Chapter 4. Focus On Processes

“We want to generate a new set of ways to meet the needs of patients,” says Dr. Victor M. Montori, a professor of medicine at the world-renowned Mayo Clinic.

In reengineering terms, what most concerns Montori are the processes of health care, especially the interaction between patient and doctor, which has barely changed in more than a century. “Medicine has changed, people have changed, technology has changed, but the exam room isn’t so different from what it was in the 1800s,” according to Dr. Michael D. Brennan, an endocrinologist. (Both Brennan and Montori have been closely associated with the acclaimed SPARC—See, Plan, Act, Refine, Communicate—Innovation Program at Mayo—Brennan as medical director and Montori as director of research and education.)

“Our problem is that we have all the wrong processes in place,” agrees Debra Geihsler, a health care executive who has worked to transform major delivery systems in Chicago and Boston, and is now embarking on a new venture in Indianapolis. What’s needed, she says, is a set of processes “focused more on prevention and wellness, and less on chronic disease and hospitals.”

But how can medical processes, developed and ingrained over decades, be successfully changed? Consider the principles that have emerged from the case studies presented in this book.

Start small and build on proven results.

You cannot reengineer an entire organization in one go-round. The scope and scale of such an undertaking is simply unmanageable. You might map out the overall journey and the steps you will take to complete it over time. But in the beginning, you should concentrate on only a few areas. Start small—not in terms of ambition, but in terms of the number of people you will initially engage in your reengineering project. Look for teams, departments, and practices with a framework for success—clinical leadership, performance issues that make the case for change, and ambitious people who will work hard to make it happen. Once you can demonstrate improved performance, you are ready to broaden your campaign.

We advise you to prove your case first in a small venue for two reasons: The changes will be easier to manage, and clinicians will want to see proof the new care-delivery processes work before they risk the well-being of patients. Conversely, they will gladly adopt a revamped process or procedure if they are shown a better way. As we have said more than once, doctors come to work to do good. The best, most effective, and caring treatment is the one they will choose. Zeev Neuwirth’s reengineering efforts have proved the point many times over.

When Neuwirth and his colleagues set out to improve the productivity of the orthopedics department at the Harvard Vanguard Kenmore medical practice, they knew it wouldn’t be easy. The practice is filled with outstanding surgeons who are in high demand, making access a problem. Patients wanting an immediate appointment sometimes had to wait days, if not weeks, to be seen. And if a patient had to go outside the practice for care, Kenmore ran the risk of losing the patient altogether. More importantly, if the patient did come back to Kenmore, his or her medical records would be incomplete, requiring numerous error-prone and time-consuming steps to stitch the pieces back together. All in all, a big mess in need of fixing.

Neuwirth and his colleagues instituted a rapid improvement event in which participants typically focus on one process, develop a strategy to increase its efficiency, and then implement the strategy, essentially shutting down the process temporarily until the fixes are in place. Initially, the orthopedics team was not enthused by the prospect. The doctors arrived for the first meeting on Monday morning wearing expressions that declared, “Why are you wasting my time?” But by the end of the week, with the process change in place, they were amazed at what they had accomplished.

“I have learned more this week than I have in the past 30 years of my career,” the chief of orthopedics told Neuwirth. “I never knew how much work and all the processes that went on around me.” Immersed in his operating schedule and clinical work, this physician never understood just how good his staff was or how dependent they were on other people, particularly the radiology department. “I learned that all the stuff my team does is just as important as what I do,” he announced to a stunned audience at the end-of-week project report.

Now the chief is a strong advocate of reengineering and has installed his own new process: He joins his orthopedics team every morning and afternoon for five-minute huddles. The whole team huddles at about 8:00 A.M. to discuss the day ahead, air any problems, and get answers to a series of set questions, including: How is every team member feeling today? At the late-afternoon huddle, the questions run to how the team functioned that day. Were there difficulties? Any patient complaints? If so, were they effectively addressed? How can we avoid similar problems in the future?

Possibly, the most important change has occurred within the culture of the orthopedics department rather than in the work-flow processes alone. When the chief instituted his process, he gave team members the freedom to speak out.

The rapid improvement event also formed a strong bond between orthopedics and radiology. The two departments are located about 100 feet apart, and for years orthopedists have sent patients to radiology. Yet the staff members seldom talked to one another before the process redesign. But afterwards, radiology staffers have daily huddles, too, and they began to stay abreast of orthopedics’ daily management board. In fact, the huddles have become shared affairs with employees from both departments intermingling. Neuwirth admits to having made “tons of mistakes” in the process redesign effort. “But I think we’re getting the big things right,” he says.

One note here: You might be confused by the advice we give here to start small with early process change and the advice we gave you in the previous chapter to go with a big bang implementation for EHR initiatives. If you have not experienced work change in your organization, it’s still helpful to start small—giving people the opportunity to experience the benefits of change and to begin the process of behavior adjustments. But once you have built the capability to implement electronic records across your organization, we assume that you have also developed the sensibilities and capabilities to broadly implement work and behavioral change—and that you can move more aggressively.

