In the following interview I asked a chief doctor of a hospital about strategy, management, and the experienced differences between professional guilds often leading to tensions in the working environment.
Editor: Process management in hospitals has gained in importance due to an increasingly competitive environment of the healthcare industry. Our hospital has become more process oriented as well and recently started to work on process (re-)definition. What opportunities and risks do you see for your department?
“Your question is challenging. If you ask about opportunities and risks in our daily routine, the biggest opportunity presents itself by getting a different view from outside, from people whose thinking is not medically oriented, who look at procedures and question the status quo. Getting such views is valuable.”
“At the same time, this also poses a risk: a view that does not account for patients, their individuality and their needs, can lead to such consequences you mention with your questions below. People who are not acquainted with the handcraft try to optimise processes without understanding why the processes are implemented the way they are. Using a metaphor: A shoemaker can probably better assess the process of shoemaking than a consultant who never manufactured a shoe. We should not forget the fact that we are not Toyota, i.e. working in the car industry – the prime example of process optimisation – where they could eliminate all waste and useless work and therefore optimise production. We are not an industry in the classic sense, and we don’t have a standardised product. Each patient is basically unique. Therefore, processes can only be optimised at a superior level.”
Editor: The arguments for more process orientation draw on performance management, resource optimisation, information management, the ability for benchmarking and interconnection with other players in health care. From the view of medical science and practice, is transparency a desirable attribute and what about doctors’ freedom of treatment?
“I don’t think doctors have absolute freedom of treatment. Decision making about the nature of treatment are based on ‘outside’ knowledge, e.g. literature, experience made elsewhere. There is a big opportunity to build networks with other hospitals and to exchange experience. Also, our decisions are made together with the patient, or at least with patient’s agreement, after explaining why and how a certain therapy is applied. Therefore, I don’t think process orientation limits doctors’ freedom of treatment. And I also think it does not necessarily lead to more transparency and comparability. It is directed towards cost control. If you want to discuss process optimisation, you need key performance indicators (KPI). And concerning quality of treatment: a totally difficult task to get KPI, requiring heroic efforts. For example, patient satisfaction: A patient is happy if the food was delicious, and if patient care was courteous. And what do you take from that? Another example: mortality. In a big hospital like ours where you have referrals of difficult cases – of course there are more casualties. If you compare us with a smaller hospital you get a distorted picture. The question is how to measure and which KPI are useful in health care.”
Editor: The administration of a hospital is increasingly composed of people with business and economics backgrounds (Albrecht and Töpfer, 2006). The various professional guilds – especially the medical fraternity and business oriented management – are often “worlds apart” (Glouberman and Mintzberg, 2001) because of differences in education, incentives, value systems, etc. Can business oriented models contribute at all in a medical department (Gynaecological Department, Emergency Department, etc.)?
“I would like to come back to my Toyota example. Of course we can learn from the car or any industry – but I would never take it as given and try to implement it in health care. The biggest problem between the medical fraternity and business oriented management is the lack of understanding on both sides. Administration has no idea what we are doing, and most of the doctors have no appreciation for business management aspects. That is really a big problem, as these guilds don’t even find a common language that could take them forward. It does not help if administration tries to optimise ‘production’ and it only makes our work more difficult. The process may look as good as it gets on paper, but at the end to no avail. Another risk is that much effort is spent in process optimisation, but some processes can only be defined to a certain granularity: a patient is not a clearly defined product and there is no standard way of treatment which could be optimised from A to Z.”
“I have a big dream: that the people with an administrative background, who know the business oriented models, would help me to extract useful KPI. And as I said, this should happen before touching any process and trying to optimise. We have no KPI as of today. The other thing is that impulses from other disciplines can be very inspiring. As Mintzberg mentioned, the professional guilds are really different worlds, but we might wring an advantage out of that.”
Editor: The danger of process orientation is that patients become an economic commodity rather than sick people in need of specialist treatment (Public Administration Select Committee, 2003, “perverse consequences”). How can a medical department balance individuality of patients against standardisation of procedures (Mentges, 2006)?
“Personally, and all the doctors I know of, are primarily concerned with the patients’ wellbeing. And then, we don’t have clear boundaries that would allow us to see everything in black and white. But we can take more or less reasonable pathways in order to achieve a desired outcome. In practice it means we have some economical thinking in the background, e.g. procurement of materials and pharmaceuticals, but treat the patient the way we think is correct. I would never send a patient home just because diagnosis-related groups (DRG) tell me that this patient has used up his lump compensation. It would be the day I change my job should this happen (and many colleagues would do the same). It is the big responsibility we have towards the patients, our ethics. Standardisation supports us in terms of a checklist, so we don’t miss anything crucial with each and every patient we treat. Standardisation can give us some guidelines or boundaries as we go along. But each patient requires an individual decision, and this is clear to all medical professionals.”
