- Email: [email protected]
Overview: Cooperating for Improvement
Overview: Cooperating for Improvement
I
n many sports, players get credit for "assists" as well as for "goals." The logic is forceful-the result depends as much on the interaction as on the final action. "Helping" is "producing." "Assists" also get lip service in medical care, but the reality has been different. Although few undertakings are as interactive in their essence as proper health care is, the health care industry as a whole migrated long ago into individual sports, in which teams earned less regard. Cooperation faded into the background as a luxury, and the core work of caring for patients was vivisected into functional categories, professional roles, and specialized institutions. Doctors tried to be better doctors; nurses, better nurses; hospitals, better hospitals; nursing homes, better nursing homes. But no one was tending the whole. We are trying now to find our way back to teamwork as a core competence for health care-not just teamwork within our familiar geographic and disciplinary circles, but teamwork across boundaries that we have spent decades and fortunes shoring up. Nothing less can
Donald M. Berwick, MD, and Thomas W. Nolan, PhD, served LZS guest editorsfor this issue. Dr Berwick, a Contributing Editor of The Joint Commission Journal, is President and Chief Executive Oficer of the Imtitute for Healthcare Improvement, Boston. Dr Nokzn is n member ofAssociates in Process Improvement, Silver Spring, Maryland. Copyright o 1995 by the Jolnt Cornrniss~onon Accreditation of Healthcare Organ~zat~ons
1070-3241/95/$3.00 + 00 45/lli'0102
VOLUME 21
NUMBER 11
achieve the experience our public wants at prices it can afford. It costs money to maintain boundaries, and it invites defects when we try to pass patients over the walls that separate our fragments. As far as our patients are concerned, good fences make bad neighbors. "Integration" has become a visible and admired strategy for improvement, and cooperation is its most important method.
What Integrating Means The word "integration" varies in its meaning. Some use it to refer to structures of governance, organizational design, or financial arrangements. That is not what we mean here by "integration." We refer instead to a notion of process design and interaction achievable under many different forms of governance, organization, or finance. To us, the test of the presence or absence of integration lies in the experience of the people served by a system. T o us, a system is "integrated if the people it serves experience it as a responsive whole. Integration is optimizing the interactions among elements of a system to provide health services ofhigh value to those the system serves. Integration can thus apply equally well within an organization (in which departments or functions are elements) and among organizations (in which the participant organizations are elements). It is intriguing to see among the papers in &is issue of TheJointCommis,ion journal ~ ~I~~~~~~~~~~ ~ how l similar i the ~ challenges are that arise when the attempt is made to develop integrated activities in these two very different contexts: intraorganizational and interogranizational. It should suggest to us that barriers to cooperation may not
be simply the result of rivalry among organizations; they may be built into our natures at a much deeper level.
Why Integrating Helps Under our definition, "integration" is a close relative of . ~mprovement." Improvement involves the design and redesign of products, services, and processes of work so that they better match the needs and expectations of the people they serve, while minimizing waste. Integration supports continuous improvement primarily because it broadens the opportunities for design and redesign. The wider the boundaries of a system, the broader are the opportunities for improvement. This is a technical point, not an ethical or emotional one. How, technically, can integrating a system produce benefits for customers?A few examples follow: 1 . Integration allowsfir betterpwdictions. Through cooperation across boundaries, opportunities increase to understand and predict demand, and thereby to better match supply and demand, which reduces waiting times, averts waste, and smooths the experience of the customer. In the papers assembled in this issue of The Joint CommissionJournal, we see the benefits of aggregating information in the report of the Maine Medical Assessment Foundation (p 619) (which ". . allowed study group participants to engage in academic research . . . not usually available to physicians who practice in rural states . . .") and in the work of the Northern New England Cardiovascular Disease Study Group (p 627), whose pooled data allowed the development of a predictive model that no individual practitioner alone could have created. 2. Integration allowsstandardhtion of equipment, rules, forms, and supplies, so as to permit leveraged purchasing (as described in the paper by Lee and his colleagues, p 593), smoother inventory management, and decreased complexity. A single trauma service will have fewer than five times as many supplies as five trauma services, each of which is onc-fifth as large. Health care organizations and their customers pay a very high price for maintaining unnecessary variation and heterogeneity in their supplies and methods. Doctors, who have tended to see standardization as a threat to their autonomy, are beginning to understand that real control, and real autonomy, can be consequences of standardization, and that they should exercise a leadership role in ensuring that smart standardization occurs. 6'
.
