April 22nd, 2013
The Science of Management and The Art of Medicine
John Ryan interviews K. John McConnell about his research group’s study of standard management practices as they relate to quality of care in hospital cardiac units. The original article appears in JAMA Internal Medicine.
Investigators used an established approach for assessing management and organizational practices in the manufacturing sector to assess performance at 597 hospital cardiac care units. Eighteen practices were evaluated in 4 domains: standardizing care, tracking key performance indicators, setting targets, and providing incentives to employees. (For a complete list of the 18 practices, click here [JAMA Internal Medicine subscription required].)
Management practices varied widely across institutions. On a 5-point scale where a higher score means better performance, fewer than 20% of cardiac units scored a 4 or a 5 on more than 9 measures. Better management practices were significantly correlated with lower mortality and with process-of-care measures, but not with lower 30-day readmission rates.
THE AUTHOR RESPONDS
John Ryan: Nearly 40% of the hospitals in your study had a mean score of less than 3 across the 18 management practices. Why are hospitals having limited success in following these practices?
John McConnell: In general, the cardiac units were performing better than I had anticipated. The Institute of Medicine reports had been beaten into my head, so I expected that units and hospitals would be doing much less in terms of improving management practices. However, with the scrutiny from Hospital Compare and the guidelines that have been promoted in cardiology, there actually has been a lot of standardization and buy-in for protocols and for modern management approaches. However, we also sensed a lack of awareness about what is possible when the quality of management is truly great.
An interesting aspect of the survey, which we have not yet published, was that at the end of it, we asked managers to rank how well their unit was managed on a scale of 1 to 10, where 10 is the best. Almost everyone gave themselves as an 8 or a 9. So they’ve adopted some good practices, but not all of them are aware how much room there is for improvement.
Ryan: How might institutions go about improving? And what examples of great success did you find?
McConnell: I think our study’s framework is a good one for measuring how well managed a hospital unit is. However, the study does not demonstrate how to move from a hospital from a score of 2 to a 5, nor does it address the science of organizational change. Improvements are still ongoing, and there is an effort to see what the practices can be when at the highest level.
That said, we could hear the excitement and engagement over the phone when we talked to nurse managers in units that had taken their management systems to a very high level. They had a tangible sense of the systems and organizational tools that empower nurses — it really gave them a sense of agency and effectiveness in patient care. Those interviews stood out because they could almost anticipate the management questions we were going to ask. With very little prompting, they would describe in detail the systems they had in place for avoiding errors, setting targets, and monitoring progress.
The majority of hospitals in our study had moved toward standardization (including, for example, standardized admission order sets), but relatively few had a process for monitoring how often the standardized policies and protocols were being followed. Similarly, many hospitals had some way of analyzing medical errors or near misses after they happened, but few had prospective policies to catch errors in advance. As an example of the latter, one hospital we studied had something called “Safety Fridays,” which involved a walk-through to determine what could go wrong — and where — before it happened.
Ryan: You found that 20% of hospitals rewarded employees the same way regardless of performance, which you characterized as a practice that can be improved. Why is this an undesirable practice, and how would you change it?
McConnell: Some of that may be influenced by nursing unions, which sometimes establish pay based on seniority rather than on how you’re doing in the position. Also, for some hospitals, once they hire someone, it can be extremely difficult to remove the person for underperformance. That type of job security can be attractive if you’re an employee, but it is probably not how you want to structure incentives if your aim is to deliver the best possible patient care. Overall, we would like to see the ability to reward or motivate better performance, along with the flexibility to re-train or remove underperformers.
Ryan: What about people who say that this kind of approach is not appropriate for medical care and that we need to retain physician autonomy?
McConnell: Thomas Lee has a nice summary of the approach that Geisinger took with their CABG practice, specifically noting that the standardization and protocols they developed were not “cookbook medicine” and that practitioners have leeway to deviate from the protocols. However, when they do deviate, they need to explain why. So there is a balance between the older “artisan” type of work versus complete standardization and automation. Too much of the former and you get unwanted variations; too much of the latter and you’re ignoring clinical nuance. Optimally we would like to have standardized practice, but there should be room for physicians to deviate from it when appropriate.
Share your observations about improving management practices in healthcare settings. How much enthusiasm for — and resistance to — improvement efforts exist at your institution?