A Team Effort to Re-Engineer Care at Hospitals

How the Cleveland Clinic is applying manufacturing principles to improve patient care.

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Kelly Labby, an attorney from Bemus Point, N.Y., suffers from a rare type of brain tumor and resulting epileptic seizures that almost ended her career. In most places in America, the surgery and radiation that gave Labby her life back, plus ongoing treatment for seizures, skin rashes, ear infections, and myriad other problems, would mean endless visits to endless specialists in different locations. But Labby arrived at the Cleveland Clinic in 2006, when its new quality-improvement program was changing the place in large ways and small. The Epilepsy Center was one of 25 centers newly organized around diseases or organ systems rather than specialties. It brings together the surgeons, neurologists, endocrinologists, psychologists, and internists expert in seizures. "It's amazing to get such coordinated care. I go there for everything," says Labby.

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That transformation is part of an unusual effort to bring the best practices of manufacturing to the hospital setting. Over the past five years, the clinic has assembled a 50-person team focused solely on "continuous improvement," or Kaizen, the Japanese word for "making things better." Most of the team members are engineers with experience far removed from healthcare. The efficiency experts quickly found out why healthcare isn't just another industry. Whereas higher profits might be the unambiguous goal at a corporation, doctors and nurses were not about to embrace any change that improved work flow without proof that it wouldn't lower the quality of care. "You cannot issue an edict," says team director Darryl Greene, who arrived at the clinic after a career spent improving processes at appliance makers and financial institutions. "You have to sell each doctor on the value, using data and results."

Consequently, the improvement experts spend a lot of time on rounds with the medical staff, and doctors and nurses weigh in on, or even come up with, re-engineering ideas. Two years ago, the average patient spent seven days in the Clinic's top-ranked cardiac unit awaiting heart surgery, as the time it took for an extensive pre-operative workup steadily climbed along with patient volume. Then A. Mark Harrison, chief medical operations officer, put the efficiency engineers together with schedulers, nurses, and surgeons to better coordinate all the processes. In less than a year, the average pre-op stay had dropped to under five days. About 18 months ago, nurses at the Heart and Vascular Institute started meeting every Tuesday at 7 a.m. to discuss performance improvements; out of those meetings came a decision to require intensive care nurses to have a dialogue about each patient with the next caregiver during handoff. Before the change, nurses would read a chart summarizing the patient's health status, which could leave out nuances and contain errors.

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It's an open question whether other hospitals can follow Cleveland's lead. For one thing, says CEO Delos Cosgrove, the program wouldn't be possible without the deep well of data on outcomes available from an extensive electronic health records system, which few hospitals have. Doctors here are also all on salary, so they needn't be wary of efficiency moves that could benefit the institution but harm their own bottom line. Even without those advantages, Harrison says, a hospital "can almost always find people who are innovators on any medical staff." The trick, he says, is to approach change as something good for patients.