Leadership is Central to Healthcare System Reform

The centrality of leadership

The recent report from the Institute of Medicine, "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America," is a powerful wake-up call to the nation. As the IOM report attests, "American healthcare is falling short on basic dimensions of quality, outcomes, costs, and equity." The human and financial costs of our health system's shortcomings — an estimated 75,000 fewer deaths if the quality of care in every state matched the highest performing state and $750 billion in waste and inefficiency — underscore the urgent need for fundamental transformation of the healthcare delivery system.

Incremental changes are simply insufficient to attain our goal of delivering higher quality care at a reasonable cost to all Americans. It is clear that that we need all healthcare stakeholders to commit to creating an integrated, patient-centered system which embraces continuous improvement, promotes greater teamwork and transparency, adopts new technologies for collecting and utilizing clinical data to improve performance at the point of care, engages patients and families in managing care, emphasizes value and care outcomes and is digitally connected so that patient-provider-caregiver teams have complete, shared patient information and access to relevant medical research and care protocols.

Undertaking the scale and complexity of necessary changes demands leaders who are able to recognize flaws, articulate a vision for the future, lay out a path for getting there, inspire change and hold the overall organization responsible. Technology can only facilitate but does not drive large scale change. Leaders are the essential agents for converting these challenges into opportunities.    

I would posit five characteristics of effective leadership that are critical to moving the entire healthcare system towards greater effectiveness, efficiency and equity:

1. Forging a new culture. The most critical task of any leader is setting the tone at the top and working to infuse a culture of excellence throughout the organization. Organizations can only progress if their members share a set of values and are single-mindedly committed to accomplishing clearly defined goals.  

The six-hospital Henry Ford Health System in Detroit has succeeded in radically recasting its culture of patient safety. Championed by the CEO and board, the organization has carried out a vigorous campaign for eliminating all patient harm, including the development of a single patient harm index to monitor progress and hold the organization accountable. The patient safety message is fully interwoven into their communications, training and even employee recognition, with the result that Henry Ford has succeeded in rapidly reducing the number of harm events.

2. Using empirical data to foster continuous learning and improvement. The rapidly accelerating amount of information available to clinicians and administrators for delivering and managing care is, according to the IOM report, "too rarely applied to improve the care experience." Having access to large amounts of data is not sufficient; the organization must be committed to applying that data and to creating processes that leverage data to drive continuous learning, innovation and improvement.  

Geisinger Health System of Danville, Pa., has made great strides in implementing what it has called its "innovation architecture," which involves engaging employees in the use of data to redesign care models to achieve higher quality, more efficient care. Further, the organization encourages sharing of information across disciplines and adapting approaches that have worked elsewhere in the system.  

Marshfield (Wis.) Clinic has not only invested in a robust electronic health records system, it uses the data it gathers to evaluate clinical practices against evidence-based medical guidelines and to identify and address gaps in care on a real-time basis. It constantly evaluates which clinical groups are in fact utilizing data to improve performance.

3. Collaborative over top-down approaches. Healthcare is so complex that no leader can accomplish much without the support of key stakeholders, such as clinicians. As physician and writer Atul Gawande, MD, suggests in his recent "Big Med" article, engaging key stakeholders early on can help leaders overcome the resistance that often accompanies efforts to "persuade clinicians to follow the standardized plan."

When Dr. Gawande's own institution, Brigham and Women's Hospital in Boston, embarked on a campaign to standardize joint-replacement surgery, the hospital brought together every specialty involved, including surgeons, anesthesiologists, nurses and physical therapists in examining all of the medical evidence and formulating a single standard way of doing knee replacements. Even after the protocol had been established, the hospital allowed surgeons to deviate from the plan if they had a compelling reason. And still it took the better part of a decade to get there.

4. Engaging the patient. The need for more collaborative approaches also extends to patients and families. Research increasingly links patient education and engagement to better health outcomes, lower costs and an enhanced care experience. With the rise in chronic conditions, the incidence of which is tied closely to patient behavior, engaging patients will be paramount to any long-term effort to enhance health and reduce costs.

Kaiser Permanente HealthConnect, which facilitates greater patient access to their healthcare records, information and physicians, has been associated with improved quality of care in studies.

5. Accountability. Finally, leaders need to establish clear lines of responsibility and institute performance-based compensation systems aligned with cost and quality goals. This also requires leaders who are willing to be transparent about measuring the organization's performance against a range of metrics. Establishing these kinds of performance and compensation systems can entail higher degrees of risk for the organization (for example, when Geisinger moved to a performance-based compensation system, it initially experienced higher levels of physician turnover). But leaders can't shy away from taking these kinds of risks in order to leverage internal and external pressures for radical change.  

Conclusion

In distinguishing leadership from management, the former is doing the right things and the latter is doing things right. Ultimately, the transformations of today will become operationalized and embedded into the systems, processes and standards of tomorrow (for example, evidence-based care protocols being incorporated into decision-making software). In the meantime, it is imperative that the healthcare system recruit and train leaders who can advance the kind of systemic reforms necessary to surmount the current healthcare crisis.

Judith D. Bentkover, PhD, is an adjunct professor of Health Services, Policy and Practice at Brown Alpert Medical School and the academic development director in the Executive Master of Healthcare Leadership program at Brown University. She is also president and CEO of Innovative Health Solutions, a consulting firm providing research and strategic analysis to healthcare manufacturers, providers, and payors, and professor of the practice in the Economics Department at Tufts University.

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