3. Integration increases responsiveness to individual need. It is often only when individuals remove the boundaries between them that they can see each other as individuals, instead of requiring each other to accommodate to separate, fragmented rules. For example, close cooperation between inpatient and outpatient rehabilitation services can create customized sequences for individual patients, instead of requiring routine "handoff" procedures at the boundaries between them. The close interactions between health care payers and health care suppliers described by Friedman and his colleagues (p 635), and the collaboration between the regulator (Joint Commission on Accreditation of Health Care Organizations) and the regulated entities (through the Public Hospital Institute) described by Kabcenell (p 579) are both examples of "customization" achieved through cooperation, which benefits all parties. 4. Integration facilitates continuousjow instead of "batching" of work. One general principle of process improvement is to attempt to meet needs at the rime they present, instead of instituting waiting times and queues. This is the core concept behind Toyota's brilliantly successful methods of "just in time" process management.' The payoff from continuous flow is high in both cost reduction and quality improvement, but smoothing flows demands a high level of cooperation, especially in the transfer of information about needs and capabilities between suppliers and customers all along the stream of production. Friedman's paper on long term care hints at this possibility, as does the analysis by Reinertsen (p 612), but, on the whole, health care has yet to discover and capitalize on the benefits of continuous flow as a dividend of integration. 5. Integration reduces the need for inrpection. Inspections, which are costly, usually occur at boundaries, as products and services move from one system to the next. In principle, at least, removing boundaries and substituting clear understandings and well-designed processes should reduce the need for checkpoints and rework. Ask any doctor about the burdens today of utilization review and precertification, and you will get a vivid and frustrated account of the costs of inspection that derive from fragmentation. In Reinertsen's account of the work of the Institute for Clinical Systems Integration, guidelines, too often the initial step toward wasteful external inspection, become an asset for improving care in the integrated culture with common
NOVEMBER 1995 JOURNAL
J O U R N A L
O N
Q U A L I T Y
aims. Similarly, the Maine Medical Assessment Foundation transforms data on practice variation from a surveillance tool inviting defensiveness and dissimilation into a resource for self-study and inquiry among cooperating physicians. We suggest that those who wish to lead effective integration of health care systems can turn these technical insights into questions that are useful to raise and re-raise as they and their colleagues reshape their organizations. For example, how can we cooperate to . . .
make betterpredictions,especiallypredictionsofdemand (when previously the best we could do was offer services at a steady rate), and thereby organize our workfbow more eficiently? reduce costly variation in supplies, rules, firms, and processes, and thereby reduce costs while improving reliability and decreasing defects? customize work in direct response to individual customers (when previously we mated evevone the same), and thereby improve satisfaction and timeliness while decreasing the waste ofmaking things no one wes? establirh continuous flow (when previously we maintained queues, waits, holding areas, and batches), and thereby reduce our costs while increasing timeliness? reduce the total burden of inspection, and thereby decrease costs, waits, and insults? In raising these questions, a leader will encounter cooperation again and again as a precondition for progress. It is important to notice that this focus on the need for cooperation arises from the questions not as a consequence of an ethical or moral position (that is, not just because cooperation is "nice"), but rather as a logical consequence of a technical understanding of systems. For example, making better predictions becomes possible in an integrated system only when people will share information on their needs, capabilities, and histories. Reaping the harvest of standardization is possible only when people can trust each other, compromise, and subordinate their own short-term interests to those of the whole, a lesson reported poignantly by Lee. Like those who accomplish a well-executed pass on the soccer field, a health care team cannot possibly achieve continuous flow if each member tries to suboptimize his or her particular element. Batching is almost always locally more efficient than meeting needs as they arise; it is the totalsystem, not the local departments, that initially benefits from smoothing the flow of work.
