So doctors are being forced to follow rules laid down by insurance companies to guarantee reimbursement and avoid malpractice suits. Given the complex regulations and paperwork, the risks to practice, and rising costs of malpractice insurance, they’ve been drawn to the protection of large groups and hospitals and pushed into an industrial-bureaucratic mode of production.
But physicians become unhappy employees in bureaucracies or in “focused factories” that specialize in a particular type of treatment. Instead of being independent physicians, they become “providers” or else managers more engaged in monitoring than in mentoring colleagues who will themselves be measured on business profitability.
To be sure, useful learnings from industry, particularly total quality management, have been used to achieve dramatic results in hospitals, reducing variability in practice and supply management and improving quality of care. Notable examples are SSM Health Care, with twenty-three Midwest facilities, led by Sister Mary Jean Ryan; and the Pittsburgh Regional Healthcare Initiative led by Paul O’Neill, the former treasury secretary and Alcoa CEO.15 Dr. Kenneth W. Kizer, led a remarkable transformation of the Veterans Administration (VA) healthcare system—comprising 172 hospitals, 600 ambulatory care and community-based outpatient clinics, 131 nursing homes, 40 residential care facilities, and 206 counseling centers. In all these cases, it was great leadership, not government laws or regulation, that produced the results. 16 The methods have been proven, but lots more leadership is needed to get physicians to collaborate with nurses and administrators. 17
Statistical process control and informatics have proved powerful tools to improve outcomes by constructing clinical pathways of best practice. When these are used by physicians at hospitals like LDS in Salt Lake City and Rady Children’s Hospital in San Diego, the cost of treating certain conditions can be cut in half. But within these hospital bureaucracies, many physicians resist any further limitation of their freedom to make medical decisions on their own.
THE IDENTITY OF DOCTORS
Resistance to change is rooted in the typical physician personality type and the professional socialization that molds this personality to fit the traditional medical mode of production. Based on interviews and questionnaires we gave to senior physicians and medical school graduates, we found that most had a particular professional variation of the bureaucratic social character. The most common personality type was a productive obsessive-erotic personality—systematic, careful, and caring. Doctors saw themselves as expert-helpers who are supposed to have all the answers to a patient’s complaint. A few doctors, particularly orthopedic and cardiac surgeons, were narcissistic-obsessives.
As defined by the Oxford English Dictionary, an expert is “a person with the status of an authority by reason of special skill, training or knowledge.” The root of expert is the Latin expertus, meaning tried or experienced. For experts in any profession, both self-esteem and employment security are gained by status and respect, recognition by peers and superiors. The physicians we interviewed typically display their awards and diplomas on their office walls to testify to their achievements and impress their patients. Experts have a strong need for autonomy. At their best, they stand for high standards of service and knowledge. The physician’s view of professionalism fits the Calvinistic concept of professing a calling to serve others—the meaning of their work is not just exercising expertise, but also helping suffering people.
However, at their worst, their obsessive qualities make these experts inflexible know-it-alls. Rooted in a craft system of master and apprentice, where knowledge is based on experience, at a time when medical knowledge quickly becomes out-of-date and competence calls for continual learning, the physician’s personality can be a major roadblock to change. Physician experts prize control and resist empowering others, which they see as loss of control. This is a complaint we heard repeatedly from nurses and administrators. Physicians, like many other experts—for example, university faculty—don’t appreciate the added value of the organization over what they do as individuals. They relate best with peers, mentors, or younger high-potential apprentices, all of whom share their values. Many of the faculty members we interviewed at academic health centers maintain their autonomy through research grants that fund their own shops. They justify being part of an academic organization for the prestige of being a professor and the opportunity to gain acolytes. But since their independence, prestige, and promotions depend on research grants and publications, serving patients is not their first priority.
In most of the leading academic health centers, we found a corrosive hierarchy of status. Full-time clinicians feel slighted, and they believe that many celebrated researchers who are known as great specialists don’t spend enough time with patients to keep up their skills as clinicians. While they recognize exceptions, most of the full-time clinicians think that the triplethreat ideal of the teacher-researcher-clinician can’t be sustained. And of course, nurses, technicians, and administrators feel that doctors treat them like second- or third-class citizens.
The clash of cultures between physicians and hospital administrators is a conflict between the craft mode of individual authority, self-generated revenue, personal style of care, and patient advocacy as opposed to the industrial bureaucratic mode of centralized management, financial controls, standardized procedures, and rules based on fairness.
TOWARD A KNOWLEDGE MODE OF PRODUCTION
Can health care be reorganized as a knowledge mode of production that tackles variability of practice, improves outcomes, and controls cost, yet allows physicians to be creative and maintain a healing relationship with patients while retaining the best values of the craft tradition? Unless this question can be answered in the affirmative, many of the policy proposals offered by the National Coalition on Health Care won’t connect with the real world of health care.
