When Healthcare Solutions Become Problems

When it comes to healthcare, bigger isn't necessarily better -- not even in Texas. In a recent New Yorker article, Dr. Atul Gawande examines the healthcare system of McAllen, TX, also known as one of the most expensive places in American healthcare. Despite the latest and greatest technologies and facilities, McAllen's five largest hospitals still rank below average on 23 of Medicare's 25 metrics for quality and care.

Gawande's article reveals the fatal flaw of our failed healthcare system: cost. The cost of healthcare is a big problem -- but not a new one. Since my graduation from medical school 40 years ago, healthcare cost has been a big problem that generated many big solutions.

But we have failed to solve the cost problem and now the stakes are higher. As President Obama recently noted, "The biggest threat to our nation's balance sheet is the skyrocketing cost of healthcare."

Einstein said: "You can't solve the problems of the present with the solutions that produced them." Could our solutions be part of the problem?

As a physician, healthcare executive, management scholar, author, advisor and, most importantly, a patient deeply immersed in the healthcare system, I have watched us repeat -- and fail with -- the same scenario, over and over again.

Start with a big problem. Then collect and analyze the data, consult the experts, and have lots of meetings to analyze, plan and predict. Finally, design and implement a big solution.

Data up, implement down, we literally think our way into a new way of acting. Here are some of the "solutions" I have experienced. Sound familiar?

• Managed care
• Payment reform (e.g., HMO's, capitation, higher deductibles and co-pays, Medical Savings Accounts, etc., now it's single-payer or something else)
• Computers and technology
• More regulation and better compliance
• Manage hospitals, doctors and nurses more efficiently
• Mergers, acquisitions, consolidation, cost cutting and downsizing
• Care rationing

These "solutions" are built into our current cost problem and more of the same simply won't solve it.

Building on the example of the Texan town, in his article Gawande identifies the direction a true transformation in healthcare might take. In comparison to McAllen, other localities (Grand Junction, CO) or organizations (like Mayo Clinic, Geisinger Clinic or Kaiser Permanente) provide high quality care at a much lower cost. He notes that when these high quality/low cost systems started, they all had a focus on, and were accountable to, the patient. He recommends we support leaders creating a new generation of organizations focused on the patient.

I couldn't agree more; that is exactly what to do. Now the question is how? The answer is well studied and not complicated, just different from what we are currently doing. We must act our way to a new of thinking. We can't design and implement transformations with big problem solutions. We must make the transformation with many small solutions.

Transformations follow a predictable course: a small number of leaders steadily adapt their organizations to deliver what the rest cannot. Harvard Professor Clayton Christensen's model of disruptive innovation tells that story over and over again. Toyota did not design and implement the Toyota Production System or the downfall of GM; they made it. Southwest Airlines did not design and implement the world's most profitable airline; they made it. And those are just two of hundreds of examples.

Healthcare transformation begins with those few organizations strategically and operationally "designed to adapt." They gain incredible competitive advantage in a rapidly changing world by following the methods that create great, transformational innovations. Here is how it works:

• Leadership sets a clear, simple, consistent, patient-focused course.
• Develop people as the number one resource.
• Rapidly problem solve as part of everyone's everyday work.
• Build trust, optimism, local knowledge and ingenuity to turbo charge success.
• Repeat and spread success opportunistically and relentlessly.

The process is called adaptive design. As reflected in my upcoming book, Designed to Adapt: Leading Healthcare in Challenging Times, this cycle has been tested and validated many times in healthcare. Consider this example of how "acting your way to a new way of thinking" improved patient satisfaction and quality, while decreasing costs:

A 45-bed medical surgical unit in a Midwest hospital focused on adaptive, real-time problem solving of patient needs for 13 months. The results: this unit had the greatest increase in patient satisfaction in a 17-hospital system. At the same time they increased staff productivity 14 percent, decreased length-of-stay by 8 percent, decreased staff turnover by 51 percent and saved $1.7 million.

The transformation of healthcare starts and ends with the patient. The answer is simple but not easy because of our top-down, big solution habits and expectations. We can't think our way to a new way of acting; we must act our way to a new way of thinking. That is the way we are going to get patients exactly what they need at continually lower cost, and in so doing -- start to fix healthcare.

Dr. John Kenagy is a former Visiting Scholar at Harvard Business School and the author of the forthcoming book Designed to Adapt: Leading Healthcare in Challenging Times (Second River Healthcare Press, 2009).

Comments

[jackybird]

I also found this post in a round about way. It has a lot of insights about how to improve care as well as control down costs. I'm going to have to read it again as well as Dr. Gawande's article in order to fully understand it.

However, the related question of how to pay for health care is unadressed. I don't want to fault you for not covering every related issue, but this is a really pressing one for a lot of average people including me and, apparently, billyfromphilly.

For twenty years I purchased individual polies from private insurance companies. Last August, Aetna raised my premiums to $960 a month for a single adult. This forced me to go without health insurance for the first time in my life. I was very healthy during those years and the insurance companies must have profited very heavily off of me. Now, that I am priced out of the insurance market, I am as vulverable as I can be.

[billyfromphilly]

patient focused.... adaptive real time problem solving.... They're just buzzwords. For middle class people like myself who are getting slammed with medical bills, they mean absolutely nothing.

[John Kenagy - Huffpost Blogger]

I appreciate that "buzzwords" seems a logical response because we live and work in a sea of buzzwords, particularly in health care.

Hence my work drops underneath verbiage and starts with getting the patient exactly what they need at continually lower cost in reality.

It's not thinking and talking, its doing that makes the difference. We have to act our way to a new way of thinking - and that is what everyone being slammed by skyrocketing costs needs to see happen to fix health care.

[cktirumalai]

Medicine focussed on the patient is certainly a good idea. If patients help the system work as well as it can by doing their part, taking care of themselves to the best of their ability, and when sick enabling doctors and nurses to get them well as soon as possible, it would be even better.
Patients respond well to doctors who combine knowledge with empathy and are not merely out to make a lucrative living. Both would do well to remember that they they have responsibilities as citizens, one of which is not to squander money.

[John Kenagy - Huffpost Blogger]

I agree. and recreating a true partnership, a healing relationship, between caregiver and patient is fundamental to health care reform. You can't implement that top-down, that's why we start with the patient and work back to design the system to meet patient needs.

[blood1]

HuffPo...thanks for getting this article onto your site....but it needs to be on the FRONT PAGE.

For the record, I learned of this article at one of the past Saturdays Democratic Symposiums that was for physicians (which I am not), but the other participants did not kick me out!

[John Kenagy - Huffpost Blogger]

Thanks. I am glad you found it! there is more to come