VOLUME 21
NUMBER 11
I M P R O V E M E N T
Thus, those who wish to reap the benefits of integration in the sense we use the term must invest heavily in building skills-their own and others'-for cooperation.They must make cooperation explicit, valued, safe, and proficient.
Types of Improvement: Another Perspective on Cooperation A slightly different framework for understanding the benefits of cooperation rests on the categorization of Kano and Nolan of "types" or "families" of improvement.2 Systems can make progress, they say, in three basic areas of quality: Type I (reducing defects, as experienced by customers), Type I1 (reducing costs while maintaining or improving quality from the viewpoint of the customer), and Type I11 (providing a new product or service, or an old one at an unprecedented level of performance; see Reinertsen). Integration and cooperation can help achieve improvements of all three types. Cooperation reduces defects by eliminating the causes of many forms of defect. Failures, for example, tend to occur more at handoffs than within functions. The better the handoff, and the fewer of them, the less the opportunities for failure. By reducing complexity, redundancy, and unnecessary variation, integration of work almost automatically reduces rates of defect. Imagine that several organizations, each of which formerly required a separate registration process, now agree to use a single registration form and to share registration information among themselves. Will errors in registration rise or fd? Will customers experiencesmoother flow or not? Simplification is among the most powerful forms of improvement in the search for lower rates of defect. Costs fall, also, as a consequence of proper integration. The same procedures of simblification that reduce defects can also reduce waste. Processes with fewer steps are generally cheaper to operate. When an inpatient physical therapist agrees to rely on the evaluation done by someone else on an outpatient basis, costs fall and the experience of the patient improves, so long as skills are high and aims are held in common. Cooperation also creates the opportunity to offer entirely new services to patients, families, and others. Many health care organizations are today able to provide care services in the home (as integrated systems) that they could formerly have offered only in high-tech hospitals (as fragmented caregivers).
T H E
J O I N T
Is Cooperation Feasible? One by one, the articles in this issue show the real and potential value of cooperation in a strategy of improvement. They also show that cooperation is achievable, even between usually estranged parties--between competitors (as reported by Solberg), between regulators and regulated entities (as Kabcenell recounts), and between legislators and providers of care (as Reinertsen seeks). But they also show the limits and barriers to cooperation in health care-barriers we will have to overcome if we want to harvest the most we can from breaking down the boundaries over which we and our patients trip daily. The barriers are manifested most in the modesty and slow pace of the improvements reported in these papers.These early efforts to work well together have scratched only the surface of what we could achieve. The authors tell us with honesty and frankness what they have learned about the rough road to collaboration. In subsequent issues of this and other journals, we hope to see even bolder and more beneficial examples of cooperation. Some desirable subjects include: H Specialists cooperating and educatingprimary carephysicians to raise their level of expertise so that some of the patients who are currently referred to specialists can now be caredfor in the primary care setting; Physicians making a change to schedules that improves patient satisf ction, improves outcomes, or lowers costs, and which progressively reducespersonal inconvenience to professionals; Drug manufacturers working with pharmacists to improve packaging and labeling to reduce medication errors. Manufdcturers of monitoring equipment cooperating with clinicians in intensive care units to reduce the complexity and the cost of equipment; HA medicalschool afiliating and cooperating with a broad spectrum of health systems to customize research and continuing medical education to the specz$c needs of these systems and their customers; H Moving health care work fiom the traditional health care setting to a more suitable locus in the community, such as care of well children in community-based clinical settings by non-physicianpersonnelas is done in the United Kingdom; and A health system cooperatingwithpayers and non-medical community organizations to make community health improvement attractive or at least financially plausible. Leadership matters. Deming was fond of saying,