Go for quick results but prepare for long adoption times.

Beginning with a small-scale reengineering effort has the major advantage of producing quick results. Projects that take too long wear people out and make them question the value of their work. A quick result—whether it’s improved quality, a lower cost, or a superior patient or physician experience—keeps people in the game. It validates the ideas at the heart of process change and sets the stage for the longer-term efforts needed to perfect a process, particularly when you have larger projects ahead.

Don’t make the mistake of starting a reengineering effort by trying to change how people think. It hardly ever works. Cognitive change just takes too long. We believe that changing what people do is the best way to change how they think. Many people must physically experience change before they can see its benefits. So the faster you change how clinical work is done, the faster the behaviors of clinicians and their staffs will change.

Dr. Tom Knight, speaking from experience at Houston’s Methodist Hospital System, says, “It’s not what we say, but what we do. It’s what we stand for to some degree, but really it’s what we stand behind. Quality and safety in health care cannot be managed. It must be led. It must be inspired. It must be modeled. And, it must be lived.” “The good news,” he goes on, “is that we have a workforce that will do it.” And when it comes to the process of change, “it’s a whole new behavioral science.”

So changing behavior is the cart behind the horse of proven process improvement. We will tell you more about how to accomplish behavioral change when we talk about people.

Following our advice to start small so as to attain quick results, and then spread process change across your entire organization, means that a complete change in the delivery of care will be a long time coming. Every reengineering effort cited in this book has taken two to three years to achieve full implementation. You should expect to spend no less time on your reengineering project.

Fix errors and breakdowns, but don’t lose sight of the end game.

Errors and breakdowns may point to areas in need of reengineering. But when a problem arises, be careful about adding more resources and layers of complexity to solve the problem. That might only mask the true issues. Solving the immediate problem and ignoring the underlying issues ends up adding costs over time, which health care delivery can’t afford if real improvement is the goal.

Look for the systemic causes of your problem and fix the processes that are creating it. You may have to invest more time and resources than you initially expected, but the more-inclusive approach will pay off in the long run, and you will be assured that the errors and breakdowns won’t reoccur.

We can provide a personal example of how more expansive process-fixing trumps limited problem-solving. A few years ago, the then administrator of the U.S. Veterans Administration (V.A.) asked Jim to assess problems that were delaying the settlement of veterans’ health care and disability claims. Some veterans had to wait months, even years, before their claims were settled—and to our everlasting shame, some died before they were paid what they were due.

As a dedicated proponent of reengineering, Jim turned to the principles being applied by businesspeople around the world in hopes of fixing the government’s problem. He discovered that several factors were contributing to the breakdown. To begin with, medical cases had become more complex and required more of caseworkers’ time. Adding to the delay was the V.A.’s inability to quickly access veterans’ service and medical records, which were mostly on paper and scattered across multiple locations. At the time, the V.A. had 80 clerks stationed at the Pentagon whose sole duty was to find the records of veterans needing assistance.

Jim recalls being directed to a well-meaning admiral who had been charged with finding a “solution to the problem.” When Jim suggested that the problems could be eliminated if the V.A. adopted new processes and updated its information technology, he was told that the standard approach—hiring extra clerks and caseworkers—was more likely. No heavy lifting would be required since Congress was sympathetic to the plight of veterans and would provide more money to get the job done. Not surprisingly, the traditional “solution” was adopted.

This approach to fixing problems is no fix at all. The truth is that many problems don’t really get fixed; they just get buried under more complexity and new resources.

The Veterans Administration has gone a long way toward implementing electronic health care records since Jim was asked to help. But we suspect that some real reengineering is still needed to meet the needs of veterans. If the V.A. asked for help again, our advice would be to go deep, address the systemic issues, and eliminate the problems once and for all.

Recognize that process change is iterative.

Once you decide something needs changing, you naturally want to get started, wasting as little time as possible. So you verify the need, think about ways to make it happen, decide which one is preferable, and formulate a plan. You check with the people who will be affected by the plan—customers, employees, suppliers—and if anyone has a serious concern, you make changes accordingly. Then, you push the “start” button. Mission accomplished, you dust off your hands and look for the next problem to solve.

Self-satisfied though you may be, that’s the wrong way to make changes, especially big ones meant to transform the way you do business. The right way is to test your ideas and get feedback at every stage, using the information you gather to improve each step in the process and shape the next move. To see the preferred method at work, we need look no further than the SPARC program the Mayo Clinic is using to improve health care by changing the way doctors interact with their patients.

