By Richard M. J. Bohmer
Harvard Business School Press, 2009
The United States is currently under pressure to drastically reduce the costs of healthcare and at the same time improve quality. Organizations that have responded to this pressure have often been tempted to apply elements of production models such as the highly successful Toyota Production System. But people are not automobiles.
In this carefully researched and clearly presented book, Dr. Richard Bohmer argues that healthcare organizations must be thoughtfully designed and properly aligned as an integrated system, not just thrown together as a pastiche of traditional practices and borrowed parts. He spells out the six capabilities required for such a design: operating capability, performance measurement, production control, anomaly detection, analysis and adjustment and redesign.
Designing Care succeeds in formulating a useful framework for inquiry and a guide for designing an organization that successfully manages healthcare delivery. Although it is written for administrators, physicians, and others interested in managing the delivery of healthcare, the processes of organization design it uses have broader applicability, especially in situations where rapidly changing knowledge is central.
Designing Care is about cooperatively managing the care itself, not just “managed care,” a term that has come to mean keeping a tight grip on finances and resources and reigning in the excesses of doctors and patients. Traditionally, care has been in the hands of physicians with the support of nurses and others. Today, medical knowledge and technology have expanded sufficiently to require teams and even whole organizations for proper delivery. The patient experience must be coherently linked with low-cost, high-quality patient relief and with the associated clinical behaviors. Components of practical redesigns are illustrated with examples from institutions such as Beth Israel Deaconess Medical Center, Intermountain Healthcare’s LDS Hospital, The Mayo Clinic, Children’s Hospital and Clinics of Minnesota, Massachusetts General Hospital, and Instituto Clinico Humanitas.
According to Bohmer, a healthcare delivery system must integrate four core elements: medical knowledge, care processes, practitioners, and healthcare delivery organizations. A design must build on a comprehensive understanding of the underlying nature, characteristics, and requirements of the processes of healthcare. Bohmer examines two such characteristics in detail.
First, if major groupings of procedures are differentiated, what is the most efficient and effective organizational design for each? Patient conditions that are well understood can be usefully separated from those that are not. Some, relatively few, are so thoroughly understood, as in the case of diabetes, that a detailed protocol can be prepared for the steps in prevention and treatment so that even the patients themselves can carry out some procedures.
By contrast, many other conditions are relatively poorly understood and the treatments more exploratory and iterative. The design potential here is that all of an organization’s elements can be tightly designed to accommodate each of these divergent processes separately, yet make it possible for them to interact appropriately and seamlessly, depending on the organization’s specific goals and mission.
Second, given the potential for new medical knowledge, how can a cycle of learning for the continued improvement of the state of medical practice be built in? The possibilities are enhanced by available technology that can be used to analyze healthcare experiences and capture them in databases for future research and treatment protocols. In this case, the design potential is that the process of learning for poorly understood conditions and patient differences can be converted into the knowledge essential to evidence-based medicine.
As healthcare funding has become such a political issue, it is refreshing to encounter a combined physician and professor of management who advocates a fundamental understanding and a comprehensive approach.