As we examined the world’s healthcare systems to find best practices, we identified many providers that had successfully increased the productivity of their professionals while also achieving gains in quality and enhanced attractiveness of healthcare work.
What we found was that, while providers vary in structure, resources and culture, there were a number of commonalities that characterized the systems that had found a recipe for productivity, quality and attractiveness gains. We call these the five successful habits for improving workforce motivation and productivity.
The first characteristic is that successful organizations tend to exhibit a strategic focus on value for patients, accompanied by empowered professionals who are responsible (often jointly with line management) for the organization of the care delivery process. Successful organizations also demonstrate strong capabilities in intelligent task and business process redesign. This means that care tasks for patients are re-allocated in a way that allows the different skills of professionals to be maximized in an environment where no task is seen as ‘out of bounds’ for some professions because of boundary disputes. As a result, decisions and responsibilities are handed to those who are best equipped for the task regardless of ingrained customs. This empowerment of different professionals goes hand in hand with the fourth habit of successful organizations which sees the control of these professionals over the outcomes of their work enhanced through increasingly sophisticated ways of steering on outcomes by leveraging available management information. Indeed, with the proper information, professionals are often able to monitor their own work processes and improve quality and productivity performance. In addition, access to management information has been shown to help create greater levels of accountability between the professionals and organizational leadership. Finally, successful organizations also tend to actively manage staff performance in a way that empowers staff to flourish through the adoption of a variety of policies such as developing clinical leadership and accountability, training and education, intelligent absentee management and so forth.
Writing in the New England Journal of Medicine Dr Tom Lee of Massachusetts General Hospital says: ‘“Value” is a word that has long aroused skepticism among physicians, who suspect it of being code for “cost reduction.” Nevertheless, an increasing number of healthcare delivery organizations now describe enhancement of value for patients as a fundamental goal’. It is clear from our case studies that this is the key first step to unlocking improved quality, reduced costs and increased productivity. Organizations need to have a clear view about what constitutes value for patients and use this to set its strategy, measure success and as the basis for conversations with front line staff. Having a strong sense of purpose based on what matters to patients and ensuring that there is a focus on this at all levels of the organization means that it is much more likely that there will be alignment between professional and managerial goals. This is a crucial requirement for success in the other key habits we have identified and makes difficult conversations about the redesign of work processes, performance, etc easier and more constructive. Our global research shows that successful organizations need to embed the search for value for patients in all aspects of the organization including their goals, management information, recruitment methods, reward systems, strategies and the behavior of staff at the frontline.
Command and control methods do not work well in complex environments. Staff that have limited discretion will be less able to solve problems, identify improvements or exercise initiative: worse, low levels of autonomy have been found to have a negative impact on patient mortality and the retention and recruitment of staff. Daniel Pink’s summary of the research in this area has found some surprising results. For simple tasks, standard monetary motivators work, but they may not work at all for complex and cognitively demanding tasks. Staff need pay that meets their needs and feels fair but once this is in place, three additional factors are required:
There are some additional steps to ensure that empowerment is effective. Firstly, if professionals are to be in the lead they will need to learn leadership and team working skills and be coached and supported as they learn. This needs to include improvement skills and the time to use them. Secondly, as the Virginia Mason case study (see page 24) shows there often needs to be an explicit discussion about what is expected from staff and how they will be held to account. There needs to be a change in the traditional relationship between physicians and their organization. In the past there has been little accountability and autonomy was interpreted as the freedom to practise medicine in a wide variety of different ways unconstrained by cost considerations. A new model of responsible autonomy needs to be negotiated in which professionals are held to account for outcomes and where decisions to depart from evidence based pathways of care are recorded and discussed. For nurses and other staff more autonomy and control, supported by high quality front line leaders is important. Thirdly, empowerment is supported by improved team working which is also associated with fewer errors, lower nurse burnout and higher quality care — including possibly reduced mortality. Team working does not just happen and needs to be developed and nurtured.