The time-honored ritual in the doctor’s office seems designed, consciously or not, to underscore the doctor’s authority and the patient’s submission to it. The patient waits for the doctor in an ill-fitting gown in a typically chilly exam room. The doctor examines the patient on a high, paper-covered, padded table that resembles the lift at a tire shop. The patient is then told to get dressed and is given license to enter the physician’s private office, where he or she receives the verdict from across the doctor’s desk.

Small wonder the patient mutely accepts the diagnosis and prescribed treatment, and then forgets the doctor’s instructions and winds up taking only half the pills or swallowing them at the wrong intervals.

Mayo has been innovating health care since the clinic was founded in the late nineteenth century. SPARC is its latest and perhaps most sweeping attempt to change the patient experience and health care delivery. On its face, SPARC is an evolving, experimental patient-consulting center on the 17th floor of the clinic’s headquarters in Rochester, Minnesota. At its core, however, the program represents a commitment to reengineer every possible aspect of patient care, ranging from the way pills are prescribed to patient check-in procedures and the ethos of exam and operating rooms.

Patients consult their doctors in a variety of settings, the center’s primary goal being to hear and understand every patient’s needs. But Mayo’s practitioners know that whatever concerns a patient is able to express cover only part of the territory that must be explored. SPARC researchers view a consultation using small, inconspicuous cameras (with patient consent) that allow them to discern unarticulated needs made apparent by a patient’s reactions and body language. And even deeper, latent needs are being identified, Dr. Montori says, by trying new approaches and watching how patients react. “We hear all the time about a clinician being empathetic. Now we’re watching empathy at work—the eye contact, the listening. We see the whole dance.”

Actual patient feedback is another critical component of the SPARC program that provides clues to a person’s real needs, and the feedback is ongoing. The researchers form their plans in segments, incorporating patient feedback every step of the way in a quest for ultimate effectiveness. Each improvement, in turn, is tested to take advantage of another round of feedback. In effect, the researchers use each new variation to shape better questions.

One innovation that grew out of the SPARC program are the kiosks located around the Rochester campus and at Mayo facilities in Jacksonville, Florida, and Scottsdale/Phoenix, Arizona. The kiosks make it easier for Mayo’s 500,000 annual patients to check in upon arrival. Many of these people find it difficult to stand in line for check-in, explained Ryan Armbruster, the program’s original director of operations and design. “The kiosk is similar to what you’d find at an airport,” he said. “You walk up and enter a little information, and it asks a few questions about what you’re [there] for. It confirms the information with the front desk, and you can have a seat.”

In its first iteration, the check-in kiosk was deliberately crude and boxy-looking. Patients were left to imagine a functioning terminal with a power supply that would enable them to check in for their clinic appointments. But based on the reactions to that first, very rough sketch, the next version featured a laptop with what appeared to be a touch screen. The screen didn’t actually work, but a technician sitting alongside with a keyboard simulated a working prototype by typing in patient responses. The next model had a working touch screen, and the adjustments continued in response to patient feedback until the real thing was in place. It was all part of the rapid prototyping that goes on in the SPARC program in response to patient reactions.

The final product was an immediate hit, with 87 percent of those who tried the kiosk saying they would use it again. And no wonder, since the kiosk was basically designed by its end users.

Build in patient education.

All too many years ago, Jim’s son, Adam, was born five weeks early. The proud parents were able to take their baby home two days later on a fine Saturday morning in Boston. But here’s how Jim remembers the happy, but anxious occasion:

“My wife and I were a bit perplexed about what the future would hold. We had studiously attended childbirth classes, but because Adam arrived early, we missed the classes on caring for a newborn. We knew next to nothing about it, and because it was a weekend, there was no one at the hospital to advise us, and we had no knowledgeable family members nearby.

“Every time the baby cried, we frantically searched through The Common Sense Book of Baby and Child Care, Dr. Benjamin Spock’s iconic guide, to see what might be the problem. Fortunately, for Adam, we finally hired a part-time nurse who did know what to do.”

Times change and people change, too. Hospitals now recognize that improving patient care isn’t just a matter of rooting out redundant procedures and telescoping tasks. It sometimes means adding a component like patient education that enhances the whole experience far more than its cost might indicate.

Today’s patients take it for granted that health care delivery will include sizable helpings of education on myriad topics. They want to know the source of their problems and their treatment options. They also want to know what they can do on their own to live longer and healthier. And studies show that patients who take part in good education programs have better clinical outcomes, are more likely to follow their treatment plans, and are less anxious about their care.

Cathy Camenga, a nurse with 25 years of experience in clinical practice, knows all about patient concerns and the value of good education. She was the founding director of the Health Education Initiative at the California Pacific Medical Center (CPMC) a decade ago. Her program has become the gold standard for Web-based patient education in the United States. Such recognition is typical for the much-honored medical center. In 2009, for example, CPMC’s three campuses were three of the 34 urban hospitals in the United States recognized as a Leapfrog Top Hospital for Quality and Safety. This represents the fourth year of recognition for CPMC.

