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.


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?

4 Responses to “The Science of Management and The Art of Medicine”

  1. Meera Mathew, M.D. says:

    Medical staff and institutions have become entirely too reliant on protocols to practice medicine, encouraging unnecessary tests and complications. Administrators are only happy to encourage as there is money to be gained in excessive testing and recurrent visits/admissions. Guidelines/protocols play an important role and we must pay attention but they do not substitute for individualizing care in the art of medicine. Those physicians who want to practice ‘critical thinking’ are penalized for not following the ‘cookie cutter’ protocols. There is something to be said about a good history which provides 80% of the diagnosis, and appropriate necessary tests should be done to support your differentials. Not the other way around which has been too often the case in the current climate of medicine.

    “Excessive Medicine” has helped those who have a financial interest including physicians who are on ‘pay for performance’ formula without having to think. Patients and country’s economic health are at risk as a result.

  2. Enrique Guadiana, Cardiology says:

    Some people think Life is an equation they use a lot of time sorting and measuring. People use clasification mainly to communicate, they are man made so they are imperfect and many times Arbritary. Are we profiling people and practices? Are we oversimplificating in medicine? Making the same mistake that have divide the world and produce so many grif. The medicine is so complex that humble must of the practitioners. Are we loosing the core of medicine to a bunch of administrators and merchants. Who can measure relations, good life, love? Who can measure appreciation, a smile a thank you? If this is medicine I will become a Chef at least they understand and follow recipes…. but not always.

  3. Kenneth John McConnell, PhD says:

    Hi there and thanks for those comments. I agree that there is tension between standardization and autonomy, and that managers can get this balance wrong. Done incorrectly, management can undermine the important “human” aspects of the patient-provider interaction.

    See the discussion here

    for concerns about too much standardization. Of note, an important tenet of Lean is that physicians can deviate from the standards and protocol, although they are supposed to document these deviations. Done correctly, good management practices should facilitate the types of care that you suggest are beneficial – for example, freeing up valuable provider time so that a complete history can be taken.

    I do wonder if the concerns expressed here are similar to those that Atul Gawande found when conducting his research on surgical checklists. When he queried physicians on the appeal of these checklists, many of them did not want to use them. But, when he asked them if they were the ones having the operation, would they want the checklist? 94% responded that they did.

    So, as a thought experiment, consider two hospitals. Hospital A has standardized admission order sets. At Hospital B, order sets are determined on an ad hoc basis. Hospital A has a policy in place to proactively identify areas where medical errors might occur before they happen. Hospital B only responds to errors after they occur. Hospital A allows family members to call a rapid response team if they feel that their loved one is deteriorating at bedside and a nurse cannot be located. Hospital B has no policies or plans in place if this situation arises. Nurses at Hospital A, when asked about the goals of their unit, state that they are trying to get their CLABSI rate down to zero. Nurses at Hospital B, when asked about the goals of their unit, cannot describe any.

    These are the type of practices that we attempted to measure. If this was all you knew about Hospital A and Hospital B, where would you want to send a family member if they needed care?

  4. Enrique Guadiana, Cardiology says:

    I believe that all of us apreciate procedures to improve outcomes and avoid complications. My concern is what to measure and how to measure it? I suggest this experiment. Consider two hospitals, same level in points. Both hospitals have standardized admission orders. But in one hospital you add in the list the following question: in your experience, how is the patient, do you have any concern, any suggestions? To promote the participation you tell them the answer is confidential and under any circumstance will it have any penalty. I would prefer to work or be a patient of this hospital. The providers are learning how to check a list, how to write a medical record in a safe way, the legal way and the administrators in the profitable way. I believe that real medicine, this days, is not completely in the medical records or check list. Are we creating a point system to improve medicine or to avoid penalties? How does this differ from the behavior to ask for many studies to avoid legal liability?, How are we going to avoid this?