Comments

Atul Gawande wrote a great article about the use of the fundamental tool ... the checklist ... as it relates to medicine, and to doing what TP suggests (http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande). The ideas are great and applicable to the rest of us too. As I recall there was some problem with using the checklists and a national medical organization put the kabosh on his program. Anyone recall or have knowledge about this? It would be a shame to lose that kind of progress in my judgment.

Posted by Dean at July 31, 2008 10:52 AM

"As I recall there was some problem with using the checklists and a national medical organization put the kabosh on his program. Anyone recall or have knowledge about this? It would be a shame to lose that kind of progress in my judgment."

There was a HIPPA problem [informing the patient], but it was beaten back successfully, I believe.

Posted by tom peters at July 31, 2008 11:04 AM

Great proposal Tom - Your structure is far more likely to succeed in healthcare improvement than most current traditional structures. Can I suggest some more positions?

Director of Empowerment of Front Line Workers
Director of Listening to Patient Stories
Director of Jargon Reduction

Posted by Trevor Gay at July 31, 2008 1:47 PM

In tom speak, simplify damn it!

therefore..
Chief butt kicker - Chief butt kicker avoider - Chief butt kicker arranger... then the Indians... :)

While the chiefs run in circles the Indians can get on with things... ;)

Posted by Steve Gray at July 31, 2008 5:09 PM

I recomend the book of "Harvard Medical School Guide To Achieving Optimal Memory"by Aaron P. Nelson Ph.D.... for your Optimal Health.. thx!! may it help...

Posted by adam at August 1, 2008 3:44 AM

These are all important tasks but I'd make one point: anyone who's bothered about their job title is probably, by definition, not suited to a job in healthcare. So, why don't we get REALLY radical and only appoint people who care about people?

Posted by Mark JF at August 1, 2008 3:45 AM

Great list of names…however, the “challenge” lies in drawing the lines & arrows (reporting hierarchy)…one has to be professionally selfless to be a part of such a structure…as the saying goes…SUBSTANCE over STRUCTURE??? or in this case, “SERVICE over STRUCTURE!”

Posted by K.Sriram at August 1, 2008 5:54 AM

With tongue firmly in cheeck, as was said by TP, often times it is necessary to respond in familiar ways--hence, the cheecky titles. The meaning of the post is well taken and MarkJF's response too. But it is often very important when dealing with failed systems or those in need of overhauling to begin to reconstruct them from a point of familiarity. Job titles with accompanying grades are a part of the system.

Yes, it is most important to do one's job from a place of personal responsibility, accountability, and love of work. But, as we know, we are often in need of certain caveats to stay motivated and a hierarchal system, with job descriptions and grades equivalent to salary increases and the like, seems to be one of the reason such a system was designed-not to mention for the sake of order.

What matters most it seems is how we see ourselves and how our work is valued, accompanied with a system of rewards that will make the difference consistently. Simply said, though perhaps not easily executed. Overhauling systems take time and as we know, change as TP says, begins with a mindset. The job titles here, obviously descriptive, seem to me to be a part of changing mindsets. Thanks, TP!

Posted by Judith Ellis at August 1, 2008 6:10 AM

As I re-read the post, that tongue is "mostly" in cheeck, as some of these titles, such as "Deputy CEO/Patient Safety & Quality" is essential. It is a "must do now." Without this job title and accompanying consistent execution, the obvious in patient care lead to imminent ends.

Posted by Judith Ellis at August 1, 2008 6:30 AM

You should tie this to your thinking on women?

It would be my view in my house full of women (bar myself of course) that they occupy each and every role described naturally?

Like other contributors I would add

The Director of useful IT?
The Director of keeping the skills in house
The Director of not outsourcing your talent
The Director of fun

Ever onwards into a healthy weekend I trust

Patrick

Posted by patrick at August 1, 2008 8:45 AM

I am commenting on the parallel posting and just posted this on the other healthcasre thread. I use the following slide in all my healthcare presentations – Mr Gandhi had it right don’t you think?