Camenga was finishing her Master’s degree in Nursing at the University of California at San Francisco when she was hired by CPMC. “The job was great,” she told us. “It was innovation—process improvement, really. The assignment was to spread patient education across a system and the continuum of care.”

At the time, she said, very few materials were available to inform patients and their families about particular ailments and treatments or about the hospital experience in general. Patients being discharged, for instance, would be handed a doctor’s note on a prescription pad. But there was no real standardization process for instruction, written or oral, about what to expect at home.

Camenga soon realized that a major part of her job was to win the support of the hospital’s doctors. They would have to sign off on any educational materials she distributed—either on paper or through the Web site. What is more, Camenga hoped to convince them to write much of the material. It took some doing, but she succeeded. She advises against contacting doctors in a group e-mail. “They like to be approached one-on-one,” she says, adding: “Develop the relationship and bring them along slowly.”

Over time, Camenga helped to create what she calls “a culture of patient education and of patient inclusion in the process of care.” The patient-centric approach now permeates doctors’ practices and the hospital as a whole, and focus groups suggest ways in which it can be improved.

A visit to the CMPC Web site demonstrates the dramatic transformation within the center’s caregiving process. Under the heading, “Learning About Your Health,” a visitor is offered online materials written not just in English, but in Chinese, Russian, and Spanish, as well. Classes or support groups designed to help people “navigate around problems related to serious diseases such as cancer” can be attended in person or accessed in podcasts.

An alphabetized listing provides online access to dozens of detailed entries prepared by the hospital’s clinicians. The topics range from abdominal surgery and how to prepare, what to expect in the hospital, and caring for yourself at home, to upper gastrointestinal issues—specifically, what an upper GI series is and how long it takes to get the exam results.

Jim would have appreciated the advice found under “P” for parenting and infant care. The topics range from sunscreen application to the normal weight loss newborns experience in the first few days after birth.

Cathy Camenga will tell you that successful patient education today requires a major investment in time and resources to achieve excellence in form, content, and delivery. It crosses all areas of a hospital’s patient care. In other words, it’s not just a handout any more—it’s a process that has benefited from reengineering.

Cope with your chronic customers.

Many businesses have what could be called chronic customers—people whose needs are great and who won’t go away, though filling their needs is simply not profitable for the provider. Businesses can get out of unprofitable lines of work, but that’s not an option for health care providers.

For hospitals, the people we are describing are those with chronic diseases who can’t seem to monitor their conditions, take their meds, or maintain a healthy lifestyle. They often end up being hospitalized or receiving expensive emergency-room treatment. The patients themselves would much prefer to stay at home—and many health care leaders think that’s wise, because it’s better for the patients and allows for a better use of medical resources. But teaching chronic patients to cope with their conditions is difficult, time-consuming, and costly.

One solution has come from the so-called disease management industry, which takes over the teaching process and provides programs to help chronic patients care for themselves. These companies primarily employ nurses to phone patients and inquire about their well-being, offering advice and encouragement. Insurance companies and large employers commonly hire the managers to help keep policyholders and employees healthy in hopes of reducing insurance costs. But the effectiveness of disease management by phone is questionable.

In recent years, more sophisticated approaches to chronic-disease management have sprung up. We talked with one of the pioneers in the field, Dr. Cheryl Pegus, general manager and chief medical officer of SymCare Personalized Health Solutions, in West Chester, Pennsylvania. After meeting Pegus, we would be hard-pressed to find a part of the health care business she hasn’t improved.

Born in Trinidad and Tobago, Pegus was raised in Brooklyn, New York, received her medical degree from Cornell University Medical College, and did her clinical training in cardiology at New York Hospital-Cornell. Her interest in minority communities led to their greater participation in clinical drug trials, which eventually took Pegus to the corporate side of health care. She accepted posts with Pfizer, LipoScience, and Aetna, and earned a master’s degree in public health at Columbia University along the way. At Aetna, she served as national director for women’s health and then was named chief strategist for clinical product development.

SymCare provides disease management companies with inTouch, a very sophisticated diabetes treatment program. The system, recently cleared by the FDA for nonprescription use, includes Web-based technology, individual coaching, educational materials, and a rewards program. It automatically collects blood-sugar readings from a glucose meter and wirelessly transmits them to a secure Web site accessible to patients and their caregivers. Algorithms are applied to help identify trends.

Nurses are available for one-on-one coaching, and a variety of written diet and exercise regimens are available. Patients who achieve and maintain diabetes management goals—picking up their prescriptions, getting their blood tested—automatically receive discounts on Amazon.com. The rewards program reflects the belief that positive reinforcement is the best motivator.

Programs like inTouch are serious game-changers. “It’s more efficient for the physicians,” Pegus explained. “When they see a patient, they can see exactly what’s been happening instead of starting from scratch. It’s more efficient for the nurses because they can work with more patients in a given period of time. It also makes their encounters with patients more productive and satisfying because they know what the patient has been doing or has failed to do.

