Understanding and Managing the Complexity of Healthcare

11 Facilitating Change

Chapter 1 initiated the discussion of the extent of fundamental change needed across our healthcare delivery enterprise. There is no doubt that incremental business process improvements can certainly yield measurable benefits. However, these types of changes will not be transformative. They will not be sufficient to result in the healthcare delivery system we seek— high quality, affordable care for everyone. Most people think that the healthcare system in the United States is broken and that we need to get about the business of fixing it. The truth is that the system cannot be fixed in the sense that an engineered system can be modernized by upgrading the propulsion system, enhancing the electronics , and so on. Our healthcare system was never engineered to provide quality, affordable healthcare to everyone; it just emerged to respond to the demands at the time (Rouse, 2000, 2008; Rouse & Cortese, 2010). This chapter considers the prospects for an engineered system that will provide these benefits. There has never been a vision or systematic design for healthcare in this country. Historically, physicians—as independent business owners— hung out their shingles and provided care to patients. Little thought was given to how these providers would relate to one another or to ancillary healthcare entities, such as medical supply and insurance companies. We should not be surprised, then, with the outputs of our system: lack of insurance, widely variable outcomes, inconsistent service, and low safety results. Further, these less than desirable outcomes are achieved at very high overall cost. It is clear that tweaks to our homegrown system will not work. Instead, we need to step back and design a true system of healthcare delivery. Engineering systems clearly plays a crucial role in this process. Several universities —including Georgia Tech, University of Wisconsin at Madison, Purdue University, and Stevens Institute—have begun to offer engineering 11 Facilitating Change 234 Chapter 11 programs in healthcare delivery. Physicians, nurses, and engineers must become partners to design interdependent systems that will measure and produce what we want from our healthcare delivery system—the best outcomes , safety, and service for all citizens at the lowest possible costs. In other words, we seek a high-value system. To consider how best to transform healthcare delivery, we first must consider the nature of enterprise transformation. Enterprise Transformation A variety of forces are driving change in the world. Globalization has become incessant, with outsourcing and offshoring on the agendas of most large enterprises. The service economy is becoming increasingly dominant in developed economies, with knowledge assets playing a greater role relative to physical and financial assets. Security has become a primary objective crossing virtually every sector of the economy and society. At the same time, according to Thomas Friedman (2005), the world has become flatter. Information and communications technologies have enabled developing economies quickly to progress on the path toward equity with developed economies. Thus, for example, China, India, and Japan graduate almost 1 million engineers per year while the United States graduates 65,000. Compounding such disparities over years and decades will undoubtedly undermine the competitive advantages of developed countries—unless we change the nature of the game. Changing the nature of the game will require fundamental transformations of many enterprises and, in the context of this book, healthcare delivery enterprises—providers, suppliers, insurers, employers, and so forth. Business process improvement, or even business process reengineering, will not be sufficient. It is not just a matter of getting better at what we already do—everyone is doing this. It is an issue of doing new things in new ways. This will necessitate fundamental change. Unfortunately, we will not necessarily succeed with such changes. Indeed, most historical attempts at fundamental change have failed (Rouse, 1996, 1998, 2006a). Enterprise transformation is driven by experienced and/or anticipated value deficiencies such as losses of market shares, profit margins, and brand images due to the marketplace coming to prefer other choices, often alternatives with better features, higher quality, better service, and lower prices. Responding to such value deficiencies requires significantly redesigned and/or new work processes as determined by management’s decision-making abilities, limitations, and inclinations, all in the context of the social Facilitating Change 235 networks of management in particular and the enterprise in general (Rouse, 2005, 2006a). More specifically, enterprise transformation is driven by perceived value deficiencies relative to needs and/or expectations due to: • Experienced or expected downside losses of value due to...