Integrating medical and operational management.

Health care is unique among industries in that nowhere else do people's lives depend so closely on how work is performed. Yet in the face of cost containment challenges, many health care organizations are reducing costs using methods that fundamentally change the way care is delivered. Physician executives must ask: Are our health care organizations being restructured to improve quality of care in a fiscally-responsible manner? Or, in a rush to find a quick solution to economic challenges, are we simply following the latest trends in cost reduction - trends that were developed outside of the health care environment? Are staffing changes being made with sensible protocols that give due consideration to quality?

If some of us are uncomfortable with the answers to these questions, we must take action. Physician executives in senior leadership positions, who have decided (or been elected) to pilot a work redesign process, have a responsibility to choose a redesign protocol wisely and lead it well. Medical leaders who do not now have direct authority over their organizations, redesign processes should consider taking on greater involvement and leadership responsibilities. Many physician executives are reluctant to do so for many reasons, not the least of which is perceived lack of experience. However, you may have more experience with managing change than you think.

Being a change leader essentially means guiding a complex system through a difficult and emotionally-challenging process of transformation. This process entails recognizing a threatening situation, diagnosing the scope of the problem, and taking action that will help the system to a better state of being. Sound familiar? It should. In fact, any physician who has guided a patient through the healing process has been a change leader. So who better to lead health care organizations through a work redesign process than the physician executive? The medical leadership role demands an ability to balance dedication to clinical standards with fiscal responsibility and acumen. This skill set makes physician executives uniquely suited to manage work redesign in the clinical environment. Indeed, as managed care continues to force the close integration of the business and clinical aspects of health care, physician executives will have a greater duty to ensure that the work of health care is performed in a cost effective and clinically sound manner.

In our work with more than 400 health care organizations, we have collaborated with physician executives and other clinical leaders to develop protocols for change that marry the requirements for work redesign in the clinical environment with the operational management skills of clinical leaders. For physician executives who are considering a change process, the following are some strategies for successfully acting on the leadership opportunities provided by work redesign.

Evaluate the options and invest in

your organization

There is a dizzying array of consulting firms, processes, products, and technology, that claim to help you manage change. And if your organization is like most, you will need to create an action plan rapidly. Fortunately, physician executives have an advantage in this kind of situation. Not only do physician executives possess quick decision-making and critical-thinking skills, their experience has taught them the importance of self-driven and self-regulated change.

We know that no patient will change his or her behavior because of external influence - at least not for long. Like a patient, an organization must build a long-term, internally-driven capacity to manage its behavior. That is not to say that your organization won't need help, because it probably will. Therefore, seek out those options and partners in change that will strengthen and support your organization's own efforts.

Once you have narrowed your search, you will want to evaluate the benefits and limitations of various methods of change. If the goal of the change process is to provide excellent care in a fiscally-responsible manner, the criteria for selecting a work redesign protocol should be its effect on patient care and its ability to generate sustainable cost savings.

Across-the-board downsizing 

Organizations facing declining reimbursement may be considering across-the-board downsizing, a baste and aggressive approach to cost reduction imperatives, in which a certain number of staff positions are eliminated to conform to internal budget forecasts or externally-imposed standards of "efficiency."

While a certain amount of workforce realignment is necessary for any change process, how that realignment is effected is of critical importance. The problem with across-the-board downsizing is that it focuses on the numbers of bodies doing the work and not on the work itself. Its aftermath is that 100 percent of the work is left for 97 percent or percent of the workers. Indiscriminate downsizing leaves fewer overburdened employees to deal with the same cumbersome system, reducing the net time available to care for the patient (with potentially dangerous results). Several years ago, we conducted a study on the effects of work force reductions on patient care. Specifically, we analyzed the relationship between various types of downsizing and the probability of increased mortality and morbidity. Hospitals that reduced their FTEs by as little as 4 percent through across-the-board layoffs saw a significant likelihood of increased mortality. Hospitals that undertook dramatic cost-cutting - more than 7.5 percent - were more than 400 percent more likely to see an increase in mortality.(1)

Ironically, this socalled cost-cutting strategy was not even useful for long-term cost reduction. To offset clinical quality problems, management turnover, staff burnout, and patient dissatisfaction, many of the organizations that used this model were pressured to rehire staff, negating any cost savings they achieved in the short term.