“We believe that a system like ours,” Pegus added, “allows you to see a better clinical outcome and a better utilization of health care resources, because people will be going to the emergency room less and being hospitalized less.”

Perhaps Pegus’s most important contribution, however, will be her effect on the process of disease management care itself. The patient information she and SymCare are gathering and analyzing will provide the first statistically rigorous evaluation of this type of care. Caregivers and chronic patients alike need to know what is and isn’t working, so that the process can be reengineered for prime performance.

Manage the continuum of care.

Debra Geihsler grew up on 2,000 acres in Nebraska, where her parents grew wheat and cattle. At age 10 she was operating a tractor, and soon thereafter she was earning money by taming wild horses. Except for the occasional bumps and bruises Geihsler suffered from getting thrown, she had little interest in the practice of medicine. The patience she acquired breaking horses, however, has come in handy over her 25-plus years as an innovative, hard-driving health care executive.

For much of that time, Geihsler has been struggling to change the system. As a nation, she jokes, “We’ve created a beautiful health care system. We’ve just forgotten two parties—those who pay for it, the employers, and those who are supposed to be cared for, the patients. Otherwise it’s great.”

Most proposals, she says, are about repairing perceived problems—the conventional wisdom, for example, that we need more primary care doctors. “Actually, we don’t,” she told us. If health care were focused on preventing illness instead of treating it, we would have plenty of primary caregivers.

Geihsler’s reengineering efforts have mainly involved process, specifically, where the work is being done—something that is every bit as important in optimizing processes as what is done and who does it. One of her major accomplishments has been to move physicians out of hospitals and offices and into the workplaces of potential patients.

Geihsler’s journey from bronco buster to increasingly responsible positions at three health care delivery systems—vice president of Mercy Health System in Janesville, Wisconsin, president of the Advocate Medical Group in Chicago, and then CEO of Atrius Health in Boston—has taken many a turn. Her latest move is to Activate Healthcare in Indianapolis.

In 1985, Geihsler became the vice president of administrative services at Mercy Hospital in Port Huron, Michigan, and seven years later, she was named vice president of medical management and operations at the Mercy Health System in Janesville. “That was where I got my grounding,” she says, “approaching health care delivery with a more streamlined, process-oriented, efficiency mind-set.” To Geihsler, that meant delivering care in a doctor’s office instead of a hospital.

Opting to bypass hospital-centric systems, she set about creating doctor-based ones, eventually managing physician groups of 300 or more in Midwestern cities. That meant reinventing the relationship between hospitals and doctors, a task that caught her interest because of its potential to drastically reduce hospitalizations. If more care is given on an outpatient basis, she says, it stands to reason that the rate of hospitalizations will come down.

Geihsler wanted the physicians she managed to become the major health care providers in their areas, responsible for treating most illnesses, practicing preventive medicine, and working collaboratively with specialists. Her doctors liked the idea but wanted extra training to handle the assignment. She arranged it.

Mercy built physician centers that provided every kind of service short of in-patient hospitalization. Financially speaking, they were enormously successful, Geihsler told us, “because with the primary care people and surgeons and lab and radiology and surgery center all together, they could all use the same staff support.” But the benefits went far beyond dollars: “We could track the continuum, from patient entry point to outpatient surgery to patient back out again, connecting all the points and providing fabulous care.”

At Advocate Medical Group, she took on a practice facing multiple challenges. A surplus of primary care physicians in Chicago meant that a newly hired physician would struggle for at least two years before he or she could build a financially successful practice. And if the economy happened to slow, so did the practice. Some patients went without medical care while others depended on hospital emergency rooms.

Geihsler had hoped to get patients to be more proactive about health care. So she switched gears, figuring out ways to get her physicians out into the community where they could attract patients. It was time to rethink process guidelines, especially the conventional wisdom that doctors should stay in their offices and refuse to make house calls. That’s when Geihsler found the Chicago Police Department.

The policemen’s union had been agitating for better benefits for its members, giving Geihsler the opening she needed. In short order, Advocate doctors began visiting police stations to interview and perform health-risk assessments. They took the officers’ histories, noted their eating and drinking habits, and counseled them about lifestyle and hereditary illnesses. Next, they developed worksheets that outlined a series of actions to improve the officers’ diets and exercise regimens, and appointments for physical exams were scheduled.

The program was a big hit with the officers, Geihsler told us. They loved the convenience of stationhouse exams, lining up out the door whenever doctors’ visits were scheduled. Within a month, 10 percent of the officers interviewed had made, and kept, doctors’ appointments.

“At first, some of the doctors had their doubts” about the stationhouse visits, Geihsler said. “They thought it was just going to add to their workload.” But as it turned out, the doctors liked doing the assessments because they could manage the patients’ care more knowledgeably and efficiently.