Many tasks and processes in healthcare have not been systematically designed and often have more to do with the convenience of the staff and tradition than with the needs of the patient. The widespread use of methods to improve efficiency through the standardization and systematic redesign of care is a key habit of the organizations we studied. The best embed continuous improvement in the work of their staff as well as more radical redesign of staff roles and work processes. A surprising finding is that improved efficiency, which may also mean seeing more patients, can increase job satisfaction by removing the pointless work staff have to do to fix broken systems, look for missing equipment or deal with failure to get care right first time. As we see in the case study from Mozambique, sometimes quality and costs can be improved by training workers to take on tasks that have only previously been done by doctors. While there are many opportunities to shift tasks to lower paid and less extensively trained staff it is a mistake to assume that this is always the answer. In emergency care it seems that having the most skilled and experienced decision maker as early in the process as possible produces better results and lower costs. In the example from Buurtzorg efficiency is maximized by integrating tasks. The extra costs incurred by using better educated professionals for tasks that could be done by lower paid and less qualified staff are offset by the reduction in travel times, the costs of hand offs and the improved decision making by staff who can use their judgment to decide what is required and identify problems. There are unexpected benefits from this, for example, while the home care nurses are doing less demanding tasks they can talk to the patients and identify risks and issues that can reduce future costs. The need to match the right skills to the task is one of the reasons why the use of pathways is a key strategy for improving processes. As the case studies from Aravind Eye Care and Circle show they are also important as tools for improving performance, eliminating waste and in engaging clinical staff in design and improvement. This is an example of how leading organizations have started to treat knowledge management as a key organizational competence. Best practice can be designed into processes rather than having to rely on hiring the most knowledgeable individuals.
Richard Bohmer of Harvard Business School identifies a number of habits of high performing organizations including: the measurement and oversight of clinical work and self-study. The best organizations are collecting more information about processes and outcomes than those required by regulators and other external reporting and they use this to drive improvement. The end point is to steer the organization by outcomes — for example measuring infection rates rather than adherence to hand hygiene policy. There is some way to go before this is a reality. The best organizations use their internally generated data to test ideas for improvement and to generate new knowledge about what works and change their practice. This requires staff that are clear about value (habit 1), empowered and trained to make improvement (habit 2) and have the tools to specify and design high quality care (habit 3). The measurement and feedback habit re-enforces this culture of improvement. In the case studies we can see how Circle and Avarind use the monitoring and sharing of outcomes with professionals to create a drive for improved outcomes. Similarly, by monitoring patient satisfaction and overall costs of care, Buurtzorg have managed to demonstrate to payers that their business model (employing more expensive nurses, in selfsteering teams) is more cost effective and works.
Human resource management is underdeveloped in many healthcare organizations. It is often transactional, traditional and risk averse. It often lacks a strategic perspective and is generally not prepared to challenge current practice. While many of the high performing organizations featured in this report have taken an innovative approach, they also appreciate that these initiatives must be built on a platform of basic good practice. Failure in this area can fatally undermine staff commitment to the values of the organization and their support of its leadership. These practices must start right at the recruitment stage by ensuring that staff not only have the right skills but that they understand and support the values of the organization. The recruitment of people who are resilient in the face of change seems to be an important factor. Induction into the organization is taken seriously and is compulsory, even for top managers. In our case studies, staff have clearly defined roles supported by systems for ensuring that they get high-quality feedback and appraisals that are linked to rewards and based on metrics that are meaningful. As well as recognizing and rewarding good performance, the best organizations are also rigorous about dealing with poor performance, behavior at odds with the values of the organization and absenteeism. There is a strong business case for a focus on staff well-being and the experience of staff. These foundational processes need to be part of a wider approach to quality governance found in the best organizations where the Board plays a key role in setting objectives and values and ensure that these are upheld and permeate the organization. We now look at some of the detailed experience from around the world where these five approaches have been effectively applied.