"Without an aim, there is no system." Cooperation is not natural; it requires external energy. That energy in a human system comes from shared aim-or, to use Senge's more exact expression, from the "creative tension" between a recognized current reality and a desired future state.3 Deming called it a "gap." In the pursuit of quality, the customer supplies the tension-acquaints us with the gap--but only if the organization chooses to listen. This is not the usual state of affairs. This takes leadership. This is why Reinertsen, in pursuit of integration, puts the customer "in the room" as he and his colleagues redesign the forms of their own cooperation. A different kind of cooperation comes between the provider and the customer, as they discover and clarify their interdependencies, as Friedman reports in his enlightened work as a clear and conscientious customer for managed care. It is the leader's job to convert the customersupplied creative tension into focused and understandable aims for the organization.These aims provide people with a reason to cooperate. Benvick4provides some examples of these types of aims. Setting aims is necessary but not sufficient for good leadership. The habits of fragmentation are strong. Almost every paper in this issue mentions the importance of assertive-even courageous-leadership in insisting that old boundaries be crossed. McLaughlin (p 646), describing the difficulties in the ground-breaking community cooperation in Kingsport, Tennessee, describes the slowdown that followed changes in management of participating hospitals and emphasizes that leaders must "hang on against the buffeting winds of change." The Maine Medical Assessment Foundation learned to select its clinical leaders carefly, looking for characteristics (trustworthiness, respect, social skill, and more) that in combination are as rare as they are necessary. To some measure, we can all cooperate only so far as our leaders will. Cooperation requires remedial skill-building. Organizations do no not cooperate; people do. These articles strongly suggest both that cooperative behavior requires a specific skill base and that the skill base is underdeveloped in our health care workforce, beginning with (but not confined to) its 1eaders.The consequences of our own ineptitude in cooperating are frustration, confusion, backsliding, and, most costly of all, a slow pace. Kingsport paid those prices, and so did the Maine Medical Assessment Foundation, which had to tiptoe into open and trusting discussion among professionals
NOVEMBER 1995 JOURNAL
knowledge that matters most of all in the search for wholeness in our behaviors together is knowledge of people-psychology. Naive theories of motivation and naive approaches to communication produce naive and counterproductive behaviors. Read carefully the reports from Maine and Indiana and other good-hearted cooperative efforts, and you come to see that a particular view of people may underlie the very best examples we have so far of effective integrative work. Our failures, we think, may often have at their root a failure to understand each other. Until we address that, we may be trapped in improving fragments and forcing our customers to maintain and repair the whole. We find great encouragement in the articles in this issue of The Joint CommissionJournal. These are early efforts, incomplete and by no means yet what they can become, but we think they are headed in the right direction.These authors are students of cooperation, since they know that cooperation is the method for achieving what integration has to offer.
about their own performance. Making virtue of necessity, some of the authors here describe the role of "confidentiality" in sharing data and the importance of "respecting culture" and "understanding adult learning." All of these are important and inescapable considerations in the leadership of cooperation and change given our current low levels of ability to cooperate with each other. But we need to also recognize some of these sensitivities as, in part, flaws and bad habits, which we all might profitably unlearn if we can. The fear of each other is costly, and when we surrender to it we lose more than opportunities to improve--we lose dignity and pleasure in learning. Our information systems are not built to support cooperation. We measure our world in the terms famil-
iar to us-the terms of fragments. We have trouble understanding our total costs as a system of the whole (see Lee's frustrations in this issue), and we configure payment in ways that erode shared aims (as Reinertsen points out). Batalden, now at Dartmouth, has recently begun analyzing general accounting practices and searching for ways to track finance that show us the world as we must manage it-in terms of processes and systems, not elements and events. Until we cut better windows On
the
we
see it
References 1.WomackJI:JonesDT, Roos D: The Machrne That Changed the WbrU NewYork: Harper Perend, 1991. 2. N o l a n m : Integrating quai^ improvementand cost reduction. The Qyn(yLegerforHealthcareLe&rs 6(8):2-5, 1994.
do Our
enough
best together. Psychology is the root science of cooperation. In
the search for integration' measurement matters' engineering matters, and vision matters. But one cannot read these pages without coming to believe that the
- --- .,
3. Senge PM: TheFiFhDiscipline: TheArt and Practice of the Learning Ogunhrtion. NewYoh Doubleday, 1990. 4. Berwick DM: Eleven worthy aims for cl~nicalleadership of health system ..form. / M A 272:797802, 1994.
