1.7. The Structure of This Book
Our focus is within the walls of the hospital, but occasionally it extends to extra-hospital initiatives. For example, if inpatient capacity is strained, one possibility would be to reduce demand by promoting healthy lifestyle choices or home therapies, possibly through a website. If the ED receives a pulse of older patients on Monday morning because no registered nurse (RN) was on duty in local nursing homes over the weekend, one response could be to put a hospital staff RN into the homes. In this way, we recognize the close interdependence between the hospital and the community it serves, but we consider it through the lens of hospital management rather than the broader perspective of public policy.
Until the final chapter, we assume a hospital configuration that is consistent with current practice. Specifically, we view the hospital as divided into four identifiable areas: ED, nursing units, ORs, and diagnostic facilities. We devote a chapter to each of these, and within each chapter we follow the common content format shown in Exhibit 1.6.
Exhibit 1.6. Hospital Operations general chapter outline.
We begin each chapter with a “stakeholders’ perspective” narrative (that continues through all of the chapters) before turning to unit-specific material, beginning with an introduction, brief history, and the unit’s assets and flows. We then list common metrics by which the unit’s performance is judged and some management decisions that the unit must make in practice. This is followed by two or more key management challenges, and for each we provide an introduction, affected metrics, relevant management principles, and a translation of principles into practices followed by illustrative case examples. Each chapter then ends with a continuation of the narrative.
1.7.1. Principles-Driven Brainstorming
To solve problems for complex organizations, it is helpful to begin with a broad landscape of options from which to choose. It is universal in books on brainstorming and innovation that one should not narrow the focus too early to only a few options. Rather, one should start with a long, open-ended, and uncensored list of possibilities to be sure that all options are considered. Then, using judgment, this list should be winnowed down to the most promising few, which are subjected to more detailed and rigorous analysis. The most difficult part of this exercise for many people is not the analysis part, for which tools exist, but the brainstorming part that involves coming up with a wide array of options. This is called the concept generation stage of an innovative process and entails a long list of concepts being generated prior to the concept selection phase of choosing one or a few for closer scrutiny and eventual implementation.
Principles-driven management provides a helpful tool for concept generation. Principles relate precursors to consequences, so if we want to improve the consequences, we should work on the precursors. For example, suppose the management challenge is to reduce delays getting onto the surgical schedule. What can we do to shorten delays? By turning to the principles, we can list the causes of delays and look at each of these individually as an opportunity. Delays, for example, can result from excessive workload, insufficient capacity, poor synchronization of demand and capacity, high variability, or poor sequencing of the jobs in queue. Improvements can be achieved by working on any one of these subtopics. So, in a brainstorming exercise, we can think of all the ways the hospital can work on each subtopic. For example, the hospital can reduce workload by reducing the patients served per day or reducing the time per patient in surgery. Likewise, increasing capacity, improving synchronization, reducing variability, and improving sequencing can be broken down into more detailed components. By continuing in this fashion—breaking down higher-order concepts into more detailed concepts—we will eventually reach a level of implementable specificity. By this process of cascading refinement, a few general principles beget a wide array of specific potential solutions.
Because each higher-level concept generates many lower-level offspring, after two or three levels we will have constructed a long list of possible action items. This is good and signals a robust concept generation phase. Many of the options may be infeasible, undesirable, or difficult to implement for various practical reasons, but all of them should still be listed. The worst enemy of a productive concept generation activity is premature censoring. Sometimes an option that appears impractical can, with a small twist, become a novel and winning solution.
This principles-driven brainstorming approach is used for the key management challenges covered in each chapter. The reader may want to flip through a few chapters and inspect the tables. Their size will be striking. The illustrative cases then describe how to analyze or implement one or a few of the options in practice. Once a reader is familiar and comfortable with this approach, he or she can use it for other challenges not covered in this book. The principles and our approach are generic.
While examining the management challenges of the different units of the hospital, it quickly became apparent that three issues—responsiveness, patient safety, and organizational learning—are ubiquitous. Responsiveness is a common problem because delays negatively affect both patient satisfaction and clinical consequences. Whether the challenge is to reduce delays in the ED, the ORs, on nursing units, or in the lab, the underlying principles driving delays are the same. Similarly, ensuring and protecting patient safety and promoting organizational learning are issues that arise in many contexts and are amenable to some general principles regardless of context. So, for each of these generic management challenges, we have constructed the first three levels of the brainstorming process and have summarized them in three generic tables in Appendix A. When addressing one of these three generic challenges, a reader can start with a pre-populated generic table and then continue to break down the third-level list of options into specific action items.
1.7.2. Policies Progress but Principles Persist
The management principles presented in this book will continue to apply regardless of how the health care policy regime eventually evolves or what internal hospital structures dominate in the future. Although our division into the four subunits (ED, OR, nursing units, and diagnostics) is common in modern hospitals, one criticism of this structure is that it accepts as given the one thing that most impedes seamless patient care: a lack of cohesive integration between these subunits. Patients (and their information) often must pass through all of them during their acute-care experience (see Exhibit 1.7), and lack of coordination among them leads to poorer clinical, patient satisfaction, operational, and financial outcomes. While we focus on individual sections of the hospital, because each has its own culture of practice, the need for coordination between sections cannot be ignored.
Exhibit 1.7. Hospital flows.
We pay attention to this need in some of our managerial challenges. For example, sizing inpatient units must take into account the need for post-surgery beds for patients coming out of the ORs (see Section 3.4.1). In other cases, the unit-specific managerial challenge that we cover can extend to interunit issues. For example, managing shift-to-shift patient handoffs on a nursing unit has the same character as managing ED to bed floor admissions handoffs (see Section 3.4.3).
However, we delay until Chapter 6 a more thorough discussion of alternatives to current practice in the internal organization of hospitals. There, we contrast the evolution of hospitals as service organizations to known evolutionary trajectories in other industries. We note that hospitals have been sheltered from the natural economic and competitive pressures that force firms in most industries to transit from “job shops” with poorly connected islands of expertise to “flow shops” of seamless processes as time and technology advances. The life-saving mission of hospitals does not exempt them from these pressures, but it does make addressing them significantly more complicated. In the end, however, the same erosion of economic surpluses that is threatening values-based conduct will challenge the current organization of health care services.
However, there is nothing in the future of health care that changes the basic principles of management. By focusing on these principles in the context of current practice, we equip readers to think strategically about their future and leverage fundamental management insights to get there. In the midst of an acknowledged health care crisis featuring high expenditures, mediocre outcomes, and confusion at the policy level, there are things we can and should do at the level of the most important transaction of all—that between patient and caregiver. It is to these we turn in the remainder of the book.