Opinion
HEALTH CARE REFORM VIEWPOINT
W. Joost Wiersinga, MD, PhD, MBA Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. Marcel Levi, MD, PhD Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
Corresponding Author: W. Joost Wiersinga, MD, PhD, MBA, Department of Medicine, Academic Medical Center, Meibergdreef 9, Room G2-132, 1105 AZ Amsterdam, the Netherlands (w.j.wiersinga @amc.uva.nl).
jamainternalmedicine.com
What Other Industries Can Learn From Health Care The hospital is the most complex human organization ever devised. Peter Drucker (1909-2005), Professor of Management, New York University
In the past 2 decades, opinion leaders from every industry, such as aviation, car manufacturing, hospitality, and retail, have tried to tell hospital executives what health care organizations could learn from their business to address current challenges. Not surprisingly, health care management consulting has become a multibillion–dollar market, with annual growth rates in the double digits. What has been the effect of this influx of fresh ideas into the health care sector? Health care consultants are expected to enable hospitals to deliver better value for patients, fuel innovation, and reduce the cost and complexity of operating systems.1 Practices have changed in health care organizations. Some hospitals have implemented “lean” manufacturing methods, originally developed by Japanese motor companies. Others have introduced the Ritz-Carlton or Disney cultures of customer service. Successful as these initiatives may be on a small scale, evidence for a meaningful effect of all these measures on important patient outcomes, major health care innovation, and substantial cost reduction is often lacking.2 It might well be that the complexity of hospital organizations in which patient care, and often research and education, are fully integrated is too immense or unique to merely duplicate ideas from other industries. In a time when crippled economies, a breakdown of trust in the business sector, and a lag of new ideas have affected companies heavily, the question should be turned around. What can other industries learn from health care organizations? What ideals and values can health care professionals teach other industries? First, create value that goes beyond short-term gain. Prioritizing short-term gain at the expense of creating long-term value can be costly. A main cause of the global financial crisis in 2008 was a pervasive emphasis on short-term gain. Medical professionals have learned to create value that goes beyond short-term gain. For example, health care workers will provide care for an ill patient that solves the medical problem and subsequently enables the patient to work, study, and participate in society. In the long run, these are the only values that matter.1 Also, health care workers are increasingly aware that fixing a single problem (eg, starting hemodialysis in a patient with kidney failure) is not useful if it does not contribute to improving the quality of life of an individual who may be affected by many problems at the same time.
Second,createclientrelationshipsbasedontrust.The erosion of trust is a key priority in corporate boardrooms around the world. The issue is how to restore trust. Simple execution of another set of rules to improve accountability and moderate boardroom excess is insufficient. Building trust takes time, and trust must be earned. Health care organizationscanserveasanexample.Therelationshipbetween the physician and patient is a prime illustration of along-standingclientrelationship,groundedinabasictrust that the physician will advise what is best for the patient. Excessesinwhichphysiciansabusethetrustofpatientsare dealt with through disciplinary actions. In this respect, learning how to communicate honestly and increase transparency—within the limits of the agreements that are determined by the patient or client and not by the physician or corporation—is instrumental. Third, always seek the evidence, and follow it. Managers are often under intense pressure to make decisions inthepresenceofincompleteinformationanduncertainty. As a coping strategy, managers often rely on their experience, intuition, or conventional wisdom, none of which is necessarilyrelevant.3 Thequalityofdecisionmakingbyexecutivescanbeenhancedbytheexplicituseofcurrentand best-available evidence in management.4 Although evidence-basedmanagementisstillinitsinfancy,evidencebasedmedicineisoftenusedinmakingeverydaydecisions about the care of individual patients. A physician’s clinical knowledge, skills, and expertise are integrated with the best-available external clinical evidence from systematic research. In many businesses, experiments are not based on sound scientific and statistical methods, and result in flaweddecisionmaking.3 Evidence-basedmedicinehasthe potential to lead the way to evidence-based