Organization Matters

Miles Shore

In this edition of the HMI World Forum, two senior consultants at HMI present what we hope is the beginning of an ongoing dialog on organizational issues in health care—and the strategies, skills, and solutions necessary to address them. The article was co-authored by Miles Shore, MD, Bullard Professor of Psychiatry at Harvard Medical School and Visiting Scholar at Harvard’s Kennedy School of Government; and Bruce Solomon, MBA, MPH, who has recently joined HMI to assist with a major hospital development initiative. Here they provide an overview of the myriad issues that constitute a disconnect between the incredible advances of the technological capabilities in health care and the structural and organizational shortcomings that can result in grave consequences for the patients to whom that care is delivered. Consider this piece an introduction as well as a broad call to action. In future issues of HMI World we will return to the subject at hand, in feature articles delving deeply into specific organizational issues, and with brief insights that might spark a thought, encourage one to consider a new tack, or drive a necessary conversation.

Bruce Solomon

A final thought by way of introduction: the authors would like to encourage thinking about “organizational issues” from two distinct but related angles: as problems that must be addressed and fixed (the most obvious definition) and as opportunities—and obligations—to move health care forward. We can point to a number of developments in patient care, training, and research that have occurred in recent years and might be viewed as organizational issues. Simulation-based medical education; the addition of instruction in health administration, policy, and finance to medical curricula; and the wellspring of ideas and initiatives focused on clinical quality measurement and improvement are but a few. We might more readily classify these as innovations, but their successful implementation and their impact on patient care has depended on strong leadership, teams of talented people, and robust and efficient systems to foster collaboration—the achievements of organizations rather than individuals.

Health care used to be fairly simple. There was a doctor, a nurse, some lab tests including X-rays, the doctor’s office, and the hospital. Technology has changed all that. Now there is a team of professionals, a great many lab tests, MRIs, CAT scans, many different offices, and a host of facilities for diagnosis and for care. Making care happen used to be a matter of a few phone calls, some visits by the doctor, a prescription, and perhaps a form or two. Now, at least in the U.S., an episode of care requires multiple forms or emails passing among a team of caregivers, conveying the results of diagnostic tests, suggesting further tests or consultations, and arranging further appointments. Even more insurance forms soon appear documenting that the care has taken place so that it will get paid for. Some of these forms warn of disputes about appropriateness or the extent of coverage, triggering a further series of forms and phone calls justifying medical necessity.

There are two linked problems here. The first is that the delivery system is most often organized to support the old, simple way, not the new complicated way. In fact the system is not fully organized as a system with central accountability for its smooth functioning, as is the case with other service delivery systems. Each of the components is relatively free-standing and professionally autonomous, responsible to professional standards but not accountable for its functioning to some authority with the power to make things happen. The second is that even in those cases where there is an organization, insufficient attention has been paid to the effective functioning of the system.

Understanding organizations has not been a feature of either professional education or, until recently, the conceptualization of health care delivery. Even the obvious building blocks of modern organizations are missing in health care. Information technology, which has been the source of increased effectiveness in a wide range of modern industries, has been slow to develop in health care. This is partly because of the formidable costs associated with information technology. It is also because the culture of individual craftsmanship and service continues to push back forcefully against technological aids to practice. A study published in 1998 (Cook, M et al. Integrating personal computers into family practice: a comparison of practicing physicians and residents. Bull. Med. Libr. Assoc. 86(3) July, 1998) found that almost a quarter of practicing physicians had never used a computer and only 36 percent had used computers for a professional application.

The paradox, of course, is that modern medicine’s defining characteristic has involved applying highly sophisticated technology to patient care. Yet technology has not been applied to any extent to the organization and delivery of that care. A doctor from 100 years ago, 1907, would feel relatively at home in a doctor’s office today. He would proceed to work up the patient much as would a contemporary doctor. Taking a history, and even doing a physical examination, would proceed much the same. It would only be when the differential diagnosis had to be checked and worked through that the differences would become apparent. And, of course, when it came time for treatment, things would be very different. Imagine automobile manufacturers attempting to produce modern cars using 100-year-old manufacturing methods.