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VOLUME 21
NUMBER 1 1
'
577
I
n many sports, players get credit for "assists" as well as for "goals." The logic is forceful-the result depends as much on the interaction as on the final action. "Helping" is "producing." "Assists" also get lip service in medical care, but the reality has been different. Although few undertakings are as interactive in their essence as proper health care is, the health care industry as a whole migrated long ago into individual sports, in which teams earned less regard. Cooperation faded into the background as a luxury, and the core work of caring for patients was vivisected into functional categories, professional roles, and specialized institutions. Doctors tried to be better doctors; nurses, better nurses; hospitals, better hospitals; nursing homes, better nursing homes. But no one was tending the whole. We are trying now to find our way back to teamwork as a core competence for health care-not just teamwork within our familiar geographic and disciplinary circles, but teamwork across boundaries that we have spent decades and fortunes shoring up. Nothing less can
Donald M. Berwick, MD, and Thomas W. Nolan, PhD, served LZS guest editorsfor this issue. Dr Berwick, a Contributing Editor of The Joint Commission Journal, is President and Chief Executive Oficer of the Imtitute for Healthcare Improvement, Boston. Dr Nokzn is n member ofAssociates in Process Improvement, Silver Spring, Maryland. Copyright o 1995 by the Jolnt Cornrniss~onon Accreditation of Healthcare Organ~zat~ons
1070-3241/95/$3.00 + 00 45/lli'0102
VOLUME 21
NUMBER 11
achieve the experience our public wants at prices it can afford. It costs money to maintain boundaries, and it invites defects when we try to pass patients over the walls that separate our fragments. As far as our patients are concerned, good fences make bad neighbors. "Integration" has become a visible and admired strategy for improvement, and cooperation is its most important method.
What Integrating Means The word "integration" varies in its meaning. Some use it to refer to structures of governance, organizational design, or financial arrangements. That is not what we mean here by "integration." We refer instead to a notion of process design and interaction achievable under many different forms of governance, organization, or finance. To us, the test of the presence or absence of integration lies in the experience of the people served by a system. T o us, a system is "integrated if the people it serves experience it as a responsive whole. Integration is optimizing the interactions among elements of a system to provide health services ofhigh value to those the system serves. Integration can thus apply equally well within an organization (in which departments or functions are elements) and among organizations (in which the participant organizations are elements). It is intriguing to see among the papers in &is issue of TheJointCommis,ion journal ~ ~I~~~~~~~~~~ ~ how l similar i the ~ challenges are that arise when the attempt is made to develop integrated activities in these two very different contexts: intraorganizational and interogranizational. It should suggest to us that barriers to cooperation may not
be simply the result of rivalry among organizations; they may be built into our natures at a much deeper level.
Why Integrating Helps Under our definition, "integration" is a close relative of . ~mprovement." Improvement involves the design and redesign of products, services, and processes of work so that they better match the needs and expectations of the people they serve, while minimizing waste. Integration supports continuous improvement primarily because it broadens the opportunities for design and redesign. The wider the boundaries of a system, the broader are the opportunities for improvement. This is a technical point, not an ethical or emotional one. How, technically, can integrating a system produce benefits for customers?A few examples follow: 1 . Integration allowsfir betterpwdictions. Through cooperation across boundaries, opportunities increase to understand and predict demand, and thereby to better match supply and demand, which reduces waiting times, averts waste, and smooths the experience of the customer. In the papers assembled in this issue of The Joint CommissionJournal, we see the benefits of aggregating information in the report of the Maine Medical Assessment Foundation (p 619) (which ". . allowed study group participants to engage in academic research . . . not usually available to physicians who practice in rural states . . .") and in the work of the Northern New England Cardiovascular Disease Study Group (p 627), whose pooled data allowed the development of a predictive model that no individual practitioner alone could have created. 2. Integration allowsstandardhtion of equipment, rules, forms, and supplies, so as to permit leveraged purchasing (as described in the paper by Lee and his colleagues, p 593), smoother inventory management, and decreased complexity. A single trauma service will have fewer than five times as many supplies as five trauma services, each of which is onc-fifth as large. Health care organizations and their customers pay a very high price for maintaining unnecessary variation and heterogeneity in their supplies and methods. Doctors, who have tended to see standardization as a threat to their autonomy, are beginning to understand that real control, and real autonomy, can be consequences of standardization, and that they should exercise a leadership role in ensuring that smart standardization occurs. 6'
.