management that uses evidence for decisions, changes, and common practices. Fourth, create a truly stimulating working environment. People are crucial for creating a competitive advantage, but many executives struggle to keep their workforces motivated. In health care, compassion and altruism are powerful sources of motivation. Health care workers are often willing to put an enormous amount of physical and psychological energy into their jobs. When outside business models are applied to health care without careful preservation of the opportunities for compassion and altruism, these important resources may be lost. Other organizations should take notice. The list of the “100 Best Companies to Work For,” compiled by Fortune magazine, includes10healthcaredeliveryorganizations.5 Suchhealth care institutions enable working environments in which people are motivated by the conviction that they are making a difference. They can serve as prime examples of organizations that use their culture and their people as the real and enduring sources of success.4
(Reprinted) JAMA Internal Medicine Published online February 15, 2016
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Rutgers University Libraries User on 02/23/2016
E1
Opinion Viewpoint
Fifth, embrace lifelong learning as a core value. Medical professionals have learned to continuously reinvent themselves to stay upto-date and ahead of new or reemerging challenges. Ongoing, voluntary, and self-motivated lifelong learning has been a key feature of medicine even before the term continuous medical education was coined. Learning organizations create, acquire, and transfer knowledge by cultivating open discussion and broadly oriented thinking.6 Fast adaptation to the unpredictable can outsmart potential competitors. Although the day-to-day reality often falls far short of the ideal, a health care institution can represent the epitome of a learning organization. Experienced physicians allocate time for a pause in the action; they encourage thoughtful, blame-free reviews of everyday processes with colleagues, other staff, physicians in training, and patients. Opennesstonewideasisvitaltoaddressingdifficultclinicalchallenges. The morning report, in which the management of patients admitted to the hospital is discussed in the context of the most recent insights, is a prime example of such openness to new ideas, as are frequent educational conferences. Successful hospitals and other health care institutions may be led by physicians and other health care professionals who embrace—but also symbolize—lifelong learning as an essential skill to adapt to change.7,8 ARTICLE INFORMATION
3. Thomke S, Manzi J. The discipline of business experimentation. Harv Bus Rev. 2014;92(12):70-79.
Published Online: February 15, 2016. doi:10.1001/jamainternmed.2015.8406. Conflict of Interest Disclosures: None reported. REFERENCES
4. Pfeffer J, Veiga JF. Putting people first for organizational success. Acad Manage Exec. 1999;13 (2):37-48. 5. 100 Best companies to work for. Fortune. http://fortune.com/best-companies/. Published 2015. Accessed December 18, 2015.
1. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481. 2. Kaissi A. “Learning” from other industries: lessons and challenges for health care organizations. Health Care Manag (Frederick). 2012; 31(1):65-74.
E2
In recent years, hospitals and other medical organizations have imported numerous business models from various industries to increase efficiency, enhance the approval of their “customers,” and advance patient outcomes.2 There have been some success stories. Nonetheless, serious questions remain about the generalizable and sustained value of these imported practices in improving performance.2 Consultants should pay close attention to the underlying ideals of the health care profession. They should know when it is a bad idea to impose a business model on some of medicine’s best traditions. An important reason is that the definition of success may fundamentally differ for health care and for other industries. A health care delivery culture should incorporate the best of the business world’s process optimization and the best of professional medical values. Health care professionals have a responsibility to live up to the best medical standards in everyday clinical practice. In business, an understanding of the many ideals and values that can be learned from health care can help companies to become better at what they do and better places to work. Unfortunately, examples of other industries that try to learn from health care organizations are, to our knowledge, virtually nonexistent. It is time for this situation to change. 7. Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med. 2011;73(4):535-539. 8. Berwick DM, Feeley D, Loehrer S. Change from the inside out: health care leaders taking the helm. JAMA. 2015;313(17):1707-1708.
