Bureaucracy Is Keeping Health Care from Getting Better

In a recent article, Gary Hamel and Michele Zanini detail the toll that growing bureaucracy is taking across industries. Many of those working in the consolidating health care industry will immediately validate several of the authors’ key findings, including:

• Bureaucracy is growing, not shrinking.
• Bureaucracy is destroying value in innumerable ways, including slowing problem solving, discouraging innovation, and diverting huge amounts of time into politicking and “working the system.”
• CEOs are substantially less likely than frontline staff to see bureaucratic barriers in their organizations.

I’ve seen many health care organizations where the clinicians and other frontline staff who actually help patients are subject to increasing numbers of fragmenting directives from above and are forced to devise work-arounds to cope with ineffective problem-solving systems.

What about solutions? Hamel and Zanini declare that there is “no map to disassembling bureaucracy.” I beg to differ.

INSIGHT CENTER

Great organizations across industries fight bureaucracy by explicitly structuring their leadership systems to connect everyone in the organization to the issues that the front line is encountering every day. They carefully define the roles of each layer of leadership to include supporting the rapid solving of frontline problems and developing those under them to do the same. Designing and actively managing their systems of daily operation (production), management, and improvement with this clear intention to fight the wastes created by bureaucratic behavior becomes the core of their competitive advantage.

Two cornerstones of this approach provide clear examples of how to fight bureaucratic bloat: lean daily management systems and a real-time problem-solving approach to eliminating workplace injuries.

Lean daily management systems were pioneered by Toyota, Honda, and other manufacturers. As John Toussaint, the CEO of Catalysis and the former CEO of ThedaCare, a health system in Wisconsin, explains, such systems, when designed and operated effectively, ensure that every leader has explicit work that they must do every day to help understand frontline problems and improvement opportunities. Lean daily management makes top-level goals and strategies very clear and present for everyone in the organization and ensures that leaders’ efforts help, rather than hinder, the frontline work necessary to meet those goals.

Real-time safety learning provides a complementary antidote to bureaucratic bloat. At Alcoa, DuPont, and other world leaders in safety, any injury is reported all the way up to the CEO, investigations and solutions are reported within 48 hours, and all of this information is shared with everyone in the company every day. For leaders, this provides a daily, concrete, values-centered indication of whether the organization is effectively learning and solving frontline problems, or whether those signals are being blocked and why. It has proven to be a great mechanism for improving operations as a whole, because it forces the bureaucracy to support, rather than impede, the rapid breaking of barriers, problem solving, and frontline learning and empowerment.

Happily, a number of pioneering health care organizations are using these approaches to successfully combat the detrimental effects of bloat. To cite just a few examples:

ThedaCare pioneered lean daily management to protect and extend care model innovations that improved quality and reduced the cost of care by 30%.

At the University of Virginia Health System, the CEO leads a huddle every day in which the health system leaders and a “slice” of each part of the organization review the unexpected deaths of patients and every injury due to incidents, such as medication errors or falls, that occurred during the previous 24 hours. This huddle team also assesses the strength of the problem solving and how effectively warnings and learning are being shared across the health system. Its members will often visit one of the clinical units where an incident has occurred, concretely demonstrating to the staff the importance they place on rapidly learning from incidents.

In the Minneapolis–St. Paul metropolitan area, the Fairview and HealthEast health systems recently agreed to merge. They’re doing so not just because the deal makes geographic sense in a consolidating market but also because both systems’ CEOs are committed to using lean management to achieve goals.

It’s easy for organizations to start using these techniques. One simple approach is for leaders to have an internal or external adviser versed in these methods to guide them in directly observing frontline work. Within 20 minutes leaders will see things that they haven’t learned in years of meetings. Some of it will be exciting: Their people have the motivation and talent to delight patients. Some will be upsetting but instructive: One executive saw a nurse hunt for an IV pump for his patient for more than 20 minutes. Another discovered that hot water had not been available in several intensive care units for several days because bureaucratic barriers rooted in budget issues and politics were inhibiting departments from working together to fix the problem.

Bureaucracy is destroying more and more value in many health care systems, but it doesn’t have to be that way. There are proven ways to fight back. They entail consciously designing your management systems to liberate the capabilities of all employees so that they can be used to address patients’ needs.