Of course, downsizing happens. Regrettably, layoffs are sometimes necessary to save an organization from impending financial ruin. When they happen, health care organizations have a responsibility to safeguard patient care by conforming to new staffing realities through work redesign.

New paradigms 

Recognizing the obvious dangers of across-the-board downsizing, the industry has offered new paradigms for cost reduction and quality improvement. Among these are patient-focused care, multi-skilled workers, and replacing professional caregivers with unlicensed assistive personnel. Aside from the obvious problems these strategies may raise for health care professional advocacy groups, these paradigms require that unique organizations adapt to a generic patient care model. In many cases, these models have not yet been rigorously tested or proven effective. The major failing of these programs is implementing a solution without a thorough diagnosis of the problem.

The clinical model of change

Earlier, we compared the relationship between a change leader and his or her organization to the physician/ patient relationship. We can draw that parallel because we recognize a health care organization as a complex living system that needs diagnosis, treatment, and evaluation to promote its immediate healing and long-term wellness.

Figure 1 demonstrates a clinical care model of organizational change. This model has long been used by physicians to manage the health of individuals, and is now being used successfully to manage the health of health care systems. The first phase involves diagnosis of an organization's problems and recognition and communication of the need for change. The second phase, intervention, includes retooling the organization for change and taking action. The third and final phase includes evaluating progress and continuously improving. Strategies for implementing each of these phases follow.

Communicate the need for change

Just as the best physicians educate and involve their patients in the process of healing, so too must change leaders involve their organizations fully in decisions regarding work redesign. Primarily, they must recognize the emotional and psychological effects of change and respond to them proactively. In a redesigned organization, some jobs will be eliminated and many employees, roles will be fundamentally changed. This knowledge can cause resistance and anxiety among the very people who need to support and implement the process. Leadership has two defenses against resistance: total commitment and tireless communication.

No change process will relieve leadership of its responsibility to lead. Successful work redesign is driven by executives who can serve as role models through mature and committed behavior. The cornerstone of an organization's success in work redesign is leadership's visible demonstration of its commitment to improving patient care - and it is also the platform for successful communication. Communicating that change is in the best interests of the patient and the organization will promote staff commitment to the process, rather than feed feelings of entitlement.

Conduct a diagnostic evaluation 

The field of medicine has benefited from a long and grand tradition of scientific inquiry. The field of management, however, has had a slightly softer focus. As a result, clinicians have up-to-the-minute diagnostic tools, while managers generally do not. We know that operating on a brain tumor without a CT-scan would be foolish and irresponsible, yet there are health care leaders who adopt new health care delivery models without empirical understanding and evidence of what was wrong (or right) with the old one. Therefore, just as physicians must do a thorough assessment of their patients before beginning treatment, today,s leaders need to undertake a thorough diagnosis of their current operations before taking action to change them.

A diagnosis of operations should include a "scan" or "image" of an organization's structures and processes - the way it performs work. Therefore, an organization should adopt or develop a formal work assessment tool that analyzes the effectiveness of work at every level. There are many methods for analyzing work, but we recommend the following components for any effective work assessment tool:

* A standard list of processes or activities to be analyzed across the organization, categorized into groups that facilitate work redesign decision-making (i.e. patient care versus support; licensed versus unlicensed activities; external customer service versus internal customer service processes; or whatever categories are appropriate for your culture.)

* A method for capturing the variables that affect work patterns, such as shift, job role, or department.

* A simple data collection methodology.

* Wherever possible, a method for analyzing the costs associated with various types of work.

Many of us have been involved in traditional time and motion studies that include some of these components. However, those systems usually rely on external observers to analyze selected processes in targeted areas. Your organization will want to gather as comprehensive and as accurate a sample of work data as possible. This means involving the real experts on the organization's work - every employee and manager, if possible - in collecting work data throughout the organization.

While a large undertaking, this process yields a wealth of information. Not only is this data valuable for outcomes research, it builds on the organization,s investment in self-directed work redesign. By actively soliciting the input of all workers, the organization enhances staff readiness for change through increased involvement and awareness. Additionally, statistical analysis of the resulting data will help leaders identify the nature and scope of problems in the design of the organization's work. And, defining a problem is the first step to solving it.

