A Process-based Approach to Fixing Healthcare - Interview with Steven Spear

What can be done to fix healthcare? In this Process Excellence Network interview, author and MIT Professor Steven J. Spear, talks to PEXNetwork.com's editor Diana Davis about how the healthcare system is broken and offers his perspective on what it will take to mend it.

Editor’s Note: This a transcript of the video interview Fixing Healthcare: Interview with Author Steven Spear, filmed on location at PEX Week Orlando January 2011.

PEX Network: You’ve done a lot of work on healthcare improvement, a lot of work in the healthcare field. Is healthcare broken?

S.Spear: It is.

PEX Network: How?

S.Spear: The problem healthcare has, in some ways, is that it’s a victim of its own success. What I mean by that is that, traditionally healthcare was delivered by the sole practitioner. The reason that was the case was that healthcare science was so unsophisticated and poorly advanced, that really, the moment of magic was the interaction between the patient and the doctor. And so healthcare built up organisations in support of that moment of encounter between the patient and the doctor. What happened then, and this happened fairly recently - in the last 20, 30 years at most - is that the healthcare sciences have proliferated. So there are disciplines now which didn’t even exist 30 years ago. And the depth of knowledge has increased exponentially in some of those disciplines.

So, now when you go to treat an illness, deal with a condition, treat an injury it’s no longer the patient interacting with a sole healthcare professional, but actually within an entire system of people – doctors, nurses, pharmacists, different types of technicians, medical assistants, secretaries, etc. There could be dozens and dozens of people just for primary care and it takes something really challenging like dealing with cancer, and you could be dealing with many dozens of people over the course of treatment which could run weeks, if not, months.

PEX Network: So would you say it became like a big corporation where you’ve got really a siloed approach?

S.Spear: Well, that’s exactly what’s happened. So, traditionally, doctors and nurses also were trained separately and doctor’s work was doctor’s work and nurse's work was nurse's work. And so you had this approach of training people within their disciplines, within their functions and then employing them also in silos, within their disciplines, within their functions. If you walk into a typical hospital now and look at a directory, everything is by the silo of discipline and specialty even though the care is provided ways which have to cross all those boundaries which separate one discipline from another.

PEX Network: What’s the starting point for fixing that?

S.Spear: Right, so I’d say there’s an internal and external starting point. The internal starting point is for senior leadership of healthcare providing organisations to recognise that managing functions and specialties is just part of what they need to do. What they need to do is manage the process of care delivery and so that would start with defining work, not just by the function and the specialist, but by the service line, so start-to-finish, end-to-end, stem-to-stern path or trajectory that patients experience, going from injured or ill to better and well.

PEX Network: But are there major cultural stumbling blocks to achieve that?

S.Spear: Oh, yes, there are lots of them. From the very beginning, people are taught within healthcare that they’re an independent professional. And you see this in every step along the way. So, I’ll give you one example. So I was following some surgical residents on rounds, they check on their patients at something like five or six in the morning. And the people I was watching were all thoracic surgeons. So, to really emphasised the silo’d stovepipe approach to managing care. First the interns are rounded to check on the patients and they report it out to the residents who report it out on another set of rounds, so the chief resident who finally reported out to Fellows and the attending physicians – that was within thoracic surgery.

Now we happen to be bedside at the third or fourth pass on patients. And again, that approach makes perfect sense if you exist in a world of craft and master craft people and professional development through mentorship and apprenticeship. So you do your work and you get it validated and it keeps popping up so you have the attending physician who is the master craft and sort of the Yoda of the relationship. So, we’re leaving a patient who’s had one surgery and because it’s an older patient, after the thoracic surgeons leave, a psychiatrist comes in because there’s some issues related to dementia. And this attending physician and psychiatrist is followed by a Fellow and a chief resident, residents and interns and a gaggle of little ducklings or geese following along.

And so he does his pass on this patient and then someone else comes in and it’s an attending physician in cardiology because she also has heart problems and circulatory problems. So he does his pass with his Fellow and chief resident, resident, and at no point does any of them talk to each other about the patient.

And then separate from that, there’s a whole group of nurses who are responsible for the moment-to-moment care of this patient who are having their own set of rounds and their own set of discussions and hand-offs across shifts not talking to the doctors. Now there’s managing the pieces, but no one has defined a process and tried to integrate the pieces into a coherent system.


PEX Network: It sounds to me that there are two competing concerns there - first making sure that junior doctors aren’t left in charge of a patient on their own and, secondly, making sure that they learn. How would you balance those competing demands?

S.Spear: Right. So there’s a couple of things you can do here. One is this notion that people learn a profession, set of skills through practise and then through coach practise – that makes perfect sense. That’s how we learned how to speak, how to use a fork and knife, how to ride a bicycle, swim, whatever it is. So that basic notion of learn-by-coach-doing makes sense. And then again, with the possible exception of learning to walk, I can’t think of a human skill we have which didn’t involve some sort of coaching.

There’s another piece to this, though. I teach at MIT and, of course, there are a lot of science and a lot of engineering students. Our students in engineering know, I think, from the get-go that they’re learning a skill set, mechanical engineering or electrical engineering, aerospace engineering, whatever it happens to be, in order that they can contribute to projects much larger than themselves. And I don’t think beyond the freshman year they ever think that they will design anything sophisticated and complex by themselves or with their friends just from within a department. They know, even at that level, that they have to understand how systems of work come together because anything they design that will finally make its way into the marketplace will be the work across all these different specialties and disciplines. So that’s engineering.