The idea for moving the health care process into the workplace grew in part from Geihsler’s earlier experience starting free clinics for people of limited means. People simply wouldn’t come in, she said. Worried about paying their bills, they were working two or three jobs while also taking care of children and elderly parents. Geihsler understood that behavior. “All of my family are either farmers or poor hourly workers of some kind,” she told us. “I’m the only one who has health insurance. If I said to my sister—who has at least two jobs—how about getting a checkup? she’d say, ‘Great. When do I fit that in?’”

It’s not that people have no interest in their health. They think and talk about it all the time. But for millions of Americans, healthy behavior and doctors’ appointments take more time and money than they can spare. The best way to reach them and convince them otherwise, Geihsler believes, is through their employers, the people who are paying for workers’ health care already. “Why wouldn’t they welcome a preventative program that improves employee health and cuts the employer’s health care costs?”

By the time Geihsler left Advocate, the medical group was solidly in the black, exceeding budget expectations for more than six years. She attributes that to tight management by people who knew how to build physician group practices and were allowed to operate independently of a hospital.

Geihsler continued her innovative ways when she moved to Boston in 2006 to become the CEO of another challenged group practice, HealthOne, which was reorganized as Atrius Health, the parent of Harvard Vanguard Medical Associates.

Geihsler told us that she has always been bothered by the failure of typical medical practices to intervene with chronically ill patients. Take a patient with hypertension who has seen a doctor four times, say, over two years, always complaining of the same symptoms. Four times he has been told to stop using salt and start exercising. “We should be reaching out to those patients between visits,” she says, “to get them to behave better so they won’t have a stroke.”

Even patients who normally follow a healthy regimen can stop eating properly and exercising regularly if a traumatic event occurs—a death or divorce, for example. Geihsler reengineered the processes in Atrius’s primary-care clinics to create what she calls “in-between coaches,” medical advisers who periodically contact these patients to get them back on the straight and narrow.

When she left Atrius in 2008, Geihsler launched a start-up, Activate Healthcare. The Indianapolis venture is embracing Geihsler’s on-site health care model to reduce employers’ insurance outlays. The company’s mission: “Enabling employees to take charge of their health and employers to take charge of health care costs.” Again, that means moving doctors out of their offices and into the places where patients spend their working hours.

“We found that, in any given corporation, 30 to 70 percent of these folks do not have an attachment to a primary care physician,” Geihsler said. When asked, they may claim to have a regular doctor, she continued, but upon further questioning, a significant share will admit that they haven’t seen that doctor for years.

The Activate model dictates that a physician and health coach spend an hour with each employee in the client company’s offices, doing a physical exam, creating an action plan that pinpoints existing or potential problems, and laying out the behaviors the employee needs to adopt. Health coaches regularly connect with the employees to help keep them on track.

Convincing employees to eat food appropriate for their health conditions is always a challenge. Activate is exploring a variety of options—among them, enlisting restaurants to deliver healthy food to offices if the employees want it. That eliminates the danger of employees leaving the office for lunch and giving in to their unhealthy appetite for fast food or other poor choices. Activate also helps employers build benefit plans that encourage healthy behavior.

In promoting the on-site model, Geihsler describes a typical medical experience: You have a sore throat, an earache, a urinary tract infection, or some other common ailment. You call your doctor to ask what you should do, and the nurse insists you come in to see the doctor. You’ve got a busy schedule or a tight budget or both, so you wait two or three days, and eventually your problem seems to subside. Whether it has solved itself or gone into hiding to reappear at a later date is unknown. In any event, you’ve been suffering—needlessly, in Geihsler’s opinion.

She insists there’s a better way. The on-site physician does a thorough intake interview and checkup of new patients, including their physical and emotional states, family histories, and lifestyles. Health coaches maintain regular contact with patients to update their records and track their progress in achieving their action plan goals. Now, when a patient calls with a sore throat, the doctor can knowledgeably get on the phone and prescribe a solution, confident that the on-site nurse or nurse-practitioner will be there to monitor the situation.

In fact, Geihsler expects that physicians following her model will one day dedicate the hours of 7:00 to 9:00 A.M. to answering e-mail or phone calls from patients. With up-to-date information about each patient at doctors’ fingertips, and with the assurance that trained aides are available at work sites, they can quickly and easily make the right decisions and provide immediate relief to patients suffering from coughs, congestion, contact dermatitis, and the like that uncomfortably strike all of us with regularity.

The greater goal, Geihsler reminds, is to improve the quality of health care delivery—not just the quality of the treatment patients receive for an injury or a disease, but the quality of their health all through their lives. And she believes her model can do that by changing the way doctors do their work and interact with their patients. “It’s not just about how I treated you once you became a diabetic,” she insists, “but whether I could have prevented you from becoming a diabetic but didn’t.”