6. Garvin DA, Edmondson AC, Gino F. Is yours a learning organization? Harv Bus Rev. 2008;86(3):109-116, 134.
JAMA Internal Medicine Published online February 15, 2016 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Rutgers University Libraries User on 02/23/2016
jamainternalmedicine.com
HEALTH CARE REFORM VIEWPOINT
W. Joost Wiersinga, MD, PhD, MBA Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. Marcel Levi, MD, PhD Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
Corresponding Author: W. Joost Wiersinga, MD, PhD, MBA, Department of Medicine, Academic Medical Center, Meibergdreef 9, Room G2-132, 1105 AZ Amsterdam, the Netherlands (w.j.wiersinga @amc.uva.nl).
jamainternalmedicine.com
What Other Industries Can Learn From Health Care The hospital is the most complex human organization ever devised. Peter Drucker (1909-2005), Professor of Management, New York University
In the past 2 decades, opinion leaders from every industry, such as aviation, car manufacturing, hospitality, and retail, have tried to tell hospital executives what health care organizations could learn from their business to address current challenges. Not surprisingly, health care management consulting has become a multibillion–dollar market, with annual growth rates in the double digits. What has been the effect of this influx of fresh ideas into the health care sector? Health care consultants are expected to enable hospitals to deliver better value for patients, fuel innovation, and reduce the cost and complexity of operating systems.1 Practices have changed in health care organizations. Some hospitals have implemented “lean” manufacturing methods, originally developed by Japanese motor companies. Others have introduced the Ritz-Carlton or Disney cultures of customer service. Successful as these initiatives may be on a small scale, evidence for a meaningful effect of all these measures on important patient outcomes, major health care innovation, and substantial cost reduction is often lacking.2 It might well be that the complexity of hospital organizations in which patient care, and often research and education, are fully integrated is too immense or unique to merely duplicate ideas from other industries. In a time when crippled economies, a breakdown of trust in the business sector, and a lag of new ideas have affected companies heavily, the question should be turned around. What can other industries learn from health care organizations? What ideals and values can health care professionals teach other industries? First, create value that goes beyond short-term gain. Prioritizing short-term gain at the expense of creating long-term value can be costly. A main cause of the global financial crisis in 2008 was a pervasive emphasis on short-term gain. Medical professionals have learned to create value that goes beyond short-term gain. For example, health care workers will provide care for an ill patient that solves the medical problem and subsequently enables the patient to work, study, and participate in society. In the long run, these are the only values that matter.1 Also, health care workers are increasingly aware that fixing a single problem (eg, starting hemodialysis in a patient with kidney failure) is not useful if it does not contribute to improving the quality of life of an individual who may be affected by many problems at the same time.
Second,createclientrelationshipsbasedontrust.The erosion of trust is a key priority in corporate boardrooms around the world. The issue is how to restore trust. Simple execution of another set of rules to improve accountability and moderate boardroom excess is insufficient. Building trust takes time, and trust must be earned. Health care organizationscanserveasanexample.Therelationshipbetween the physician and patient is a prime illustration of along-standingclientrelationship,groundedinabasictrust that the physician will advise what is best for the patient. Excessesinwhichphysiciansabusethetrustofpatientsare dealt with through disciplinary actions. In this respect, learning how to communicate honestly and increase transparency—within the limits of the agreements that are determined by the patient or client and not by the physician or corporation—is instrumental. Third, always seek the evidence, and follow it. Managers are often under intense pressure to make decisions inthepresenceofincompleteinformationanduncertainty. As a coping strategy, managers often rely on their experience, intuition, or conventional wisdom, none of which is necessarilyrelevant.3 Thequalityofdecisionmakingbyexecutivescanbeenhancedbytheexplicituseofcurrentand best-available evidence in management.4 Although evidence-basedmanagementisstillinitsinfancy,evidencebasedmedicineisoftenusedinmakingeverydaydecisions about the care of individual patients. A physician’s clinical knowledge, skills, and expertise are integrated with the best-available external clinical evidence from systematic research. In many businesses, experiments are not based on sound scientific and statistical methods, and result in flaweddecisionmaking.3 Evidence-basedmedicinehasthe potential to lead the way to evidence-based management that uses