Together with Drs. Bulger and Griner, I began to sketch out a model of health care as a knowledge mode of production. We contrasted the logic of productivity in the industrial and knowledge modes as it applied to health care. In manufacturing, productivity depends on the producer’s processes and practices. In professional knowledge work—law, medicine, consulting, teaching—and in any solutions work, it depends on both producer and client, on coproduction. The lawyer or accountant’s productivity rises when the client keeps good records, the teacher’s when the student studies, the consultant’s when the client can use advice.
This is especially the case for health care in regard to chronic conditions like diabetes, asthma, and congestive heart failure. When patients manage these conditions, not only in terms of diet and exercise, but also record keeping and self-medication, their health improves and so do medical costs. At Intermountain Health Care, an average of $30,000 annually was saved over a period of fifteen years for those diabetes patients who managed their own care. This was because these patients didn’t end up in emergency rooms, in desperate shape with kidney failure, blindness, or the need for an amputation. At present, 225,000 Americans die of diabetes each year.18 If diabetics were educated to manage their own care, lives would be saved. Intermountain estimates such education takes over a year, and until recently, insurance paid for treatment but not education. (The incentives are all wrong—the doctor makes more by doing for patients what they would be better off doing for themselves.) Intermountain also helps to connect patients through the Internet, so that doctors can monitor the patient’s self-treatment. But again, doctors need to be paid to do this, or patients need long-term membership in HMOs like Intermountain and Kaiser-Permanente, so that it’s in the interest of the insurer to educate patients to treat themselves.
Bulger also tackled another persistent problem—errors in medication. These often result from incomprehensible physician handwriting. Bulger demonstrated this to a group of doctors by writing a number on a blackboard. Half of them thought it was a 0 and half a 6. In a knowledge mode of practice, doctors use IT in making decisions and ordering treatment. Bulger a
rgued persuasively that using IT and advanced informatics in prescribing can also increase safety as well as quality of care.
The ideal health system will challenge physicians and all healthcare professionals—nurses, administrators, technicians—to work together to improve productivity and also the patient’s experience. In most systems today, patients with complex problems have to trudge from one specialist to another, making their own appointments, carrying their records from office to office, repeating their medical histories, filling out similar medical history and insurance forms over and over again. It’s a hassle that can only be solved by transforming the medical mode of production.
The ideal moves from what is essentially a sick care system to a true health maintenance system. It expands the care model from a purely biomedical and craft mode to a biopsychosocial and epidemiological knowledge mode of production. This move requires collaboration between healthcare professionals and everyone in a community.
The ideal also calls for a new kind of medical education that was pioneered by Dr. Ed Hundert when he was dean at the University of Rochester medical school. Students learned the business of medicine as well as science and the clinical arts. They learned to collaborate with patients and other healthcare professionals. The ideal calls for organizations in which all the professionals collaborate to further their common purpose, not in response to the command-and-control systems of the industrial mode of production, but because they understand and support the purpose and practices (see table 7-1). Then there won’t be any conflict between physicians’ autonomy and the organizational goals. For example, physicians will be fully convinced that by tackling variability of practice they’ll benefit their patients as well as their organizations.
TABLE 7-1
The transformation of health care
Transforming the healthcare mode of production to a knowledge mode of production resolves the conflict between physicians and hospitals in a way that preserves the best values of both (see figure 7-1). And this transformation is essential to improving the healthcare system, not only in the United States, but in all countries where physicians are wrestling with the explosion of medical knowledge and technology. But this system needs leaders with skills that are different from either the craft or industrial modes. We’ll come back to that after we visit some of the organizations that are trying to transform themselves toward this ideal.
I first proposed the model shown in figure 7-1 in 1998 at a meeting of heads of academic health centers, where it was well received and became the leading chapter in the Association of Academic Health Centers (AAHC) book Creating the Future.19 More recently, it was featured in a book based on a project headed by Richard Normann, as a model for European healthcare systems. 20
FIGURE 7-1
Hospital versus physician mode of production
How close are our best healthcare organizations to this model? In 1999, at an AAHC workshop, leaders of academic healthcare organizations filled in a survey on the elements of the knowledge mode. These leaders indicated that there’s a large gap between ideal and practice in making service to patients the highest priority. (A notable exception is the Mayo Clinic.) They reported major gaps in adopting the information systems needed for order entry, antibiotic safety, electronic records, and, beyond these, the informatics that facilitate doctor-patient collaboration on managing chronic conditions. Vanderbilt University Medical Center proved to be an exception, and we later found that Kaiser-Permanente and Intermountain Health Care, not academic organizations, have also made significant strides in IT development, as have others, like the VA system and Partners HealthCare in Boston.
Consistent with the craft mode, there was also a large gap in addressing practice variability, as well as in evaluating physician results. These executives reported that the specialists in their faculties resist attempts to limit their autonomy or to judge each other’s work.