Leverage the physician’s time.

A veteran specializing in cardiology and internal medicine at one of Harvard Vanguard’s sites was presiding over a shared medical appointment. In a shared appointment, up to a dozen patients—some with relatives in tow—see the same doctor at the same time. This innovation is one of the process reforms that Zeev Neuwirth believes will improve access to health care and raise the effectiveness of its delivery while also making the doctor’s increasingly complex job more doable.

It was perhaps predictable that not all of Neuwirth’s physician colleagues would be delighted with group patient visits. Would patients be candid in a group setting? Would they resent the loss of privacy? Could a doctor probe into each patient’s personal problems or deliver bad news in a group setting?

The patients sat in a semicircle on chairs in the big conference room. The physician was assisted by a nurse, a documenter to enter his observations in each patient’s medical record, and a facilitator to keep the visit process moving along. A longtime patient—we’ll call him Bob—was reporting on his latest symptoms when he suddenly announced, “You know, I think I’m depressed, and I need some help with it.”

After the session, the doctor buttonholed a colleague. “For years,” he said, “I’ve been telling Bob he was depressed, and he wouldn’t believe me. Now, in his first group visit, he stands up and acknowledges it. I almost fell off my chair!”

Bob’s sudden self-realization, Neuwirth told us later, was not all that uncommon at group visits. “When people go for a one-on-one appointment,” he said, “they often don’t get to report new problems or get the information they need. Maybe they recognize that the doctor is pressured by time constraints, or maybe they just forget to ask. Many patients also feel isolated and vulnerable—being sick or having a chronic disease can be a very lonely thing.” Group visits, he explained, have a kind of social network ambience. Patients feel freer to share their symptoms and their treatments and to learn from the experiences of others.

Bob’s epiphany was testimony to the effectiveness of shared appointments, but the added efficiency they provide is just as valuable. By breaking down the doctor’s work in patient visits and assigning others to keep a record, elicit questions, and facilitate the discussion, the group visit lets the doctor focus on what he or she does best. It also allows the doctor to process patients in parallel rather than singly, radically increasing the bandwidth of a process that had been linear. The cardiologist’s 90-minute session with a dozen patients would have taken three hours if each had been given just 15 minutes, one-on-one.

And because they are both efficient and effective, group patient visits are slowly but steadily working their way into the practice of medicine. According to the American Academy of Family Physicians, 8.4 percent of doctors offered patients that option in 2008, up from 5.7 percent in 2005. At Harvard Vanguard, nearly 40 group visits run on a regular basis in specialties ranging from internal medicine to dermatology to ophthalmology, with dozens more planned.

The group approach was initially designed to give patients access to their doctors without the usual days or weeks of waiting, while also making far more efficient use of the doctor’s time. But research suggests that the shared events can actually inspire better compliance. In some studies, for example, diabetics enrolled in shared appointments had lower blood sugar levels than comparably ill patients who saw their doctors singularly.

The group visits appear to be highly popular with patients. In a 2008 survey of 720 people who signed up for shared appointments at Harvard Vanguard, 77 percent said they would schedule another, while only 5 percent said they would not. Seventy-three percent thought their relationships with their doctors had improved as a result of shared appointments.

At the start of a typical group follow-up visit, before the doctor enters the room, the facilitator gets all the patients to sign an agreement saying they won’t divulge what others say during the visit. Meanwhile, a nurse checks patients’ vital signs and provides medication refills as needed. The facilitator has also written patients’ names and the reasons for their visit on a whiteboard. Displayed on a second whiteboard, or easily accessible on a computer, is all the information the physician needs about each patient’s medical history.

The doctor takes a history and does a brief physical examination based upon each patient’s symptoms, announcing issues and conclusions so that they can be entered by the documenter in the patient’s medical record. If the symptoms or problems require the patient to undress for a more thorough physical exam, it’s done behind a curtain. The doctor delivers a diagnosis and treatment plan based on his or her findings, answers the patient’s questions, and moves on to the next person.

After completing a patient’s history and physical exam, the physician checks over the documenter’s entries to make sure all questions have been answered and no problem overlooked. While the doctor is checking any previous notes with the documenter, the facilitator is starting a discussion among the patients. After Bob announced his depression, for example, the facilitator asked, “Who else has had problems with sadness or depression? Let’s talk about it.” One and then another patient would typically have spoken up, describing symptoms and treatments before the facilitator steered the talk to the next topic.

At some point, the doctor might have weighed in with suggestions regarding depression. But what the patients find most rewarding about group visits, according to Neuwirth, is not only the doctor’s contribution but the discussion itself—the sharing of patient knowledge and experience.

Some patient visits are particularly suited to group treatment. Post-operative sessions with surgeons, for instance, are often devoted to repetitive lectures. In a shared medical appointment, a surgeon can quickly check out the post-op conditions of a dozen rotator-cuff patients, let’s say, answer their questions, and deliver the standard lecture only once. Then the patients can trade experiences with others in the shared-recovery process.

