Josh Clark, R.N., M.H.A., vice president, quality and safety operating systems at the Institute for Healthcare Improvement (IHI), recently co-authored an article in the Harvard Business Review that describes several examples of operationally integrated and technology-enabled approaches to health system transformation. The paper refers to these health systems as “care operating systems.” In short, the authors argue that health systems should focus on fixing systems, not people. Clark recently sat down with Healthcare Innovation to explain this concept.
Prior to joining IHI, Clark served as the senior vice president of quality and safety operations at Jefferson Health, an 18-hospital system covering the Philadelphia region and southern New Jersey, and before that as senior director of quality and safety at Carilion Clinic, a health system based in Roanoke, Virginia.
Healthcare Innovation: First, could you talk about your new role at IHI?
Clark: I transitioned over from Jefferson about six weeks ago. My role at IHI is vice president of quality and safety operating systems, and I am essentially charged with building out a new consulting arm for IHI that will be helping health systems around the world adopt and implement this care operating system approach.
HCI: In the Harvard Business Review paper, the definition of the care operating system is that it involves building dynamic operating models that support continuous learning and continuous improvement via system redesign. I've written a lot about the concept of a learning health system where data from the EHR might feed internal improvement efforts. Are those concepts different in some way or are they aligned?
Clark: They're aligned, It is more expanding on that and making it part of clinical operations. I think traditionally in healthcare, we've been focused on being a learning organization, but somehow it has lived within the quality department. This approach is driven not just by the quality officer, but also operations, the informatics leadership, and the analytics leadership, so it is doing work differently.
Historically, healthcare has paid a lot of attention to learning about things that can be improved in the system, but hasn't paid as much attention to how they actually evaluate those systems issues, triage them and then ultimately resolve them — and how you engage the staff. When the staff members elevate something that ultimately becomes a system issue and has a large impact to the organization, you have to have that feedback loop to let the staff know that you appreciate that they took the time to tell you about something in the system that can be done better. That creates a snowball effect for more staff to continue to tell you about those opportunities.
HCI: Your paper starts by recognizing a common flaw in improvement efforts — that instead of focusing attention on the systems, they focus on fixing the people. Here's an example of that I can think of, but maybe there are better ones: We often write about health systems trying to get clinicians to do more training to improve how they write notes in the EHR, so it doesn't take so long. Is that an example of trying to fix the people rather than fixing the system that they're using?
Clark: Yes, I think that’s a good example, and it’ something that is so common that clinicians have become kind of numb to the amount of things they are asked to do on a daily basis. In the care operating system approach, you're really trying to limit the cognitive load on the clinicians of doing more than just providing the best possible care to the patients. That is why we included a concept of “quality is everyone's job,” which has been a kind of a traditional theme for a long time. We just want you to take the best possible care of the patients, and we want you to tell us when the system can be improved, and we'll do the rest. We'll send you out for success. That systems-based approach is really effective, because it starts to get at some of the pain points of burnout and of just exhaustion that the clinicians have, because the complexity of the care that they deliver every day is increasing anyway.
HCI: Your Harvard Business Review paper notes that people who seek to transform a culture without building the systems that enable it are doomed to failure. Have you seen health systems that do that? They say, “we’re going to transform the culture here," but they don't do the underlying work to be successful at that?
Clark: I think that is extremely common. If you talk to quality leaders or HR leaders across the country, they would say, “well, we're working on our culture,” but ultimately it ends up being education for the frontline staff. You can change your culture by focusing on the system and creating that snowball effect. It starts to create this culture of reporting and of learning and of improving, and that ultimately becomes a major driver of engagement and reduces burnout. It's one of the more critical missteps that we are hoping to course-correct: this idea of just focusing on culture, without focusing on improving the underlying operating system is more than just destined to fail, it actually has a negative impact on the workforce.
HCI: This gets back to another point that you brought up earlier. Maybe a flaw is seeing patient safety, health equity and patient experience as siloed improvement operations Your paper describes the Greater Baltimore Medical Center as a good example of breaking down those silos.
Clark: Yes, they're making it very clear what the priorities are in the workflow of their staff, and they're living this idea of of trying to enable their staff to do the things that matter and making sure that meaningful and actionable data is available to the frontline clinicians so that they understand what levers to pull to impact the outcomes that matter most to the organization, and they're doing a good job of messaging that to the frontline staff.
So it's one thing to do it, but if you don't tell the staff that you're doing it and involve them, and it's sort of a continual co-design or redesign of the work, then you lose some of the value that you're getting from that approach.
There's a very clear commitment from their board to their CEO all the way down, in quality and safety. You hear the same kind of talk often from other health systems, but you don't see it in the practical application of how they go about their daily work. So they do a great job of that.