evidence for decisions, changes, and common practices. Fourth, create a truly stimulating working environment. People are crucial for creating a competitive advantage, but many executives struggle to keep their workforces motivated. In health care, compassion and altruism are powerful sources of motivation. Health care workers are often willing to put an enormous amount of physical and psychological energy into their jobs. When outside business models are applied to health care without careful preservation of the opportunities for compassion and altruism, these important resources may be lost. Other organizations should take notice. The list of the “100 Best Companies to Work For,” compiled by Fortune magazine, includes10healthcaredeliveryorganizations.5 Suchhealth care institutions enable working environments in which people are motivated by the conviction that they are making a difference. They can serve as prime examples of organizations that use their culture and their people as the real and enduring sources of success.4
(Reprinted) JAMA Internal Medicine Published online February 15, 2016
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Rutgers University Libraries User on 02/23/2016
E1
Opinion Viewpoint
Fifth, embrace lifelong learning as a core value. Medical professionals have learned to continuously reinvent themselves to stay upto-date and ahead of new or reemerging challenges. Ongoing, voluntary, and self-motivated lifelong learning has been a key feature of medicine even before the term continuous medical education was coined. Learning organizations create, acquire, and transfer knowledge by cultivating open discussion and broadly oriented thinking.6 Fast adaptation to the unpredictable can outsmart potential competitors. Although the day-to-day reality often falls far short of the ideal, a health care institution can represent the epitome of a learning organization. Experienced physicians allocate time for a pause in the action; they encourage thoughtful, blame-free reviews of everyday processes with colleagues, other staff, physicians in training, and patients. Opennesstonewideasisvitaltoaddressingdifficultclinicalchallenges. The morning report, in which the management of patients admitted to the hospital is discussed in the context of the most recent insights, is a prime example of such openness to new ideas, as are frequent educational conferences. Successful hospitals and other health care institutions may be led by physicians and other health care professionals who embrace—but also symbolize—lifelong learning as an essential skill to adapt to change.7,8 ARTICLE INFORMATION
3. Thomke S, Manzi J. The discipline of business experimentation. Harv Bus Rev. 2014;92(12):70-79.
Published Online: February 15, 2016. doi:10.1001/jamainternmed.2015.8406. Conflict of Interest Disclosures: None reported. REFERENCES
4. Pfeffer J, Veiga JF. Putting people first for organizational success. Acad Manage Exec. 1999;13 (2):37-48. 5. 100 Best companies to work for. Fortune. http://fortune.com/best-companies/. Published 2015. Accessed December 18, 2015.
1. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481. 2. Kaissi A. “Learning” from other industries: lessons and challenges for health care organizations. Health Care Manag (Frederick). 2012; 31(1):65-74.
E2
In recent years, hospitals and other medical organizations have imported numerous business models from various industries to increase efficiency, enhance the approval of their “customers,” and advance patient outcomes.2 There have been some success stories. Nonetheless, serious questions remain about the generalizable and sustained value of these imported practices in improving performance.2 Consultants should pay close attention to the underlying ideals of the health care profession. They should know when it is a bad idea to impose a business model on some of medicine’s best traditions. An important reason is that the definition of success may fundamentally differ for health care and for other industries. A health care delivery culture should incorporate the best of the business world’s process optimization and the best of professional medical values. Health care professionals have a responsibility to live up to the best medical standards in everyday clinical practice. In business, an understanding of the many ideals and values that can be learned from health care can help companies to become better at what they do and better places to work. Unfortunately, examples of other industries that try to learn from health care organizations are, to our knowledge, virtually nonexistent. It is time for this situation to change. 7. Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med. 2011;73(4):535-539. 8. Berwick DM, Feeley D, Loehrer S. Change from the inside out: health care leaders taking the helm. JAMA. 2015;313(17):1707-1708.
6. Garvin DA, Edmondson AC, Gino F. Is yours a learning organization? Harv Bus Rev. 2008;86(3):109-116, 134.
JAMA Internal Medicine Published online February 15, 2016 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Rutgers University Libraries User on 02/23/2016
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