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CHAPTER 1
FOUNDATIONS OF WELL-MANAGED HEALTHCARE ORGANIZATIONS
CRITICAL ACTIONS
1. Emphasize mission, vision, and values:
• Be prepared to state your healthcare organization's mission, vision, and values (MVV).
• Know how to explain how MVV were developed by a stakeholder consensus.
• Be prepared to answer questions such as "Why are MVV important?", "Do people really believe that?", "What if I see things that do not reflect the MVV?", and "How do we use the MVV in decision-making?"
2. Recruit and support a diverse and inclusive workforce:
• Establish recruitment programs that encourage underrepresented groups to attain technical and professional skills.
• Ensure that evaluations and promotions are free of bias.
• Uphold respect as an organizational value, so that every associate is comfortable in the workplace.
3. Guide coordinated action of interprofessional care teams and support teams. Describe excellence and identify worker actions that deserve encouragement.
4. Relate to stakeholders. Know which dimensions of excellence each stakeholder group focuses on and how HCO leadership should listen to its concerns.
5. Build a transformational culture: • Seek best practices rather than fixing problems.
• Define what constitutes a "constructive response" to associates' and stakeholders' concerns.
• Practice rounding by managers and senior leaders can improve the performance of associates.
6. Use measured performance, seeking benchmarks and continuously improving.
Know the following terms and be able to explain clearly to any stakeholder how they contribute to excellence: scorecard, goal, current performance, benchmark, 90-day plan, opportunity for improvement (OFI), process improvement team (PIT).
Purpose: Mission of Healthcare Organizations
Patient care is a central purpose of any healthcare organization (HCO). Excellent care to each and every patient is often stated as the HCO's mission. HCOs provide care in a variety of inpatient and outpatient settings, using their organizational strength to meet patient needs. Many started as acute care hospitals and then grew as care sites broadened and specialized.
Many HCOs now expand their mission to "sustaining population health," a substantially broader mission seeking the World Health Organization (WHO) goal: "a state of complete physical and social well-being and not merely the absence of disease or infirmity." For HCOs, "not merely" is the operative phrase. Population health includes
• excellence in care to individual patients, including preventive care;
• fulfillment of needs that go beyond healthcare — the housing, food, and social support that are essential to sustaining health and managing chronic disease; and
• meeting the needs of people who are not patients to help them stay well and avoid becoming patients.
The US Department of Health and Human Services specifies national goals and objectives for population health in the Healthy People program. The goals for 2030 are the following:
• Attain healthy, purposeful lives and well-being.
• Attain health literacy, achieve health equity, eliminate disparities, and improve the health and well-being of all populations.
• Create social and physical environments that promote attaining full potential for health and well-being for all.
• Promote healthy development, healthy behaviors, and well-being across all life stages.
• Engage with stakeholders and key constituents across multiple sectors to take action and design policies that improve the health and wellbeing of all populations.
"Healthy, purposeful lives" is deliberately ambitious. HCOs that adopt a population health–focused mission create collaborative systems that encompass public health, safety, education, housing, and urban planning organizations to move their communities toward the WHO goals. The HCO is only one participant. Its patient care contribution is central, but healthcare disparities may be created by variations in income, race, ethnicity, and geographical dwelling place. Persons with lower incomes have greater challenges to their health and fewer resources to respond to those challenges. Housing, safety, and food supplies are often inadequate. People of color are often victims of less desirable health outcomes than white counterparts.
HCOs must address disparities and develop goals that are consistent with Healthy People 2030. Fortunately, leadership concepts that create excellence in care are also successful in the population health mission. The transformational culture and continuous improvement themes that create the best possible patient care also support the interagency collaboration that drives population health. Chapter 9 describes HCO actions that can form the foundation for this expanded mission.
Defining Excellence
Excellence in Patient Care
Excellence occurs when every patient care act is the right thing, only the right thing, and delivered as soon as the patient needs it, creating the best possible outcome for every patient. The challenge is formidable. Most serious patient health events — a birth, a heart attack, or ongoing diabetes care, for example — require hundreds of specific acts. An error in diagnosis can cascade into a series of problems that sometimes leads to fatality. An error by an early team can create problems for downstream teams. A strategic failure or a logistic failure — a staff or supply shortage, for example — can force a care team to improvise or delay care.