Bombay Hospital Motto

A patient is the most important person in our hospital. He is not an interruption to our work. He is the purpose of it. He is not an outsider in our hospital; he is a part of it. We are not doing a favour by serving him; he is doing us a favour by giving us an opportunity to do so. - Mahatma Gandhi

Posted by Trevor Gay at August 1, 2008 8:48 AM

I love it Tom... may start recommending it to my clients! Heck, if you want really world class quality, you might even consider beefing it up a little. Maybe add:

Director - Measure How Were Doing and Find Quality Gaps Department (Informatics)

Director - Fix the Quality and Patient Safety Problems Department (Clinical Process Improvement)

Director - Lets All Do It the Same Way Based on Demonstrated Best Practices Department (Evidence-Based Care)

Then you will stand a chance of not loosing your shirt when the new Medicare Reimbursement regulations take effect in October!

Posted by Scott Hodson at August 1, 2008 11:45 AM

it posible learn in spanish your web?

Posted by Eva Gonzalez at August 1, 2008 5:29 PM

Tom, if I have a problem with all this, it's not in the overall intent but your "proposed" solution. I realise that to a large extent this org chart is a metaphor for a philosophy, an approach, rather than a workable structure, but... does creating Directors Of (Whatever) actually make any situation better? Does it ever lead to embedded new behaviours at all levels of an organisation, or instead to a plethora of individual territorial policies and priorities that end up competing and confusing? And some more fat cats skimming off the cream? Apart from organisations that are already pre-disposed to respond, has any organisation achieved major conceptual change through the introduction of a Director Of (...)? I'd be glad to know.

Of course some of this issue is about the what and why, with the principle of national healthcare provided through multiple commercial (and therefore beholden to shareholders) ventures containing some inherently challenging paradoxes. But it also has to be about the how, and a tier, even such an innovative replacement tier, of Directors looks likely to do little more than shift the deckchairs. As you have said elsewhere, this is an area which can make extraordinary (and effectively free) improvements from empowering the staff who deal directly with patients. That's where I would start, on the ward floor, letting a thousand flowers bloom.

All the best

Posted by Rob at August 2, 2008 3:19 AM

'That's where I would start, on the ward floor,letting a thousand flowers bloom.' - Brilliant!

Needless to say I agree with Rob about empowering front line workers in healthcare – they KNOW how to do patient care stuff. The second and equally cucial part of the solution is having role model leadership from managers whether we call them Directors or whatever. I’ve always said the ONLY task of a healthcare manager is to move heaven and earth to make the job of front line workers dealing patient care easier. Managers who live that culture are leaders who add value to the patient journey. Those who spend their time sat in the office writing reports that no-one reads are not adding value to patient care. Probably far too simplistic from me .. As usual.

An overcast Saturday morning in Shakespeare’s County but do I care? … I’m off on holiday today ... Best wishes to all in the TP team .. and all commenters … See you in a week

Posted by Trevor Gay at August 2, 2008 4:28 AM

I agree that the front line workers' jobs should be made as easy as possible. However, I have found that often the back office managers are often closed to new ideas about how they can do this.....particularly learning lessons from other industries.

Chris
http://learn2develop.blogspot.com

Posted by Chris at August 2, 2008 5:16 AM

I rarely set foot in a hospital but I went to Massachusetts Eye & Ear (affiliated with Harvard Medical School) this week to consult to an expert on inner ear issues. The doc was almost 3 hours late for my 10:15am appointment (which I waited 3 months to get) - and no staff member checked in on me to update me or apologize. The doc apologized when we finally met and was extremely helpful in the end. But the operation as a whole was not organized from a customer perspective (oh, that)) and the staff was badly in need of some people skills training. BTW, waiting 3 months to see a specialist is not unusual in Boston. (Maybe it's that bad in other US cities as well?) In fact it takes me 3 to 4 months to get an appointment with my primary care doc.

Posted by John O'Leary at August 2, 2008 8:49 AM

Great idea Tom- but you missed the Director in Care of Caregivers.

Caregivers are notorious for neglecting themselves in caring for others. (And yes, this includes the housekeeping, maintainance and all other support staff)

They need someone high up to stare squint-eyed at every schedule, every protocol, every memo, every disciplinary measure, walk every hallway, examine every locker room, lunch room, employee entrance, car park to see where the stressors beyond the giving of self to care for others are hiding, and rout them out relentlessly.

