Unification – Making the System Greater than the Sum of its Parts

Unification in healthcare is a common objective these days and for good reason. Billions have been spent in the acquisition of physician practices and facilities across the country and now leaders are facing the challenges associated with bringing these diverse entities together to behave as one. As one CEO said, “I have a Ferrari in the garage, but it is in parts.” This fragmentation impacts every aspect of the organization. It increases the costs, decreases the patient and physician experience, it frustrates employees.

The vision of all the parts working together in a unified, efficient way to solve patient problems by seamlessly connecting all the dots exists but putting it together is more like building a car from the parts than fixing it with glue.

“The only way to avoid using so much glue is to start with bigger fragments – in other words, bigger jobs…. A process focus changes the boundaries of traditional jobs, expanding their scope and breadth, so that less non-value-adding effort is required to put them together.”

 Michael Hammer – Beyond Re-Engineering

To illustrate this, consider Care Management (CM) as an example. A system had invested heavily in (CM) through consulting and the addition of resources. Care Managers were included as normal in the in-patient (IP) setting, ambulatory and the ACO. The IP CMs as well as the Ambulatory CMs were on the same technology system. The ACO had a separate system to do analytics on the member patients. The highest-level symptoms included:

  1. Excessive lengths of stay with overutilization of some of the facilities in the system and underutilization of others
  2. Patients “touched” by multiple care managers
  3. Patients who needed support were not being supported at all (only about 5% of the patients who needed ambulatory support received it)
  4. Cultures varied significantly across the major groups

A key problem was not only the fragmentation within each of the 3-major areas but fragmentation across the areas. Non-value-added work was the glue attempting to bind together the value-added work in these processes.

Solving this problem required stepping back and re-engineering care management to common goals as a system vs. gluing together the disconnected parts. Re-Engineering analysis and design demonstrated that realigning resources and their tasks to the new purpose to avoid gaps and multiple touches across the system would provide the most value for patients and be the most cost-effective way for the system.

A straightforward way of determining whether you need to consider re-engineering is to look at whether you have many problems in multiple related areas or a single problem in an isolated area. For example, do you have Length of Stay (LOS) issues on many units or only one? Are the LOS issues related to ambulatory care or lack thereof? Are the right patients being cared for in the most efficient manner or are some patients being “over-touched” while others are not touched at all?

Re-Engineering is a scientific discipline developed to redesign these highly complex organizational issues that span multiple areas of a system. The photo above shows a heat map of a large CM organization showing that the problems were integrated into the fragmented design in a way that process improvement could not have efficiently solved the problems.

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