Excellence is a multidimensional concept. It is achieved by measuring, analyzing, and improving performance on each dimension of exhibit 1.1 and by striving for benchmark, the best-known performance. "Benchmark" is a realistic comparison — a value that a similar organization has achieved. It is often a moving target, as better processes are designed and implemented, but it marks the achievable frontier.
Excellence in Population Health
Excellence in population health is also measured and benchmarked, but the measures are of population, not patients. Population health is measured by the incidence and prevalence of disease, disability, or premature loss of life.
The definitions of incidence and prevalence illustrate the need for collaboration to achieve the population health mission. Although any HCO can calculate its exhibit 1.1 measures, the population-based incidence and prevalence measures must be approached as a community-wide project.
Sources for The Well-Managed Healthcare Organization
The Well-Managed Healthcare Organization describes excellence in proven processes used by HCOs with top-tier outcomes. It focuses on the patient care mission (recognizing that excellence in patient care is an essential foundation) and on the HCO's unique contribution to the broader mission of population health. It describes tested processes that have achieved superior results with real patients. Much of the text is based on reports of HCOs that have received the Malcolm Baldrige National Quality Award. Award recipients have carefully documented their culture, processes, and results. Their documentation has been independently audited. Their results are typically in the highest quartile and often in the highest decile. Collectively, they provide a full range of care, from preventive to palliative, to a broad spectrum of US communities. The processes they use constitute the Baldrige model, an integrated set of best practices and work processes that produce benchmark results. While there are many excellent HCOs that do not explicitly follow the Baldrige model, there are no comparable documented, audited descriptions of HCO excellence.
Team Structure of Twenty-First-Century Care
Modern healthcare is complex, expensive, and enormously successful. It has added decades to countless lives, as well as the health to use those decades productively. Its success, complexity, and cost arise from the diversity of scientific advances in treatment and the need to tailor treatment to individuals with varying needs. Healthcare delivery is almost always a team activity. Cases in which individual care providers change the course of disease are real but rare. Excellent HCOs have committed to diversity, equity, and inclusiveness in their workforce. They select individuals based exclusively on the skills they bring, independent of ethnicity, gender identity, sexual orientation, religious affiliation, or other identifying features with the goal of associates that represent the communities being served.
Clinical Teams — Interprofessional Care and Clinical Support
Interprofessional (also called interdisciplinary) care teams, shown in the top triangle of exhibit 1.2, deliver virtually all twenty-first-century healthcare. As shown in the upper left box, they provide highly specialized technical responses to diverse patient needs. They include physicians, nurses, other allied health professionals, and nonprofessional caregivers. A sequence of several interprofessional teams is often necessary as a patient's needs evolve. It is not unusual for a lifesaving event — cardiopulmonary resuscitation, cancer cure, or treatment of an endangered pregnancy, for example — to require several teams with different skill sets and several dozen different care providers.
The care teams in the top triangle have three major duties:
1. They assess and diagnose, a crucial first step and an ongoing process. Diagnosis labels symptoms and complaints as illness, indicating possible disease and its prognosis. Effective and efficient therapy — including reassurance, watchful waiting, and supporting patient self-efficacy — depends to a large extent on an accurate interpretation of (early) symptoms and the outcome of the diagnostic process.
2. They provide and coordinate treatment, integrating drugs, surgery, rehabilitation, and other activities into a plan of care that involves the patient in key decisions and maximizes the patient's safety, recovery, and comfort.
3. They monitor the patient's response and adjust treatment interventions as indicated.
Excellence of care teams is measured by their performance on the factors shown in exhibit 1.1.
Care teams are almost always small and interdisciplinary, including a licensed independent practitioner (LIP), a nurse, and other professional and supportive care providers as needed. Teams are organized to treat similar patient needs. Primary care — the patient's first contact — includes teams for general internal medicine, family medicine, obstetrics and gynecology, mental health, and emergency care. Clinical specialty teams provide surgery, intensive care, and other specific therapeutic interventions. Other teams address rehabilitation, management of continuing disability, and palliative care.
HCOs approve privileges for LIPs based on their credentials, specifying their role within the scope of their license and assigned clinical responsibilities.