HCI: Another thing the paper says that in these care operating system organizations, you've identified that the quality team is not seen as reactive policing or scorekeeping. Is that how they're seen in a lot of health systems — as cops who are policing people?
Clark: Yes, it's a little bit of an old school reference. But you know how quality assurance and regulatory expectations evolved over the last 20 to 30 years, and then with medical malpractice being a major driver, that is kind of where we were. It became more risk-focused and about protecting the organization. We've evolved a lot since then, but there’s still some perception that sometimes the frontline clinicians are only engaging with the quality team when something's gone horribly wrong. When the quality team understands the complexity of the daily work that the frontline clinicians are doing and they're working to help reduce that complexity and enable them, then the frontline clinicians are much more willing to engage with them in helping to understand how the system is performing and how it can be improved.
HCI: Another aspect the paper talks about is transparency, and it points to MedStar’s Communication and Resolution (CANDOR) program as a good example. I have seen a presentation about that program, and it’s quite compelling, but are they still seen as a pioneer and outlier in this or have other health systems seen what they've done at MedStar and replicated it?
Clark: I think CANDOR has been well-adopted across the U.S. The evidence is very clear. In fact, the line in the paper about CANDOR actually reducing litigation is very well-known evidence, and so that approach has been widely adopted. MedStar was one of the first to fully commit and start to publish on it, but it is considered a best practice now.
HCI: What about transparency on health equity issues, like actually publishing results on trends in disparities and your health system’s progress on decreasing them?
Clark: Yes, I think there's a lot of work to be done there. There's certainly a great amount of interest and passion and energy around that. Just this past January, CMS started to require collection of social determinants of health and health-related social needs screening, so that’s a really great step. It is important to have standard data points at the local and national levels, so that we can understand the challenges that our folks face. But again, it comes down to the fact that if you have that data and you have the commitment to take on those disparities, it really has to come through system design; otherwise you're just telling the clinicians that your African-American patients have these outcomes, and your white patients have these outcomes, and we need to do better. That doesn’t sit very well with clinicians. You have to do the work to understand what's the driver of those inequities and design them out of the system.
HCI: One example the paper gives is at Jefferson Abington, where unit leaders have a real-time dashboard that orients the care team to unit-based and system-level priorities that matter most during that shift. Do you see that type of setup at multiple organizations?
Clark: It's fairly new. It’s an approach of connecting leading indicators or process measures to outcome measures that the organization cares about. One of the mistakes that we've traditionally made is we've just shown outcome measures to frontline clinicians, but they don't actually know what they're doing in their daily work that impacts those outcomes.
This is a dashboard that's built within the EHRs that lets them understand, for their shift, these are the things that we can do that ultimately will help us improve on the things that matter most, and it's built within their workflow.
There’s a five-minute huddle in the morning and in the evening. There’s a clear handoff if there's something that needs to be addressed from the staff. We got a lot of positive feedback from staff on that, because we were making it easier for them to understand what the priorities were, and we were making it part of their daily work so that they could actually contribute. It created awareness, it created engagement, but it also is a driver of helping to improve on large scale improvement activities.
HCI: Is this kind of work easier for large academic medical centers to do and more difficult for smaller community health systems?
Clark: It can be done in both settings, because of the the blueprint for how you communicate this, how you start to shift the limited resources that you have to focusing on system redesign as a way to account for daily learning and improvement, and also large-scale improvement.
It can be done if you have two hospitals or 20. The only difference, I would say, is that the approach is the same for both, so a lot of times larger systems can get more value because the same work is happening at scale. It's being done at an enterprise level, and then the redesign is happening throughout the systems and through how we function as a care operating system and as a team.
HCI: Could the work you are starting to do at IHI be done in a cohort model where you get leaders from three or four health systems working together?
Clark: Absolutely, it could. We’re definitely talking to folks who are interested in that cohort model. It's highly scalable and adaptable to any sort of care continuum or care environment. At Jefferson, we were able to apply it to inpatient, outpatient, virtual care, post-acute SNF care, and it really helped in some of the things that we were doing to rapidly adapt to COVID. But it helped us with the unique challenge at Jefferson, where five different health systems merged over a period of less than five years. I started there right at the beginning of COVID and really led the integration via quality and safety operating system work — getting folks on the same system, having a data management strategy in which we had very clear and transparent priorities across the organization.
HCI: Is there anything else about this work that you'd want to stress?
Clark: I think the thing that is resonating with the folks that I'm talking to about this work is being able to bridge the gap to quality and safety actually being a part of operations, being embedded in operations, and the effect of that not only improved outcomes, but improved workforce wellness.
