Changing the Way Operations Works

Having served as chief operating officer for Stanford Hospital & Clinics for over a year now, I have been able to closely observe how our system works to support the delivery of care. I have drawn several conclusions from these observations that I would like to share:

• Stanford has amazing talent, especially the clinical staff who are engaged in the delivery of care.

• Those individuals work very hard to deliver the highest level of care possible.

• Our care isn't consistently delivered at a level that is commensurate with what our patients expect, and what we should expect. This is despite the level of talent and hard work, and the number of people involved in the clinical enterprise.

When I say quality, I'm really speaking in the broadest sense of that term. This would include the technical aspects of care, along with the patient's experience and the amount of resources and time that is consumed to deliver that care. One way of describing this in the current nomenclature of Accountable Care Organizations is value.

My other observation for health care generally, and Stanford specifically, is that we have the most operationally complex environment of any industry.

• We are labor intensive, with more than 10,000 people involved in the clinical enterprise everyday.

• We are capital intensive. We use extensive space and equipment that is specifically designed for narrow purposes.

• We are in a service business, in which our patients are participants in our processes.

• We are also in the knowledge business, where our highest trained people are on the front line, and where the creation and sharing of knowledge and information is critical.

• And, finally, we operate in an enterprise that is literally about life and death, where many of our actions on any given day can lead to devastating consequences.

And yet despite the level of complexity described above, most health care organizations, including ours, largely rely on very antiquated approaches to creating and running a system to support it. The result is that individuals have to act as "human glue," engaging in constant inspection and firefighting to make the system work. What a tremendous waste of the human potential that is in our organization!

There is a better way

This better way has evolved over many years, with many of its basic principles developed at Toyota and pulled into a category often labeled as "lean." These lean principles have been implemented at many organizations and by many practitioners, many of whom are in the health care field—most notably, Virginia Mason in Seattle and Thedacare in Wisconsin.

There are several methods that are associated with this new management system—but they all rely on two basic principles. The first is respect for people. This assumes that people are capable and motivated, and can and should be engaged in the work of deciding how care should be delivered. The second is continuous improvement. The assumption is, no matter how good we are, we can always get better, and the people who are closest to the work are in the best position to drive down improvement.

Several methods are derived from these two foundational principles such as setting clear standards for what is expected based on the patient's requirements. Other methods include creating standard work, not as an end state, but as the beginning for ongoing improvement. Standard work also extends to managers and leaders, describing how their work supports the principles and methods.

This approach relies on making standard work visible, with clear targets, identifying any gap as problems to be solved, and then applying standard approaches to solve the issues identified.

It is difficult, if not impossible, to fully describe this approach to creating a system that unleashes the incredible talent of this organization and focuses it away from fire fighting towards continual improvement of the quality and value created for our patients. This kind of system does exist, and if applied systematically and rigorously at Stanford, there is an opportunity to create a level of excellence that will be a model for all.

By James Hereford, Chief Operating Officer