Healthcare, they’re not trained that way - to think of themselves as deeply skilled professionals who contribute to a system much bigger than themselves. And I’ll give you one example of that. I have a friend, Alan, and he was complaining that he discovered at his hospital that if a certain number of his patients develop surgical site infections in a year, that he would lose his privilege to perform surgery at that hospital, which essentially is his income, right. And he was complaining about how unfair that was. Now, you and I as laypeople say, Alan, patients don’t want to get surgical site infections – isn’t that fair? He said, well, here’s the thing – the surgery I do, maybe it runs 30 minutes, an hour, three hours, four hours of really complex work. But that patient has been in the system for days before I touch them, will be in the system for days, if not, weeks and months after I touch them, and all these points of contact over these hours, days and weeks is an opportunity for an infection to occur; for an infection to be sustained and nurtured and grow out of control. He says, not only can’t I control that, I never even see those things, yet I’m being held responsible.

It’d be like holding the junior engineer who’s designing a single component on an aircraft for the performance of the aircraft as a whole, rather than what would happen in Airbus, Boeing, Ford Toyota – holding the chief engineer responsible for the integration of the parts into his system.

PEX Network: So, effectively, this comes back to the whole, that healthcare [as a system] is broken. None of these parts are all working together as part of a cohesive whole?

S.Spear: That’s right, that’s right.

PEX Network: In other work that you've done you talk about what it takes to become a high-velocity organisation – is there such a thing or can there be such a thing as a high-velocity healthcare organisation?

S.Spear: Absolutely. The term high-velocity organisations refers to those organisations which have achieved exceptional levels of performance. I didn’t call them great companies or high-performing companies because the pattern is consistent to most outstanding organisations in many different industries. It could be high-tech like semi-conductors, it could be auto services. What matters is that they achieve their position of leadership through exceptional rates of sustained improvement and internally-generated innovation - the velocity of getting better leads to the point of being ahead of the pack.

Within healthcare, what we’ve seen is that certain organisations, which have started to take on a more mature, more sophisticated view of designing, operating and improving systems, have been able to do remarkable things: eliminate complications like patient fall, central line infections, surgical site infections, missed medication, wrong site surgery. At certain organisations those things have disappeared. Now when those things disappear, the cost of providing healthcare go way down - the cost of human suffering, financial cost of dealing with complications, and so on and so forth.

The other thing is when you start creating systems with an eye towards what are the parts and how they relate to each other, you lose a lot of the inefficiency of things which are designed which don’t mesh properly. For example, when we first started this work, which was about ten years ago, I remember being in a conference where the surgeon says, "son-of-a-gun, I get it! We spend so much time individually creating value and we destroy it in the hand-offs."

Well, destroying value in the hand-offs means that you have rework, you have time loss, money lost, quality of care lost. But if you create a system and you create value and then hand it off and someone else is adding to the value rather than having to recreate the value, not only do you increase quality, but you reduce cost, increased capacity, so on and so forth.

My friends who were really adamant about trying to bring system thinking - the real discipline about designing, operating and improving systems into healthcare – they say healthcare can handle twice the patients at half the cost.

PEX Network: Amazing. And are there specific things that some organisations are doing that seem to really be about sending them towards this goal?

S.Spear: Right. So I’d say there were three distinct things. One is structural; one is dynamic; one is leadership.

The structural issue is actually starting by defining and designing systems of processes start-to-finish, end-to-end, stem-to-stern out of the currently disconnected pieces. So, for example, you walk into most hospitals and you’ll find there is a department of radiology, orthopaedics, orthopaedic surgery, medicine, pharmacy, nursing, etc, etc. Very rarely will you discover that there’s a service line defined for new repair as opposed to hip repair and shoulder repair, where somebody’s actually responsible for bringing all of these things together.

So, step one is creating some structure out of the discombobulated parts – that’s one. Then there’s the dynamic piece which is, and it gets back to this issue of high-velocity, that when you’re trying to design things which are complex – I think we all know this from our own personal experience, the first time is going to be imperfect. For some reason you get it wrong. So characteristics of the high-velocity organisations is that when they built process, they wrap the process in constant learning. They’re very, very attuned to things going wrong, abnormalities which they hadn’t expected in their initial design because this is not what we predicted; this is not what we expected. We have to figure out why things are surprising us so they can be less surprising, more reliable, more high job going forward.

So if one piece is a structural response of creating process, creating system out of parts; the second is a dynamic response of wrapping, incorporating learning into the part of daily work. And it’s that you treat patients, but you treat patients and learn how to treat patients better tomorrow than you did today. So that’s the second piece.

And then there’s a third piece – the third piece is leadership. What we find both within and outside of healthcare is that organisations which struggle, is that leaders think that operational excellence, process excellence, system design and management is something to be delegated away from the managerial concerns of finance strategy and that sort of thing. The organisations which really excel make sure that process excellence is at the C-Level of the organisation, that the basic skills of how do you design, operate, improve complex work for it has a very high velocity improvement and innovation, that that’s a concern, a worry, a daily responsibility of the senior leadership to resolve the structural and the dynamic issues.

Editor's note: Some parts of this interview have been edited for readability.