructed with the patient at its center, in a shared system that decentralizes the authority into Empowered Decision Making, so that each member of the team is authorized to make decisions in real time without waiting for approval from above.
This is also true for the integration of medicine into both the community and medical centers (the macro-level). A hospital intended for complex, time-limited, focused medical procedures will be integrated into the community system, as it was until the 20th century, before the establishment of “factories” for the mass production of medical care (hospitals.) The workers – doctors, nursing, imaging, social work, sanitation and administration – will all be involved across all locations, including patients’ homes, the community, and medical centers. According to this holistic ecological model, medicine is not closed-off in a fortress, but rather is spread out and decentralized, so that it can better-serve the people who live within the community.
Boaz Tamir, ILE.
Watch Zeke Emanuel Keynote on the future of health care: