The secret to improving healthcare: It’s obvious

Last week I was privileged to attend a special session of fifteen medical institutions that gathered for the purpose of formally understanding the nature of medical variability in healthcare delivery. As most people are likely aware, the large geographical and institutional differences in treating various diseases, particularly those related to chronic diseases and end of life care are perceived to contribute significantly to the cost of healthcare. Controlling differences by implementing best practices is seen as vital to improving the system.

As the work of the group unfolded, it became clear that the simple correlation of reduced variation with reduced expenses became less clear. The more I learned, the more complex the reality. Patient economic standards, the individual demands of patients, the variation of practice of physicians from within the same institutions, the challenge of creating normalized data, etc. make this issue far more complex than originally understood. Indeed, in some cases, extra expense such as end of life care does increase length of life. But one factor above all else accounted for performance impact far above all others. Here there was no question. In the midst of all the technical jargon and the search for a fix, this one does not seem to be on the radar screen.

Primary drivers

A study completed by the University HealthSystem Consortium of medical hospital teaching institutions finds these factors to be of greatest impact:

1. Shared sense of purpose

    • Hospital leaders articulate that patient care comes first
    • Leaders are dissatisfied with the current state of quality and safety
    • Service excellence is added to the focus on quality and safety
    • Service quality, and safety are seen as a source of competitive advantage

    2. Leadership style:

      • The CEO is passionate about service, quality, and safety, and has an authentic, hands-on style
      • Everyday events are connected to the larger purpose through stories and rituals
      • Governance structures and practices minimize conflict between missions
      • The institution is led as an alliance between the executive leadership team and the clinical department chairs

      3. Accountability systems for service, quality, and safety

        • Prioritizing, developing measures, and setting goals are centralized, and tactics to improve are centralized
        • The chairs accept responsibility for quality and safety within their departments
        • There is accountability, innovation, and redundancy at the unit level

        4. A focus on results

          • There is a relentless effort to improve, employing performance against external standards as a measure of success
          • Results outweigh the approach to performance improvement
          • There is a focus on human behavior and work redesign as the keys to improvement
          • Technology is employed as an accelerator and not as a substitute for work redesign

          5. Collaboration

            • Collaboration characterizes the relationships between administration, physicians, nurses, and other staff
            • Recognition of employee contributions at every level is frequent
            • Employees value each others’ critical knowledge when problem solving


            My observation of many healthcare systems is that they fail to mirror the behaviors described by the study cited above. Instead, administrators, physicians, and staff seem unaligned and often distrustful of one another. For example, a few years ago I presented at the national Association for Healthcare Executives.  My session was comprised entirely of non-physician leaders. It was apparent to me and to the physician leader with whom I presented, that there was great animosity and dislike of physicians by the administrators. The seemingly pervasive antagonistic relationship has a significant deleterious relationship with cost and outcomes as well as morale and professional satisfaction.

            Top performing healthcare institutions are characterized by:

            • Strong positive cultures: mission, safety/quality in terms of impact
            • Strong leader who gets into the middle of the pack to the top tier. They are more performance driven and communicate a sense of value
            • Strong department heads and chairs impact performance
            • Aligned relationships lead to decreased performance
            • How things get managed influences a great deal how things get used

            These finding are consistent with decades of data for non-healthcare related institutions.

            Essential questions:

            Many healthcare organizations are complex. There are often parochial competing interests and perceptions of what is best. Yet changing the local environment in which care is delivered seems to be critical if we are to achieve the agenda.

            1. What is the culture of your healthcare institution?
            2. What keeps healthcare institutions from effectively implementing these kinds of leadership development/culture change programs?
            3. What would help heal the system? What medicine do you advise?

            Your thoughts are appreciated.