Like in every other aspect of our culture, we communicate complex ideas in simple terms, “buzz words.” Unfortunately, these buzz words often taken on a life of their own and they hide important ideas as much as clarify communications. Recently, a survey was published concerning “high-performing health care systems.” On the face of it, this sounds like something every organization would want to be. Sure enough, 79% of the survey respondents said this was a goal of their organization, but 11% said it was not and 10% did not know. When the authors probed, though, they found little agreement about what was meant by the phrase “high-performing.” There did seem to be some agreement that excellent patient care and patient safety were key elements, but few mentioned financial considerations. In fact, they highlighted a comment from a clinician in a large mid-Western community hospital, which suggests why this is so.
“Health is not an assembly line and should not be measured like one. Without the tools for motivated physicians, nursing staff, and allied medical staff to function, middle management will destroy the ability to maintain quality medicine in an attempt to grind the numbers into a false illusion of success, while destroying the clinical base of medical care, and lowering the engagement of frustrated clinical staff. These people will leave, and their ranks will be filled by ranks of substandard clinicians.”
Robert Centor, M. D., wrote an article over a year ago suggesting the word “productivity” should be banned. He thinks productivity entered physician consciousness with publication of the resource-based relatively value scale and its attendant “RVU.”
“Productivity implies that seeing more patients each day is a good thing. But likely most patients and physicians will agree that we need to optimize the time with each patient. How many patients can we comfortably see in one day and deliver high-quality care? High-quality care does not refer to performance measures, but rather complex multi-dimensional factors that will improve the patient experience. For many patients talking is both therapeutic and diagnostic. We shorten our conversation time at the risk of diagnostic errors, higher health care costs, and dissatisfied, confused patients.”
One evident problem illustrated by these two quotations is clinical reality looks different to the “provider” than it does to the “manager.” The manager has to depend on an abstract of patient care, such as census, money, or “quality” metrics, whereas the clinician experiences a non-verbal, visceral contact with the reality of day to day to care unfiltered, in most cases, by metrics. As my preacher said in today’s sermon, “The truth is in the story, not the statistics.” I believe organizations that can find productive ways to integrate these two perspectives are on the way to becoming “high-performing.” But there is a third element: all healthcare involves services provided to people by other people. We are not providing a product, no matter how often we use the word.
Lee and Duckworth have described what they think is needed to become a high-performing organization: teams with “grit.” Grit is a “buzz word” describing high-achieving persons who have stamina, a commitment to constant improvement, and who are steadfast, refusing to take the easier way.
“In health care, patients have long depended on the grit of individual doctors and nurses. But in modern medicine, providing superior care has become so complex that no lone practitioner, no matter how driven, can do it all. Today great care requires great collaboration—gritty teams of clinicians who all relentlessly push for improvement. Yet it takes more than that: health care institutions must exhibit grit across the entire provider spectrum.”
They go on to describe how some organizations strive to create a gritty culture and what that looks like. If you are intrigued, I recommend the whole article to your attention. What I want to note, though, is the first sentence in this quotation: “patients have long depended on the grit of individual doctors and nurses.” So too have health care systems. It seems many systems assume the clinicians will just “do the right thing” because of their own intrinsic motivation and fail to recognize the impact of a corrosive culture. As medical organizations become larger, more geographically diffuse and consequently bureaucratic, they often fail to recognize how much of their ultimate success still depends on individual grit. One way to interpret the burnout epidemic in medicine is that the gritty individuals have ground against their local bureaucratic barriers to the point where they have broken. This is bad for the individual provider, but worse for patient and the organization, as it selects for those who will take the path of least resistance over doing what they believe is best for patient care.
So, what would a high-performing health care organization look like? I think it would be one where commitment to putting safe, excellent patient care foremost was a reality, not a slogan pasted on the bulletin board. It would be one where there were functional groups of people who could develop working definitions of what constituted safe, excellent patient care from the clinical, financial, and human resource perspectives. While the organization would have to amass and report metrics required by payers, it would focus most of its efforts on developing its own way to monitor things like “spending the appropriate amount of time” with patients, and interacting with patients in humane, supportive ways. It would also focus on measuring the extent to which its clinical staff was spending their personal “grit” fighting the Four Horsemen of the Apocalypse, not the internal, bureaucratic irritations and would be committed to minimizing organization friction.
A frictionless organization, like a perpetual motion machine, is not possible. But I do think being a high-performing organization should mean getting the mission done with the least amount of time, money, and friction. Metrics are necessary, but not sufficient, to achieve high performance. There must be a persistent effort to capture the elusive reality of “the story,” which constitutes patient care, as a corrective to taking the easy way of believing it is all “in the numbers.”
28 October 2018
 Swenson S, Mohta NS. Leadership Survey: High-Performing Organizations. 24 July 2018. Accessed 25 July 2018 at https://catalyst.nejm.org/high-performing-organizations-health-care/?ut.
 Center R. It’s Time to Ban Productivity From Medicine. Accessed 29 September 2018 at https://kevinmd.com/blog/2017/09/time-to-ban-productivity-medicine.
 Lee TH, Duckworth AL. Organizational Grit. Harvard Business Review, Sep-Oct 2018. Accessed 28 October 2018 at https://hbr.org/2018/09/organizational-grit.
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