By Dale Hershfield:
I am fortunate to have recently transitioned into health care from outside the sector. As someone with lean and performance improvement expertise, I recognized opportunities in health care for both professional and personal growth. I've taken a small measure of the industry through my job search networking and initial on-the-job experience and here are a few first impressions.
Structurally, the organization of lean, quality and performance improvement resources within a hospital is similar to other industries—an arrangement that connotes the value and emphasis placed on these roles.
Perhaps 80% of the performance improvement job openings I found required the successful candidate to be a registered nurse (RN). There were very few positions specifically devoted to lean—judging by job titles, at least. The primary focus for improvement centers appears to be on clinical quality (thus the prerequisite for an RN). In larger hospitals and systems, I found two separate departments:, one for clinical quality improvement and another for “operations” improvement. The operations improvement group more frequently welcomes professionals without a clinical background. I learned that this is the group most likely to apply lean principles given that they focus more on business process related improvements (in both clinical and non-clinical parts of the hospital).
The structure and the areas of emphasis echo the majority of manufacturing companies I know: improvement is a part of the mix but it does not define the core of how they operate as a business. Yes, I am familiar with a refreshing, though small, number of hospitals that have embraced lean (or Baldrige) as a central tenet of who they are and how they operate. However, the balance of organizations (in my sample, at least) appear to view lean and six sigma in a supporting role. I suspect that the rate of improvement in results in health care organizations, like their counterparts in manufacturing, matches the level of resources, focus and commitment for improvement.
While I can't claim a scientific sampling, the proportion of energetic and committed-to-improvement organizations within healthcare seems about the same as the ratio outside of health care. Yet, I think the balance will shift over time and that a greater proportion of healthcare organizations will embrace lean. Many organizations that have not yet begun an improvement journey, or who are at a very early stage, will be motivated to become lean leaders in order to keep pace with the changing landscape of health care.
I admit to one culture shock experience so far: peer review. I learned the rudiments of peer review during a couple of sessions at a conference I attended recently. Here is a process, as I understand it:, that peer review is invoked when there is suspicion that the level of care provided by a physician has not met an appropriate standard, e.g. a wrong site surgery. All right, I can understand that. Here's the piece that is dissonant for a lean thinker: for most of the 60 years of its existence, peer review has never been connected to clinical process improvement. A perpetual Check, with no Plan, Do or Act. Peer review occurs only after-the-fact, and it looks backward in time. The outcome of peer review is binary, yes or no, did the care provided meet the standard?. Review outcomes, historically, were not connected with process improvement, preventive action or best practice development and sharing.
The implications of an adverse peer review action for a physician can be significant. In turn, what kind of culture has this approach shaped, where the physician is the central actor in the provision of care yet he or she is conditioned by a react-after-it-happens method instead of a continuous improvement mentality? What kind of cultural and mindset impediments will there be for a lean transformation where a focus on process improvement is fundamental for success?
Notably, the sun is rising on a new approach for peer review based on revised guidelines recently issued by The Joint Commission. Some conference attendees reported that, in fact, they have conjoined their peer review and performance improvement approaches into a single framework. (Check on Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation.)
With that note of optimism—I always like to carry a little sunshine in my pocket—I look forward to more joyful discoveries on my journey.
Dale Hershfield is a lean professional with 18 years of performance improvement experience in manufacturing, process and service industries.
For more resources on making a career transition to healthcare, visit www.movetohealthcare.com.
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