Shifting Care to the Front Line

An article in the October 2010 issue of the Scientific American titled “Closing the Healthcare Gap” revealed the importance of primary care physicians in improving the healthcare system and also the problem of a shortage of primary care physicians. The results from business process redesign effort at Group Health Cooperative have were highlighted, “…patient satisfaction was up, visits to the emergency room were down, and costs were lowered just one year after it started providing more primary care services.” To read and learn more about the ongoing lean transformation effort that is supporting a massive shift in how healthcare is being delivered at Group Health, read the blog DailyKaizen.

From a lean management consultant’s point of view this finding is not surprising at all. Essentially what this article says is that providing more care earlier in the process prevents the need for more urgent and expensive care later on. This is the entire premise of TPM (Total Productive Maintenance), the rationale for visual management and leader standard work to actually go and check the condition of the workplace as indicated by these visuals, as well as the emphasis placed on developing front line supervisors and team leaders who are strong at facilitating and doing problem solving. Anyone who has spent any time solving problems can attest to the fact that early detection is a key element to minimizing the problem. A major behavior change in lean management deals with shifting care to the front line, whether it be in moving support staff closer to the internal or external customer, or in creating leader standard work routine that bring leaders to the places where they can coach and enable problem solving on a routine basis.

We can draw some direct analogies between primary care as a gap closer in health care and in other industries. For example the article states that in delivery primary care general practitioner physicians are better able to “look at the whole person” when hearing a patient’s medical complaint or recommending a diagnostic step. This is because by nature generalists tend to have a broader view and wider exposure to various ailments and as a result can take what we might call a systems view as opposed to a specialist or sub-systems view. In business, general practitioner who can look at the business as a whole system also have better success in pointing out and addressing obvious problems with simple solutions while at the same time being able to recommend deeper analysis where there are familiar signs of more complex problems.

The article stated also that specialists tend to be not as good at diagnostics as the generalists. Lacking expertise in medicine it’s not possible for me to comment on this, but this can certainly be true in business. Specialists tend to find the problem that fits their pet solution or what has worked for them in the past. When this is embodied in a chief executive arriving from outside the organization with a lack of desire to listen and learn before recommending a course of action the results can be disastrous. Many “flavors of month” business transformation programs are born and die this way. There is nothing wrong with these business transformation programs themselves, just as the diagnostic expertise and technologies of the specialist doctor are not to be faulted; it is their application by specialists in a hurry to find the solution for which they will be rewarded, without the first step of a generalist diagnostic, that makes them so dangerous.

The article points to the looming problem of a lack of general practitioners needed to make primary care a much more significant part of the healthcare process. This is due in part to the fact that primary care doctors are paid less than specialists. We have an incentive system that drives the opposite of behaviors desired to improve the whole system. It is as if nobody in a business wanted to take the customer order until the only way to deliver it on-time was to pay extra fees for expedited shipment. This is great for the shipping company but nobody else. Perhaps in time a well-functioning free market system will find a way to reward the right behaviors and motivate more doctors to become primary care physicians.

The next logical step in shifting care to the front line of healthcare would seem to be preventive medicine. But here again the incentives, especially for food, beverage and pharmaceutical companies, may be even more perverse. We have a conflict between the profits from selling more drugs and consuming more addictive foods, and the overall cost to society of sickness that is enabled by a lack of focus by drug and food companies on consumption that keeps us healthy. The profits in the former are short-term and concentrated on the few firms that find the right product, while the profits from the latter are delayed and distributed across all members of society, so it’s no wonder. Hopefully as we make progress in shifting more resources to primary care we can approach the frontier of systemic and wide-scale preventive medicine also.

This article made me recall a conversation from about 10 years ago. A seasoned manufacturing manager who had initially resisted our lean approach but came around when he recognized it as simply something familiar which he already believed in but under a new name, told me (and I paraphrase from memory):

“The problem is we don’t have sustaining engineers anymore. Used to be we had lots of ’em. Now the engineers are out here for product launch and then we never see them again until the next line gets set up. That’s why we’re always running overtime. We’re too busy to fix the simple problems during the day.”

This is not a criticism of engineers but of the priority being put or not being put on primary care of the mature production lines. It is as if we took care of our babies until they were aged 6 months but then never took them to a doctor again unless they got sick. We don’t do this to our children because the cost (both human cost and financial) is clear. Yet we do this to our business processes. Perhaps our measurement system needs to reflect the “human cost” as well as financial cost of regular process check ups better. Or perhaps we just don’t care enough about our work or our workplace to invest in primary care and the development of managers, engineers and supervisors capable of providing it.

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