3. Integration increases responsiveness to individual need. It is often only when individuals remove the boundaries between them that they can see each other as individuals, instead of requiring each other to accommodate to separate, fragmented rules. For example, close cooperation between inpatient and outpatient rehabilitation services can create customized sequences for individual patients, instead of requiring routine "handoff" procedures at the boundaries between them. The close interactions between health care payers and health care suppliers described by Friedman and his colleagues (p 635), and the collaboration between the regulator (Joint Commission on Accreditation of Health Care Organizations) and the regulated entities (through the Public Hospital Institute) described by Kabcenell (p 579) are both examples of "customization" achieved through cooperation, which benefits all parties. 4. Integration facilitates continuousjow instead of "batching" of work. One general principle of process improvement is to attempt to meet needs at the rime they present, instead of instituting waiting times and queues. This is the core concept behind Toyota's brilliantly successful methods of "just in time" process management.' The payoff from continuous flow is high in both cost reduction and quality improvement, but smoothing flows demands a high level of cooperation, especially in the transfer of information about needs and capabilities between suppliers and customers all along the stream of production. Friedman's paper on long term care hints at this possibility, as does the analysis by Reinertsen (p 612), but, on the whole, health care has yet to discover and capitalize on the benefits of continuous flow as a dividend of integration. 5. Integration reduces the need for inrpection. Inspections, which are costly, usually occur at boundaries, as products and services move from one system to the next. In principle, at least, removing boundaries and substituting clear understandings and well-designed processes should reduce the need for checkpoints and rework. Ask any doctor about the burdens today of utilization review and precertification, and you will get a vivid and frustrated account of the costs of inspection that derive from fragmentation. In Reinertsen's account of the work of the Institute for Clinical Systems Integration, guidelines, too often the initial step toward wasteful external inspection, become an asset for improving care in the integrated culture with common
NOVEMBER 1995 JOURNAL
J O U R N A L
O N
Q U A L I T Y
aims. Similarly, the Maine Medical Assessment Foundation transforms data on practice variation from a surveillance tool inviting defensiveness and dissimilation into a resource for self-study and inquiry among cooperating physicians. We suggest that those who wish to lead effective integration of health care systems can turn these technical insights into questions that are useful to raise and re-raise as they and their colleagues reshape their organizations. For example, how can we cooperate to . . .
make betterpredictions,especiallypredictionsofdemand (when previously the best we could do was offer services at a steady rate), and thereby organize our workfbow more eficiently? reduce costly variation in supplies, rules, firms, and processes, and thereby reduce costs while improving reliability and decreasing defects? customize work in direct response to individual customers (when previously we mated evevone the same), and thereby improve satisfaction and timeliness while decreasing the waste ofmaking things no one wes? establirh continuous flow (when previously we maintained queues, waits, holding areas, and batches), and thereby reduce our costs while increasing timeliness? reduce the total burden of inspection, and thereby decrease costs, waits, and insults? In raising these questions, a leader will encounter cooperation again and again as a precondition for progress. It is important to notice that this focus on the need for cooperation arises from the questions not as a consequence of an ethical or moral position (that is, not just because cooperation is "nice"), but rather as a logical consequence of a technical understanding of systems. For example, making better predictions becomes possible in an integrated system only when people will share information on their needs, capabilities, and histories. Reaping the harvest of standardization is possible only when people can trust each other, compromise, and subordinate their own short-term interests to those of the whole, a lesson reported poignantly by Lee. Like those who accomplish a well-executed pass on the soccer field, a health care team cannot possibly achieve continuous flow if each member tries to suboptimize his or her particular element. Batching is almost always locally more efficient than meeting needs as they arise; it is the totalsystem, not the local departments, that initially benefits from smoothing the flow of work.
VOLUME 21
NUMBER 11
I M P R O V E M E N T
Thus, those who wish to reap the benefits of integration in the sense we use the term must invest heavily in building skills-their own and others'-for cooperation.They must make cooperation explicit, valued, safe, and proficient.