As Neuwirth put it to us: “Think about how many times a physician says the same thing over and over each week to patients in individual visits. There are mini-lectures about blood pressure, diet, headache, back pain, medication side effects, pre- and post-operative instructions. If the physician were able to say all of it to a dozen patients at once, think how much time would be saved. Instead of the one-minute sound bite of information, a doctor could take a few minutes to really teach patients—and really listen to what’s going on with them. Also, patients would have a chance to ask questions of one another and to support each other.”

Even when they understand the benefits, though, not all physicians are enamored of the shared appointment model. Some say they don’t want to give up the kind of intimate, knowledgeable connections they have with their longtime patients. But Neuwirth believes the group experience is inherently preferable. “People want to share their medical problems, and they want to hear about other people’s medical problems,” he says. “Health care should be a communal activity; the development of the individual visit in the ambulatory care setting was a medical establishment misstep. Doing surgery one patient at a time makes sense. Using the same model for chronic disease and preventative primary care doesn’t.”

Part of the patients’ preference for group visits, Neuwirth told us, derives from an almost prurient curiosity about other people’s problems. At the same time, patients genuinely empathize with others, and in shared appointments they constantly “step up and help each other,” he said.

Neuwirth cautions that doctors and their teams need some training to make shared sessions successful. “Most physicians and staff are not competent in this kind of experience,” he remarked. The facilitator, documenter, and medical assistant must be trained for their tasks along with the doctor. With the right training and setting, patients can have the kind of relaxed, in-depth experience that’s difficult to find nowadays in a single-patient appointment. As for the physicians, Neuwirth declared, “It takes them back to the reason they went into medicine in the first place—to focus on their patients and to provide relationship-based medical care.”

A Checklist for Process

• Have you identified the processes for which reengineering can make a significant improvement in efficiency and quality? In the final chapter of this book, we will tell you more about how to focus your reengineering efforts, but be sure that you have chosen areas that will produce important changes. Although we have told you to “start small”, your results should still be significant. Your target processes and results must be compelling for clinicians to take notice.

• Can you demonstrate results quickly enough to maintain momentum? It’s important for people engaged in reengineering to experience successful work change quickly. The faster they experience the benefits of work change, the faster they will become engaged. Early indicators of success also tell you that you are headed in the right direction.

• In setting the objectives for process change, have you gone far enough to address the systemic issues that are driving inefficiency and endangering safety? It may look easier to accomplish incremental change, but unless you go far enough, you may just be covering up problems—not really making the workplace better.

• Have you selected a reengineering leader who has the respect of other clinicians? We will talk more about this in the next chapter dealing with people, but health care professionals can only be led by those whose knowledge and character they highly respect.

• Do you have the support of the executive team of your enterprise? The details of health care-delivery change will come from the bottom up, but top-down engagement and support is also critical to accomplish major change. If you don’t have support from the top, you will be limited in what you can do. We offer some advice in the pages ahead on how to get the support you need.

• Are you focused on processes populated with knowledgeable and engaged people? Go to where you have expertise and at least one catalyst to begin the change.

• Have you prepared for a long reengineering journey? Although we emphasize focus and starting in small venues where you can be successful, your reengineering will be a journey, not a single event. The more you experience the success of change, the more your appetite for change will grow—especially in the delivery of care where so much needs doing. If you pace change correctly, you will not be left exhausted, and the exhilaration of success will keep you going.

• Does your process redesign address the fragmentation of health care? One of the objectives of reengineering should be to address a continuum of care that can be managed by both the physician and the patient. Care will be delivered in multiple places—physicians’ offices, clinics, hospitals, the workplace, and in patients’ homes—and all will need to be elegantly connected.

• Will your process improvement lead to a more knowledgeable and engaged patient, able to make more intelligent decisions? What the patient hears and learns is critical. Education must be built into delivery processes. It cannot be an afterthought.

• When you are done, will you have significantly improved the lives of physicians, patients, and staff? Of course, dramatically improved clinical outcomes should be the objective of your reengineering, but your success will also be measured by how both patients and physicians experience the change in the quality of their lives.

We have only begun to describe the myriad medical processes that will have to be transformed in the reengineering of health care delivery. From birth to death, most of us will experience hundreds, maybe thousands of processes in hospitals, clinics, and doctors’ offices, not to mention those in schools, corporate offices, pharmacies, ambulances, and medevac choppers, or at accident sites and on ski vacations. The venues are endless—and all can be improved. What counts, as we have stressed in this chapter, is how process changes will be made and the need for open-mindedness as the people entrusted with health care reengineering risk new approaches.

All of us who are involved with health care, not just those at the top, must be ready to embrace change while learning to operate in a transformed world. That’s the subject of the next chapter.