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"Bohmer, Richard M. J"
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The Hard Work of Health Care Transformation
Examination of health care organizations that have achieved and sustained substantial performance improvements reveals that lasting transformation requires the relentless hard work of local operational redesign, led by multidisciplinary teams.
Governments and regulators influence the performance of health care organizations and practitioners primarily through positive and negative financial incentives, regulatory constraints on their licenses to practice, and support of performance-improvement activities through education, research, and measurement programs. The financial approaches aim to motivate change in the way organizations and practitioners configure their systems and deliver care, under the assumption that once they’re motivated to seek surplus or avoid sanction, they’ll be willing and able to make local operational changes to reduce cost and improve safety, patient experience, and outcomes. Unfortunately, experience shows that although a changed market may be a . . .
Journal Article
The Four Habits of High-Value Health Care Organizations
Health care organizations considered among the nation's highest performers often have unique personalities, structures, resources, and local environments. Yet they often have remarkably similar approaches to care management, common habits that may be transferrable.
Recent attention to the question of value in health care — the ratio of outcomes to long-term costs — has focused on problems of definition and measurement: what outcomes and which costs? Less attention has been given to an equally difficult but important issue: how do health care delivery organizations reliably deliver higher value?
It would certainly simplify health care reform if we could show the superiority of a dominant delivery model (e.g., the accountable care organization or the medical home) and roll it out nationwide, developing and proving new approaches to creating value only once. However, experience suggests that . . .
Journal Article
Leading Clinicians and Clinicians Leading
More effective models of care delivery are needed, but their successful implementation depends on effective care teams and good management of local operations (clinical microsystems). Clinicians influence both, and local clinician leaders will have several key tasks.
Stubbornly high costs and the expected care needs of aging baby boomers make more effective models of care delivery a pressing need. Unfortunately, new models often perform below their potential. Their designs — usually comprising some combination of alternative sites of care or caregivers, new care processes, and enabling technologies — promise global improvements in quality or cost. But successful implementation depends on two local factors: effective care teams and good management of local operations (“clinical microsystems”). Clinicians influence both.
The prospects for care redesign and performance improvement depend on clinician leadership in units, wards, clinics, and practices. Models such . . .
Journal Article
The Shifting Mission of Health Care Delivery Organizations
New payment models reward health care providers for producing outcomes rather than for performing procedures. Drs. Richard Bohmer and Thomas Lee examine the implications of this shift for the mission and operations of health care organizations.
An important transition has begun in payment for health care delivery in the United States: organizations that have long been paid for transactions, such as visits or procedures, are beginning — at least in some markets — to be paid instead for producing outcomes. As physicians and hospital leaders contemplate the implications of new payment models, they realize that the transition will be long, difficult, and messy, with major ramifications for providers.
After decades of discussion about the problems inherent in fee-for-service medicine, skepticism about whether real change is under way would be understandable. But it would be reckless in . . .
Journal Article
Organizational Differences in Rates of Learning: Evidence from the Adoption of Minimally Invasive Cardiac Surgery
This paper examines learning curves in the health care setting to determine whether organizations achieve performance improvements from cumulative experience at different rates. Although extensive research has shown that cumulative experience leads to performance improvement across numerous contexts, the question of how much of this improvement is due to mere experience and how much is due to collective learning processes has received little attention. We argue that organizational learning processes may allow some organizations to benefit more than others from equivalent levels of experience. We thus propose that learning curves can vary across organizations engaged in the same \"learning task,\" due to organizational learning effects. To investigate this proposition, we investigate cardiac surgery departments implementing a new technology for minimally invasive cardiac surgery. Data on operative procedure times from a sample of 660 patients who underwent the new operation at 16 different institutions are analyzed. The results confirm that cumulative experience is a significant predictor of learning, and further reveal that the slope of the learning curve varies significantly across organizations. Theoretical and practical implications of the work are discussed.
Journal Article
ANALYSIS & COMMENTARY: Lessons From England's Health Care Workforce Redesign: No Quick Fixes
In 2000 the English National Health Service (NHS) began a series of workforce redesign initiatives that increased the number of doctors and nurses serving patients, expanded existing staff roles and developed new ones, redistributed health care work, and invested in teamwork. The English workforce redesign experience offers important lessons for US policy makers. Redesigning the health care workforce is not a quick fix to control costs or improve the quality of care. A poorly planned redesign can even result in increased costs and decreased quality. Changes in skill mix and role definitions should be preceded by a detailed analysis and redesign of the work performed by health care professionals. New roles and responsibilities must be clearly defined in advance, and teamwork models that include factors common in successful redesigns such as leadership, shared objectives, and training should be promoted. The focus should be on retraining current staff instead of hiring new workers. Finally, any workforce redesign must overcome opposition from professional bodies, individual practitioners, and regulators. England's experience suggests that progress is possible if workforce redesigns are planned carefully and implemented with skill. [PUBLICATION ABSTRACT]
Journal Article
Managing The New Primary Care: The New Skills That Will Be Needed
Developing new models of primary care will demand a level of managerial expertise that few of today's primary care physicians possess. Yet medical schools continue to focus on the basic sciences, to the exclusion of such managerial topics as running effective teams. The approach to executing reform appears to assume that practice managers and entrepreneurs can undertake the managerial work of transforming primary care, while physicians stick with practicing medicine. This essay argues that physicians currently in practice could be equipped over time with the management skills necessary to develop and implement new models of primary care. [PUBLICATION ABSTRACT]
Journal Article
Learning How and Learning What: Effects of Tacit and Codified Knowledge on Performance Improvement Following Technology Adoption
This paper examines effects of tacit and codified knowledge on performance improvement as organizations gain experience with a new technology. We draw from knowledge management and learning curve research to predict improvement rate heterogeneity across organizations. We first note that the same technology can present opportunities for improvement along more than one dimension, such as efficiency and breadth of use. We compare improvement for two dimensions: one in which the acquisition of codified knowledge leads to improvement and another in which improvement requires tacit knowledge. We hypothesize that improvement rates across organizations will be more heterogeneous for dimensions of performance that rely on tacit knowledge than for those that rely on codified knowledge (H1), and that group membership stability predicts improvement rates for dimensions relying on tacit knowledge (H2). We further hypothesize that when performance relies on codified knowledge, later adopters should improve more quickly than earlier adopters (H3). All three hypotheses are supported in a study of 15 hospitals learning to use a new surgical technology. Implications for theory and practice are discussed.
Journal Article
Care Platforms: A Basic Building Block For Care Delivery
Without significant operational reform within the nation's health care delivery organizations, new financing models, payment systems, or structures are unlikely to realize their promise. Adapting insights from high-performing companies in other high-risk, high-cost, science- and technology-based industries, we propose the \"care platform\" as an organizing framework for internal operations in diversified provider organizations to increase the quality, reliability, and efficiency of care delivery. A care platform organizes \"care production\" around similar work, rather than organs or specialties; integrates standard and custom care processes; and surrounds them with specifically configured information and business systems. Such organizational designs imply new roles for physicians. [PUBLICATION ABSTRACT]
Journal Article