Finally, these academic leaders were frank in admitting that they had not forged relationships of trust with the doctors they managed, and they were failing to communicate a vision of transformation. When they held off-site planning meetings, typically facilitators boarded the wish lists of the department chairs. Then the group prioritized the areas they wanted to support. Inevitably, these were the areas that would attract the most research money: cancer, heart disease, the brain. Usually at the end of the offsite, the doctors signed on to a value statement. The top of the list was patient service, even though everyone knew this wasn’t really their organizations’ highest priority.
Few of these leaders aspired to be transformational leaders. They were more like ombudsmen, representing and defending their medical faculties. By protecting members of their guild they gained loyalty as the feudal lords of the academic castles. The leadership consultants they hired advised them to sharpen their emotional intelligence, storytelling ability, and mentoring competence to tighten their transferential hold over their vassals.21 But those are not the essential qualities of the leaders we need to transform organizations in the age of knowledge work.
THE BEST OF THE BEST
Which of the healthcare organizations we visited came closest to the ideal? There were four, each somewhat different from the others. According to our findings, these were the Mayo Clinic, Intermountain Health Care (IHC), Kaiser-Permanente (KP), and Vanderbilt University Medical Center (VUMC). (Our method was to interview organizational leaders—executives, chairs, head nurses—based on their responses to a gap survey that described the qualities of an ideal knowledge model. The survey can be found at the end of this chapter.)
Mayo Clinic
The most collaborative organization we visited is the Mayo Clinic, founded a century ago by two brothers, William and Charles Mayo. The visionary leader was William, who challenged the growing trend of individual professionalism in American medicine. He wrote: “It [has become] necessary to develop medicine as a cooperative science; the clinician, the specialist, and the laboratory workers uniting for the good of the patient. Individualism in medicine can no longer exist.”22 Long before current efforts to develop integrated information systems, Mayo pioneered a medical records system for sharing information. The clinic was among the first to offer organized medical specialties like orthopedics and pediatrics, and the first to organize those specialties in patient-focused teams. William Mayo also built a learning organization to continuously improve patient care. Whenever he heard of a new surgical treatment, he went to study it.
Recently restating their “core principles,” Mayo physicians write: “Practice medicine as an integrated team of compassionate, multi-disciplinary physicians, scientists and allied health professionals who are focused on the needs of patients from our communities, regions, the nation and the world.”23
And they mean it! We observed in our visits to Mayo clinics in Rochester, Minnesota, and Scottsdale, Arizona, that the patient really does come first; research and teaching are important but secondary, and research is aimed at clinical utility. Furthermore, specialists cooperate across disciplines in ways seldom seen in other academic health centers. Mayo doctors are salaried, and all departments are treated as cost centers, so physicians can take as much time with patients as they consider necessary. On the wall is this quote from William Mayo: “The best interest of the patient is the only interest to be considered.” And administrators at Mayo see their role as serving doctors rather than struggling with them about costs. Of all the organizations we surveyed, Mayo was the only one in which most gaps between ideal and practice were small; whereas others said that they espoused but did not practice “patient service as the highest priority,” Mayo doctors saw themselves as constantly striving towards this ideal with the full support of the institution.
Mayo offers a glimpse into a resolution of the clash between the bureaucratic-hospital mode of production and the craft-physician mode: one that sustains a knowledge mode, a transparent learning culture where physicians become persuaded that principles and processes are good for all
stakeholders. In Rochester, we found a harmonious relationship between the Clinic and St. Marys Hospital, founded and run by Franciscan sisters. The partnership, created by William Mayo, still thrives.
Although Mayo is clearly physician led, nurses sit as equals on major committees. Each clinical department has both a clinical manager and a nurse manager, and they are both involved in research. There is a career development program for nursing. Unlike in most other healthcare organizations, nurses feel they have the authority to criticize doctors who haven’t done things properly, and there are protections for those who speak up. A nurse manager told us, “We accept the doctors as leaders, but not as bosses.”
Openness, self-criticism, and self-renewal are Mayo strengths. By constantly reinforcing a culture focused on the customer-patient and encouraging criticism among professionals according to what is best for the patient, Mayo raises the level of collaboration. Contrast this with most healthcare organizations (and most corporations), where professionals keep quiet about their colleagues’ errors and whistle-blowers are punished. Mayo is a model for professional knowledge companies of all kinds that are trying to create collaboration among specialists.
Mayo is inspiring. If I had a complicated illness with the probable need for specialists in more than one field, I’d take a plane to Rochester. But no one is perfect, and the Mayo doctors did check some gaps.
As in many of the best companies I’ve worked with, there’s an attitude of rejecting ideas from the outside, the not-invented-here syndrome, a distinct contrast to the Mayo brothers, who traveled great distances to learn the newest surgical techniques. While some department leaders have persuaded physicians to adopt evidence-based medicine, others have lagged behind. One Mayo chair said: “Many physicians are still in a cottage industry and resist evidence-based medicine. And it can still take too much time to negotiate between departments, which results in patients having long waits.” A nurse suggested that patients bring along a Russian novel to occupy themselves during these waits.
The Leaders We Need, And What Makes Us Follow Page 14