Editor: To take an example process: the Manchester Triage System (MTS) was introduced in 1996 by the Manchester Triage Group in order to determine the priority of patients’ treatments based on the severity of their condition (Mackway-Jones, 1997). The Anglo-Saxon world quickly accepted MTS, whereas in Switzerland the system was adopted relatively late. What is the situation in our hospital?
“We introduced MTS approximately two years ago, and yes, this makes us a late adopter. Switzerland is indeed late with the adoption of MTS, and also the other system we used before was implemented only 4 years ago. We are late with everything – DRG is another example. On the one hand, economical aspects of health care in Switzerland come secondary – or used to be inferior until the introduction of DRG in 2012. Before that, a hospital was a necessary public service, and a cost factor as a logical consequence, i.e. loss-making. Only private clinics worked in an economical direction, but generally they have no emergency department (ED). On the other hand, paramedicine has become an independent subject on its own in the last couple of years with the effect that we look across the borders and learn what other countries are doing. Exchange of knowledge is more common now.”
“The reason for having a triage system is when we find ourselves in a situation of permanent capacity overload. To be honest, Switzerland cannot be compared to situations we find in Australia or Manchester. We don’t really know capacity overload in hospitals. If you consult some literature and read what crowded emergency rooms mean in Australia and what is the case in our context, then you can also speak of “worlds apart”. In Switzerland we complain on a high level. The time slots we are allowed in the triage system are much higher than those we actually need here. Even the triage system itself was adapted for Europe to have shorter waiting slots. And this might be the reason why there was not really a need to have MTS. So we need it only to be prepared for times of higher demand. Of course if you introduce such a system, you always work with it, not just if you find yourself in a ‘crowded’ situation. Additionally, MTS was not very popular in Switzerland because the Swiss Organisation for Paramedicine favoured another system which is called IES. In contrast to MTS, IES also considers expected consumption of resources – a very important aspect. In other words, such considerations whether a patient needs x-ray, laboratory analysis, wound treatment, etc. However, many triage experts are not very much concerned with which triage system is adopted, but that there is one in place at all. Important is to take one that matches the situation in the hospital. We have evaluated many and think that MTS is very useful in our daily practice. Especially when you have the younger, less experienced doctors on duty and you face a high workload, it helps them to prioritise their assignment. The first triage is done by nurses, and the second by the doctors.”
Editor: In his seminal article, Porter (1996) argues that operational performance optimisation – which includes process orientation – is not a surrogate for strategic thinking. In my search for a hospital strategy, I found a declaration of intent at best, but nothing that would make for a strategy. Do you think that a known strategy would facilitate work (Drucker, 1990) or is the general orientation given in your department anyway?
“From a medical point of view, it is very clear what we have to do in our clinic. We don’t need a strategy to do our work. But if we think of a planned direction of our house or of the clinic, and if we think long-term, a strategy is indispensible. It is of uttermost importance how to attract young academics, how to focus our efforts, how to acquire patients, increase employee motivation and job satisfaction – it has implications on our daily work. It is not a piece of theory: first you need to know where you are going, and then how to get there. I miss the big picture. You have fifty clinics in a hospital, with fifty chief directors, and everyone looks after themselves. All have their particular interests and it is not orchestrated. You can only have a look at our hospital information system (HIS), where each department has its own forms. Even here there is no ‘strategy’ to keep it simple and have a common work base. I admit it is not an easy task and sometimes it involves having to say ‘No’ even to some important individual. The fact that hospitals are very hierarchical constructs does not make is easier as well. Anyway, the paroles they sell us as ‘strategy’ at the moment, like growth and 10% more patients – a bit of Ansoff – does not give a direction. Accordingly we see the consequences: jobs are created although we don’t need them at the moment. A dangerous situation…”
Editor: I noticed that all hospitals define their orientation, processes and procedures on their own, i.e. re-invent the wheel. Is that really necessary? Is every hospital basically an isolated entity?
“Not at all. No. There are things which need some customisation. But there are many things some hospitals developed which could be transferred to other organisations. Take IT as an example: As doctors with a very busy day, why do we have to attend additional project group meetings and develop a basic patient history for our HIS? I don’t understand it. Why do we have to redefine the OP management? Too much wasted energy, and I am sure there are already dozens of acceptable solutions on the market. Our hospital does not need an isolated application for every bit. And if we look beyond our own nose: We are an educational hospital – a training place for academics. Why must an assistant doctor, who used to work in one hospital, learn to handle our HIS from scratch when he starts to work here? Why are they not the same? And in the next hospital it is different again!”
Editor: Thank you very much for these insights, chief doctor.