Clinical Support Teams
Frontline care-providing teams are supported by other clinical teams providing specialized professional services, such as laboratories, pharmacies, anesthesia, imaging, surgery, rehabilitation therapies, and home health. Treatment plans developed by the primary care team call for specific requests and services for specific patients. The team's excellence is also measured by the six exhibit 1.1 dimensions, and the support services they provide often use powerful and potentially dangerous technology. The terms safe and effective are not trivial where small errors can be fatal. Rigorous protocols and extensive training, often professional certification, are the key drivers of clinical support excellence.
Logistic and Strategic Teams
Both interprofessional care and clinical support teams are supported by logistics teams providing information, training, supplies, facilities, food, and financing. These teams contribute to excellence by furnishing patients, guests, and clinical teams with critical resources. The dimensions discussed in exhibit 1.1 measure excellence for logistics teams, broadening "patient centered" to "customer centered." Safety remains important; HCOs are open to numerous threats, from dangerous substances to catastrophic events. Timely, efficient, and equitable care depends on these systems.
Strategic teams are responsible for achieving long-term excellence, for maintaining the teamwork structure, and for sustaining the HCO's relations to its stakeholders (individuals or groups who have a direct interest in the organization's success and whose needs shape its mission and strategies), customers, payers, and the community at large. These activities are the central functions of leadership. They are measured by the exhibit 1.1 measures and by additional dimensions, such as the extent of HCO services, unmet needs in the HCO's marketplace, and the long-term sustainability of performance.
A population health mission requires a fifth level that goes beyond the HCO itself. As noted earlier, population health is measured by incidence and prevalence of disease, disability, and premature death.
Real HCOs have used a wide variety of relationships to assemble the exhibit 1.2 teams. Historically, not-for-profit community HCOs served most of the nation, contracting with LIPs as credentialed affiliates who operated their own small corporations rather than being employed. Volunteers, usually including governing board members, have served without compensation and continue to be an important resource.
Current Trends
The current trend, however, has been toward centralization and employment. Most care is now provided by large HCOs with a full array of exhibit 1.2services. LIPs are now mostly employed, rather than independent contractors. For example, Kaiser Permanente, the largest nongovernmental HCO in the United States, uses a formal employment structure for almost all of its needs.
Clinical support teams are now employed or organized as corporations contracting with the HCO. Many logistic and some strategic needs are met by contracts with corporations providing specialized services to many HCO customers. It is still true that many thousands of small care teams operate as independent corporations, focused on specific patient needs such as psychological counseling, dialysis, and long-term care. They refer patients to larger HCOs to meet any needs outside their expertise.
Stakeholders
All organizations, including HCOs, exist because they fulfill a need that individuals working alone cannot meet, and they thrive because they fulfill that need better than competing alternatives. Organizations serve stakeholders. HCO stakeholders are patients, patient families, insurers, workers, suppliers, regulators, and owners, as shown in exhibit 1.3. Most stakeholders can choose to participate with a specific HCO or not. Any HCO's survival depends on attracting sufficient numbers of each kind of stakeholder; otherwise it fails and disappears.
Stakeholders' desires are inherently conflicting. Patients want immediate service; insurers want low costs; workers and suppliers want high compensation. HCOs and other organizations exist by negotiating solutions to those conflicting desires. Business can be understood as a set of relationships among groups that have a stake in the activities that make up the business. Business is about how customers, suppliers, employees, and managers interact and create value. To understand business is to know how these relationships work. HCOs represent one of the most complex applications of the stakeholder model. Stakeholders in each of the four categories actively express their needs and can "vote with their feet" — that is, change their affiliation to a different HCO. Leadership's basic obligation is to identify and meet the stakeholders' important concerns and to negotiate unmet needs as opportunities for improvement (OFIs). The following sections identify the principal concerns of the major groups in each stakeholder category: patients and families, associates, other customer partners, and owners and community groups.
The exhibit 1.1 criteria fulfill most stakeholder needs. HCOs that excel onexhibit 1.1 measures thrive in the stakeholder marketplace. They become "great places to get care" and "great places to give care," easily passing governmental and accreditation requirements. Their finances are strong, and their owners have no cause for concern.
Patients and Families
Patients seek accurate diagnosis and effective treatment but also confidentiality and as much comfort as possible for themselves and their families. Patient-centered care increasingly involves patients and families in providing "care that is respectful and responsive to individual patient preferences, needs, and values."
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Excerpted from "The Well-Managed Healthcare Organization"
by .
Copyright © 2019 Kenneth R. White and John R. Griffith.
Excerpted by permission of Health Administration Press.
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