The nature of inefficiency

To better understand the value of empirical diagnosis, let us briefly examine the results of a study conducted using the work analysis process described earlier.

Research design

Conducted to identify trends in health care work patterns that might explain inefficiency, the study analyzed the job role activity profiles of 17,472 direct patient care RNs, 16,528 licensed/registered health care professionals (including pharmacists, respiratory, physical, and other therapists, and various types of technologists), and 18,086 support staff (including unit clerks, secretaries, housekeepers, patient care assistants, etc.), representing 148 different hospitals. In addition to these work pattern variables, the study included indicators of quality from patient, physician, and employee surveys. Among these variables were quality of care (patients, perceptions of the quality they received from a participating hospital) and quality of worker life (employees, perceptions of their job satisfaction, a measure of stress). The study also included standard financial data, such as cost-per-case and operating margin.

A preliminary examination of the data led us to the hypothesis that three concepts defined measurable, and thus "fixable," problems in the design of health care work. They are:

* Complexity - the scope and variation of a role or process. It is quantified by the number of activities performed by a particular job role (role complexity) or the number of employees involved in a process (process complexity).

* Focus loss - the extent to which resources are used inappropriately. It is a measure of the percentage of time and labor dollars a work structure (organization, department, or role) expends on activities inconsistent with its primary function.

* Overlap - a measure of duplication of effort. It can be quantified by calculating the percentage of time spent by different roles on the same activities.

Findings

Based on these operational definitions, we measured complexity, focus loss, and overlap, and found them present to a significant degree in all participating hospitals - although some demonstrated much higher levels than others. (Please see Figure 2.) On average, we found the roles of health care employees to be somewhat complex - the typical health care employee performs 33 different activities (as defined by the standard list of 200 activities or work processes used in collecting the data). However, the research found substantial variation between the complexity of professional and non-professional roles. For example, the role of a Registered Nurse includes more than 74 different activities, while other licensed/registered professionals perform more than 43 distinct activities. By contrast, support workers perform an average of 21 different activities.

The study also revealed a powerful connection between role complexity and loss of focus (an increase in the number of an employee's work activities causes a corresponding decrease in his or her ability to spend time on important activities, such as patient care). The average health care employee was unable to focus more than 60 percent of his/her time on core job responsibilities. (Approximately 9 percent of employees' time is spent on such universal and inescapable activities as handwashing, breaks, and uniform changes). However, further research revealed that this situation is even grimmer for nurses and other professionals. The work profile of most non-professional roles included a well-defined set of responsibilities, but these tasks were mainly support activities that provided few direct benefits to the patient. On the other hand, the design of professional caregiver roles was much broader in scope, with only some activities related to patient care.

Figure 2 Role complexity, overlap, and focus

Average Organization - Wide Focus 44% (percentage of labor dollars spent on mission specific activities related to patient care.)

Average Role Complexity 33 activities per role

RN Role Complexity 74 activities per role

Other Professional Role Complexity 43 activities per role

Support Role Complexity 21 activities per role

Average Role Overlap 41% (Percentage of time spent by professionals and non-professionals on shared work.)

Average Role Focus 60% (Percentage of time spent by professionals and non-professionals on shared work.)

RN Role Focus 49%

Other Professional Role Focus 54%

Support Role Focus 87%

The study also identified role overlap, a situation where identical work is performed by differently-skilled employees at widely varying costs. For example, professionals and non-professionals spend 41 percent of their time on shared work activities. Support activities comprise most, but not all, of this shared work. These results suggest that professionals often do work that non-professionals are equally capable of performing, and that, in some cases, support staff perform work that is inappropriate to their level of training and preparation.

Role overlap increases confusion about the appropriate mix of professional versus support staff and makes it difficult to put the right employee in the right job at the right cost. This overlap between professionals and non-professionals also signals a lack of clear accountability for specific activities and leaves the patient care delivery system susceptible to duplicated effort and missed hand-offs.