I think the answer to Rob's query whether Directors would be useful is to hire passionate leaders and give them the authority to slash and burn through every 'but that's the way it is' that stands in the way of their collective vision.

I'm thinking of the executive that came out of the office for the checklist team in Chicago(?) in the New Yorker report. The ICU teams had trouble keeping to the checklist because not all areas had antibacterial soap or full drapes. The executive made sure the soap and drapes orders weren't lost in the paper jungle and went one better- working with other hospitals in the area to have their common supplier make up central line trays with all the components included.

Trevor- that's the kind of director you mean, yes?

Posted by Lois Gory at August 2, 2008 1:14 PM

Eva,
I'm sorry that we don't have resources for translating the whole website into Spanish, but, if you ask for one blog entry to be translated, we'll do our best to accommodate you.

Posted by cathy mosca at August 2, 2008 6:28 PM

Rob: "...empowering the staff who deal directly with patients..." Brilliant in theory. But just because someone's suddenly been empowered to do something doesn't automatically mean they're capable, qualified or even comfortable doing it. And since empowering one person often means de-empowering another, will they support each other, especially when things go wrong? You make a great point about the need for new values and behaviours to be embedded at all levels and I think that unless the organisation buys this, recruits, trains and operates to that notion, it isn't going to stick.

I sometimes think that most people know the problem and have an intuitive understanding of what the answer should be - so the problem isn't at all about healthcare management. It's about change management, and that's much harder.

Posted by Mark JF at August 4, 2008 5:15 AM

There was a UK documentary a little while ago when a tough business exec (Gerry Robinson) was asked to visit a financially strapped NHS hospital and look for improvements. He noticed that the operating theatres were under-utilised (mainly only day work) and different surgeons got through varying numbers of patients.

One surgeon had created a team around him that prepped the patient, brought him into theatre ready to operate, closed up for him and took him into recovery. He had several patients going through the process concurrently. This contrasted with most other surgeons whose "teams" all exercised their own speciality consecutively, i.e. one after the other and with large amounts of waiting around for someone else to do his job. The first surgeon was about 3 times more productive through recognising that the purpose of theatre is to operate on patients so he organised himself and his people around maximising surgery time and minimum hanging around. His view: he was doing what he wanted to do - be a surgeon. His teams view: they were busy but would would rather be busy than under-utilised and bored.

Could Mr. R. get the others to change? We had, "It wouldn't work for our team" and "not invented here" and every variety of change resistance. It was unbelievably dispiriting.

Posted by Mark JF at August 4, 2008 5:27 AM

eva/cathy,

or try the Google translator:
http://translate.google.com/translate_t

Posted by erik hansen at August 4, 2008 7:20 AM

Mark, I agree that many things are marvellous in theory only to fall flat when (if ever) someone tries to put them into practice, so yes, of course your caveat is valid. But there are instances of junior (relative at least to the god-like status of doctors and surgeons) hospital staff given the mandate to halt or change things that they can see are not according to agreed practice, and those staff have, simply by being "empowered" to intervene, prevented mistakes from being made. So empowerment can work, and I don't agree that one person's empowerment has to be at the expense of another's. Unless, that is, you believe that authority should never be questioned, even if someone can see that it's just plain wrong. Anyway, the really disempowered in hospitals are the patients.

That's not to say that doing it is as easy as saying it, but that's where great leaders come in. (And with one bound, our hero was free.)

Posted by Rob at August 4, 2008 1:35 PM

The barriers to change within healthcare organizations are truly immense. Might I suggest the single greatest challenge facing the U.S. healthcare system is scientific focus. We have a great illusion of quality of care. We stand in awe of masters of anatomy and physiology and see great technological breakthroughs that save a life. Yet the data suggests (as suggested by TP’s Post, "The Healthcare14: U.S. Healthcare Trauma in 2008.") that the knowledge and technology are not brining about the desired outcomes. They do suggest a need for dramatic change in services rendered. Not just better customer service and process efficiency. (I get the connection between services rendered and customer service. Its application in healthcare is another conversation altogether.) What we have is a “technology” centered disease system poised for exponential growth. What we need is a smaller health centered system with far greater impact on population health. The scientific understanding to have such a system exists. It only need be applied in a customer centered, economically sustainable way. "but that's where great leaders come in."

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