The most dramatic example of problems with the organized delivery of health care is recent findings about medical error. In 2000, he U.S. Institute of Medicine (IOM) published a report entitled To Err is Human: Building a Safer Health System, a review of patient safety that documented that medical error is responsible for some 98,000 deaths per year, making it a leading cause of death. Most striking was the finding that individual practitioner errors were not the issue; even the most seasoned, dedicated, and careful professionals make mistakes. Instead, the report emphasized that medical mishaps were the product of deficiencies in systems of care, which had not been organized to prevent error. This finding ran directly counter to the assumption in professional education and practice that individual skill and attention are the main protections against mistakes. “Do no harm” is the traditional first admonition to health care professionals. That not doing harm is significantly out of the control of individuals came as an affront to professionalism and professional education. The finding created considerable pushback on the part of the public and professional groups.

More profoundly it struck at the view of health care as almost exclusively a humanitarian activity based on service to benefit suffering individuals. It placed health care among the technological fields, such as nuclear power generation and commercial aviation, that carry lethal potential to do harm unless organized as high-reliability organizations. Those industries could never have existed without systems of organization that could guarantee a level of safety far better than health care.

The implication of the IOM findings is that health care delivery systems must pay a great deal more attention to the organizational framework of care, and health care professionals must know a great deal more about how to function successfully in organizations. Fortunately there is a considerable literature on the nature and functioning of organizations that is rarely applied to health care organizations or consulted by health care professionals. Some of this literature consists of anecdotal accounts of “clinical” experience in a great variety of business, military, and educational organizations. Increasingly, these reports are supplemented by insight from social science researchers studying leadership, teamwork, and organizational dynamics to develop data that are useful in improving the functioning of organizations.

What do health care professionals need to know about organizations? First and foremost of course are basic concepts of leadership. Physicians in particular tend to think of themselves as leaders by definition who exercise their authority by issuing orders, and nurses feel similarly about themselves. In both cases, the presumed authority is derived from attention to the welfare of patients. That simple formulation has inherent problems in the modern world where health care is delivered by teams of professionals with their own areas of expertise, prerogatives, and cultures. Leadership of teams involves creating an environment conducive to high performance of the group, and the skill to forge consensus from a collection of independent experts, each of whom brandishes special knowledge. Fortunately a great deal of small group research by Hackman and many others has established the ground rules for effective team work.

Leadership styles vary among individuals and must be adapted to the situation at hand. Goleman, based on his own research and that of others, has described a roster of leadership styles, some of which are useful, others of which are toxic to organizational performance. The “Commanding” style of leadership, in which the leader issues orders that are not to be resisted, is essential in emergency situations. As a chronic style, it creates resentment, passivity, and rebellion, as does the “Pacesetting” style in which the leader tries to lead by outdoing the followers in creativity, productivity and success. More successful in the long haul are the Visionary, Coaching, Affiliative, and Democratic styles that establish collaborative relationships that reinforce the self-motivation of the followers. Flexibility in using these differing styles is the aim of education in “emotional intelligence” advocated by Goleman.

Selecting the right people is always a challenge in organizations where talented individuals must work together. There is considerable experience available to assist in this process. The next step, creating organizations in which talented professionals can be engaged and productive, is a constant challenge in health care organizations. Here, again, experience in other technological industries has much to offer. Providing clarity, structure, access to leadership, and yet sufficient latitude to foster creativity has been studied in a variety of situations that offer instructive lessons for health care.

The ability to deal with the interpersonal conflicts endemic in most organizations is not a skill that education for health care offers. This is often the organizational rock on which talented health professionals founder when they must deal with organizational issues. However, there is a robust technology available to assist in helping health care organizations with their struggles. Negotiation and conflict resolution as a field of research and practice was originated by Roger Fisher and William Ury, and has been applied to a number of fields including health care. The structured approach of this discipline moves conflicts into an area where they can be resolved peacefully, with minimal organizational and personal trauma.

Health care has changed radically. Having once been the province primarily of dedicated, caring practitioners working largely alone to care for patients, it is now an activity of many talented people. They can no longer work alone, but must be integrated into complex organizations that function with the safety and efficiency of the most advanced technological organizations while retaining the concern with the humanitarian value of service that is so important to all of those concerned with healing.

Now, as never before, in health care, organization matters.

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