What is the overall impact of this overlap? The average health care organization in the sample spent less than 44 percent of its labor dollars on its mission - work related to direct patient care. Additional statistical analysis showed that ineffective role design - as measured by role complexity, overlap, and loss of focus - was highly correlated with decreased quality of patient care, decreased operating margins, decreased efficiency of such key patient service processes as scheduling, transportation, and patient care documentation, and increased personal stress for workers, at both the professional and non-professional level.

Good news?

These findings raise serious questions about the design of work in health care. What's the good news?

First, the study identified some operational definitions of ineffective work design - complexity, focus loss, and overlap. And because these concepts are measurable, they become actionable. (Note, however, that these results do not support the indiscriminate or widespread replacement of professional staff with unlicensed workers. Rather, these results support analyzing work in the context of what is best for the patient, and then matching people to purpose.)

Second, a follow-up study showed that organizations that took action on complexity, focus loss, and overlap in key job roles experienced improvements in cost-per-case, operating margin, and indicators of quality and,satisfaction.

Third, and perhaps most importantly, the study found that reduced quality of care, employee stress, and increased operating costs were all correlated to complexity, focus loss, and overlap. Previously, many leaders had reason to dread cost reduction challenges, believing that no single intervention would be able to balance the needs of patients, employees, and the bottom line. This study challenges that notion, suggesting that high quality, low costs, and employee satisfaction are all related to how work is designed at the role and process levels.

Treat inefficiency

through work redesign

Complexity, focus loss, and overlap threaten the quality of patient care by scattering the energy of professional caregivers and the resources of the organization. Successful work redesign means reducing the complexity, focus loss, and overlap that impair the efficiency of health care workers. Effective change leaders recommend pursuing work redesign on three concurrent tracks:

I. Individual manager action

"Think globally, act locally" is a phrase that applies to work redesign, as well as environmental conservation. To produce global changes in an organization's work patterns, each department or work area must act to change its own work profile. Therefore, each manager should be given the responsibility to redesign work in his or her department. By sharing the responsibility for change with managers, leadership exponentially increases the organization's potential for success.

Along with this responsibility come certain rights, however. This means that all managers must be taught the critical concepts and skills needed to redesign work, if they are expected to do so with any measure of success. This is a large undertaking, but one that will create a team of internal work redesign consultants who can sustain the organization's investment in continuous improvement. Additionally, when leadership establishes an expectation that the job of managers is to manage and redesign work, this clarifies their role and reinforces the importance of their contribution to the organization.

2. An infrastructure

for role redesign

Too often, the design of work is perceived to be only a department-specific rather than organization-wide concern. However, since the aim of a redesign process is to help the organization better fulfill its mission, there should be a methodology for monitoring the design of work on a cross-functional level. The second level of work redesign is the formation of a steering committee that establishes an infrastructure for role design across the organization. The purpose of the cross functional team is to establish patient-centered objectives for work redistribution and to provide support and guidance to individual managers. Because the work of the steering committee involves redesigning roles, many of which are in the clinical setting, it is a highly appropriate place for medical leadership.

3. Cross-functional

process improvement teams

The third leg of a successful work redesign venture is process improvement - streamlining a few key processes that impact large segments of the organization. Process improvements have primary and secondary benefits. First, process improvements can reduce operating costs and increase the satisfaction of both customers and suppliers of the process. Secondly, process simplification lightens the workload of employees involved in the process, increasing their ability to focus on their core functions.

These three tracks of work redesign act in synergy to create a cycle of effective work on all levels. Of course, when so many teams and managers are acting concurrently, there is the potential for chaos. Leadership should use a formal tracking system to monitor and guide the actions of all groups. To reduce the possibility of confusion, the same tracking mechanism should be used with both managers and cross-functional teams.

Evaluation

Evaluation is a vital component of change. Unless we know what we have accomplished, we will not know what else to do, or we may not have the enthusiasm to do it.

Following the clinical model of change, successful leaders advise using the same tools to evaluate progress as those used in the initial diagnosis. Just as a test may be used to diagnose a disease, that same test will be used to evaluate the efficacy of treatment. In this way, continuous evaluation breeds continuous improvement.

Like a patient, each health care organization will face many situations that will require diagnosis, treatment, and evaluation to ensure ongoing health. The process we have described shows how physician executives can apply their clinical background to work redesign and, in so doing, meet the challenges of continuous change.