Fixing Health Care from the Inside, Today

How can health care professionals ensure that the quality of their service matches their knowledge and aspirations? As a number of hospitals and clinics have discovered, learning how to improve the work you do while you actually do it can deliver extraordinary savings in lives and dollars.

Last year on Christmas day, a 32-year-old Belgian woman celebrated the birth of a healthy daughter. Nothing remarkable about that, you might say, except that seven years prior, this same woman had been diagnosed with Hodgkin's lymphoma. Because doctors feared that chemotherapy would leave her infertile, they surgically removed, froze, and stored her ovaries. Once her treatment was concluded, with her cancer sufficiently in remission, they thawed the tissue and returned it to her abdomen, after which she was able to conceive and deliver.

Such medical miracles -- improvements in fertility treatment, cancer cures, cardiac care, and AIDS management among them -- are becoming so commonplace that we take them for granted. Yet, in the United States, the health care system often fails to deliver on the promise of the science it employs. Care is denied to many people, and what's provided can be worse than the disease. As many as 98,000 people die each year in U.S. hospitals from medical error, according to studies reviewed by the Institute of Medicine. Other studies indicate that nearly as many succumb to hospital-acquired infections.[ 1] The Centers for Disease Control and Prevention (CDC) estimates that for each person who dies from an error or infection, five to ten others suffer a nonfatal infection. With approximately 33.6 million hospitalizations in the United States each year, that means as many as 88 people out of every 1,000 will suffer injury or illness as a consequence of treatment, and perhaps six of them will die as a result. In other words, in the 15 to 20 minutes it might take you to read this article, five to seven patients will die owing to medical errors and infections acquired in U.S. hospitals and 85 to 113 will be hurt. Health care safety expert Lucian Leape compares the risk of entering an American hospital to that of parachuting off a building or a bridge.

How can this be in the country that leads the world in medical science? It's not that caregivers don't care. Quite the contrary: Health care professionals are typically intelligent, well-trained people who have chosen careers expressly to cure and comfort. For that reason, perhaps, many policy makers and management scholars believe that the problems with American health care are rooted in regulatory and market failures. They argue that institutions and processes mandated by law and custom are preventing demand for health care from matching efficiently to those most capable of providing it. In this view, the best treatment for what ails the U.S. health care system is strengthening market mechanisms -- rewarding doctors according to patient outcomes rather than the number of patients they treat, for instance; increasing access to information about health care providers' effectiveness to employers, individuals, and insurers; expanding consumer choice.

I won't dispute the benefits of these reforms. The efficiency of health care markets may indeed be gravely compromised by poor regulation, and economic incentives should reinforce health care providers' commitment to their patients. But I fear that the exclusive pursuit of market-based solutions will cause professionals and policy makers to ignore huge opportunities for improving health care's quality, increasing its availability, and reducing its cost. What I'm talking about here are opportunities that will not require any legislation or market reconfiguration, that will need little or no capital investment in most cases, and -- perhaps most important -- that can be started today and realized in the near term by the nurses, doctors, administrators, and technicians who are already at work.

The scale of the potential opportunities can be seen in the results of a number of projects I've been following over the past five years at various hospitals and clinics in Boston; Pittsburgh; Appleton, Wisconsin; Salt Lake City; Seattle; and elsewhere. Consider just one example. The CDC cites estimates indicating that bloodstream infections arising from the insertion of a central line (an intravenous catheter) affect up to 250,000 patients a year in the United States, killing some 15% or more. The CDC puts the cost of additional care per infection in the tens of thousands of dollars. Yet, two dozen Pittsburgh hospitals have succeeded in cutting the incidence of central-line infections by more than 50%; some, in fact, have reduced them by more than 90%. Rolled out throughout the U.S., these improvements alone would save thousands of lives and billions of dollars.

Other hospitals have dramatically lowered the incidence of infections arising from surgery and of pneumonia associated with ventilators. Still others have improved primary care, nursing care, medication administration, and a host of other clinical and nonclinical processes. All of these improvements have a direct impact on the safety, quality, efficiency, reliability, and timeliness of health care. Were the methods these organizations employ used more broadly, the results would be extraordinary. In fact, you could read an entire issue of HBR, even several, and during that time the number of fatalities would be close to zero. (See the exhibit "The Health Care Opportunity.")

To understand how the improvements were achieved, it is necessary to appreciate why such a gap exists between the U.S. health care system's performance and the skills and intentions of the people who work in it. The problem stems partly from the system's complexity, which creates many opportunities for ambiguity in terms of how an individual's work should be performed and how the work of many individuals should be successfully coordinated into an integrated whole. The Belgian woman's treatment, for instance, required a large number of oncologists, surgeons, obstetricians, pharmacists, and nurses both to perform well in their individual roles and to coordinate successfully with one another. Unless everyone is completely clear about the tasks that must be done, exactly who should be doing them, and just how they should be performed, the potential for error will always be high.

The problem also stems from the way health care workers react to ambiguities when they encounter them. Like people in many other industries, they tend to work around problems, meeting patients' immediate needs but not resolving the ambiguities themselves. As a result, people confront "the same problem, every day, for years" (as one nurse framed it for me) regularly manifested as inefficiencies and irritations -- and, occasionally, as catastrophes.

But as industry leaders such as Toyota, Alcoa, Southwest Airlines, and Vanguard have demonstrated, it is possible to manage the contributions of dozens, hundreds, and even thousands of specialists in such a way that their collective effort not only is capable and reliable in the short term but also improves steadily in the longer term. These companies create and deliver far more value than their competitors, even though they serve the same customers, employ similar technologies, and use the same suppliers. Operating in vastly different industries, they have all achieved their superior positions by applying, consciously or not, a common approach to operations design and management.

As I have argued in previous articles in Harvard Business Review, what sets the operations of such companies apart is the way they tightly couple the process of doing work with the process of learning to do it better as it's being done. Operations are expressly designed to reveal problems as they occur. When they arise, no matter how trivial they are, they are addressed quickly. If the solution to a particular problem generates new insights, these are deployed systemically. And managers constantly develop and encourage their subordinates' ability to design, improve, and deploy such improvements. (See the sidebar "Delivering Operational Excellence.")

This approach to operations can work wonders in health care, as the case studies in this article will show. We will see examples of how health care managers and professionals have designed their operations to reveal ambiguities and to couple the execution of their work with its improvement, thus breaking flee of the work-around culture. We will also see how health care managers have transformed themselves from rescuers arriving with ready-made solutions into problem solvers helping colleagues learn the experimental method. I won't claim that moving to the new environment will be easy, given the complexities of the health care workplace. It will probably take some time, as well, because changes will have to be introduced gradually through pilot projects so as not to disrupt patient care. These changes will require serious commitment from health care managers and professionals at the highest levels. But the potential savings in lives alone -- never mind the improved quality and increased access to health care that the dollar savings will make possible -- are surely ample justification for attempting the voyage.

Let's begin by taking a closer look at what lies behind the health care tragedies we so often hear about.