Process optimization in hospitals
Agile working - another of those buzzwords everyone is talking about, but where hardly anyone knows what it is actually about? Not quite. We spoke with Achim Schütz, a freelance business consultant and hospital manager, who is also intensively involved in system theory. After reading our interview with him, at the latest, you will also have some idea of and probably an opinion on the theme of "agile working in hospitals".
Mr, Schütz, can we start by asking how you define agile working?
I derive the term from system theory. In this construct, agility is the basis for being able to respond quickly to changes in external conditions. This includes, for example, working in delimited, self-organized teams, or a holocratic communication. These ways of working are widely known today from scrum theory. However, scrum as it operates in practice is only suitable for project work. Creating agile hierarchies too, would require hybrid methods, so that organizations are set up in such a way that they can react quickly and contextually.
But a hospital is not a business enterprise like any other, but an actor in a partly-regulated market. Can the principles of system theory be transferred that simply to healthcare facilities?
In fact, system theory indicates that complex open systems cannot be managed in a linear-causal manner. Rather, it requires contextual, systematic thinking in cause-effect networks with interactive effects. To give an example to illustrate this: If an engineer is commissioned to build a bridge, the planning and execution are guided by the laws of statics and those of nature. These produce interactive effects which have direct influence on the stability of the bridge - for example, if the bridge is in a location exposed to wind.
In part-regulated markets, these mechanisms only bite to a limited degree, because interactive effects are frequently not taken into consideration at all. In a hospital, patient needs could be one such interactive effect. Part of the reason for this is that there are framing conditions which the manager of the hospital cannot change. Despite that, I am convinced that agile working can also succeed in hospitals. At the moment, admittedly, only in a rudimentary way, because the organization of a healthcare facility is still too rooted in the past.
Does the "health" product not demand precisely such conservative framing conditions, in order to ensure a certain measure of safety and thus boost patient confidence?
An argument that often put forward is that ultimately it's about people's lives. But that is no different in the car industry, the nuclear industry or the aviation industry. Here, too, the quality of service provision plays a prominent role. And despite this, the aviation industry in particular - for instance - is very far advanced in implementing agile ways of working.
The actual dilemma in hospitals is rather that the people who work here, since forever, are practically all people who spend their entire working life in this environment. So there are no lateral thinkers, and few impulses to learn from other industries. The insight is lacking, to some extent, that physicians can get valuable tips from, say, the automotive industry - even if that is only picking up on minimizing the number of hazardous areas from trailing cables in the OT.
What might agile working in hospitals look like in practice?
Agile working can be reflected in repeatedly-optimized standards. They are achieved through a consistent focus on the customer and the use of checklists and treatment pathways. That continues to be used, as previously, far too little. For the medical part, there are structured specifications from the guidelines, and what's missing are treatment pathways created through the eyes of the patient. Then, you start looking at issues such as reducing waiting times, avoiding duplicate examinations, a service mind-set, friendliness, and much more. A reliably-consistent treatment outcome might be ensured via this approach too, in order to close the quality gap that arises partly through the question of which physician - with which range of experience - a patient is assigned to.
In addition, teams need to be formed with the patient as the focus, and not just the illness. In illustration, you need to ensure that for a patient with a primary diagnosis of "cardiac insufficiency", secondary diagnoses that also require treatment, such as diabetes mellitus, are recognized and treated. Such teams involve medics, care staff and also coders/medical controllers, who take medically sensible and economic decisions. The precondition for this is that they are equipped with sufficient specialist and decision-taking competence, and are self-organizing.
And lastly, the senior physicians need to work as entrepreneurs within the hospital. However, that would mean a paradigm change: away from measuring performance indicators and towards an evaluation of the quality of treatment and outcome. In other words, away from rewarding high case numbers of case-mix points, and towards qualitative incentivization. A corresponding infrastructure for this is currently still lacking - along with the desire to put such a structure in place.
What role does IT play within these scenarios?
An important one. In other sectors, IT has been used - in some cases, for decades already - to counteract growing intensification of work and cost pressure. In hospitals, the prevailing thinking is: more work - more staff. That approach can cure the symptoms, but doesn't remove the causes. If further resources are invested into an inefficient system, good money is being thrown after bad.
The potential for IT investments in hospitals is disproportionately high compared to other sectors. In hospitals too, it is IT that can ensure leaner processes, alleviation of workloads and greater efficiency - whether in the medical and care area, or in administration. Realizing such positive effects requires excellent networking, in order that information is brought together in a patient-centered way. There are already a number of attempts at doing so, but this consolidation needs to be implemented consistently, with commitment, understanding and strategy. Central data storage covering all medically-relevant information not only improves the medical and care treatment, but also delivers boosts to profits: Duplicate examinations are avoided, treatment quality raised, the work of the coder made easier, while the individual cases can also be assessed from the business viewpoint.
The availability of data across departmental boundaries also promotes the establishment of effective, small, interdisciplinary teams with their own decision-making competence. For as long as data leads an island existence and is buried in sub-systems, it is not possible to take sensible medical, care of business decisions on a cross-disciplinary basis. The bringing together of information and the breaking-up of structures that are proprietary in character is therefore a basic precondition for agile working.
Before Achim Schütz went freelance with systcoach.consulting in Hennef as interim manager and business consultant, he was a managing director of the Sankt Franziskus-Hospital and departmental head of finance for the Hospitalvereinigung der Cellitinnen zur hl. Maria hospital association in Cologne.
As managing director, he restructured the not-for-profit company Ökumenische Verbundkrankenhaus gGmbH in Trier. He currently heads up a hospital for the Swedish Capio Group in Germany.
His work also draws on his experience of company development in the insurance and industrial sector. Achim Schütz is also a systems coach, and is a published author on the subject of "Systemic management"