Types of Improvement: Another Perspective on Cooperation A slightly different framework for understanding the benefits of cooperation rests on the categorization of Kano and Nolan of "types" or "families" of improvement.2 Systems can make progress, they say, in three basic areas of quality: Type I (reducing defects, as experienced by customers), Type I1 (reducing costs while maintaining or improving quality from the viewpoint of the customer), and Type I11 (providing a new product or service, or an old one at an unprecedented level of performance; see Reinertsen). Integration and cooperation can help achieve improvements of all three types. Cooperation reduces defects by eliminating the causes of many forms of defect. Failures, for example, tend to occur more at handoffs than within functions. The better the handoff, and the fewer of them, the less the opportunities for failure. By reducing complexity, redundancy, and unnecessary variation, integration of work almost automatically reduces rates of defect. Imagine that several organizations, each of which formerly required a separate registration process, now agree to use a single registration form and to share registration information among themselves. Will errors in registration rise or fd? Will customers experiencesmoother flow or not? Simplification is among the most powerful forms of improvement in the search for lower rates of defect. Costs fall, also, as a consequence of proper integration. The same procedures of simblification that reduce defects can also reduce waste. Processes with fewer steps are generally cheaper to operate. When an inpatient physical therapist agrees to rely on the evaluation done by someone else on an outpatient basis, costs fall and the experience of the patient improves, so long as skills are high and aims are held in common. Cooperation also creates the opportunity to offer entirely new services to patients, families, and others. Many health care organizations are today able to provide care services in the home (as integrated systems) that they could formerly have offered only in high-tech hospitals (as fragmented caregivers).
T H E
J O I N T
Is Cooperation Feasible? One by one, the articles in this issue show the real and potential value of cooperation in a strategy of improvement. They also show that cooperation is achievable, even between usually estranged parties--between competitors (as reported by Solberg), between regulators and regulated entities (as Kabcenell recounts), and between legislators and providers of care (as Reinertsen seeks). But they also show the limits and barriers to cooperation in health care-barriers we will have to overcome if we want to harvest the most we can from breaking down the boundaries over which we and our patients trip daily. The barriers are manifested most in the modesty and slow pace of the improvements reported in these papers.These early efforts to work well together have scratched only the surface of what we could achieve. The authors tell us with honesty and frankness what they have learned about the rough road to collaboration. In subsequent issues of this and other journals, we hope to see even bolder and more beneficial examples of cooperation. Some desirable subjects include: H Specialists cooperating and educatingprimary carephysicians to raise their level of expertise so that some of the patients who are currently referred to specialists can now be caredfor in the primary care setting; Physicians making a change to schedules that improves patient satisf ction, improves outcomes, or lowers costs, and which progressively reducespersonal inconvenience to professionals; Drug manufacturers working with pharmacists to improve packaging and labeling to reduce medication errors. Manufdcturers of monitoring equipment cooperating with clinicians in intensive care units to reduce the complexity and the cost of equipment; HA medicalschool afiliating and cooperating with a broad spectrum of health systems to customize research and continuing medical education to the specz$c needs of these systems and their customers; H Moving health care work fiom the traditional health care setting to a more suitable locus in the community, such as care of well children in community-based clinical settings by non-physicianpersonnelas is done in the United Kingdom; and A health system cooperatingwithpayers and non-medical community organizations to make community health improvement attractive or at least financially plausible. Leadership matters. Deming was fond of saying,
"Without an aim, there is no system." Cooperation is not natural; it requires external energy. That energy in a human system comes from shared aim-or, to use Senge's more exact expression, from the "creative tension" between a recognized current reality and a desired future state.3 Deming called it a "gap." In the pursuit of quality, the customer supplies the tension-acquaints us with the gap--but only if the organization chooses to listen. This is not the usual state of affairs. This takes leadership. This is why Reinertsen, in pursuit of integration, puts the customer "in the room" as he and his colleagues redesign the forms of their own cooperation. A different kind of cooperation comes between the provider and the customer, as they discover and clarify their interdependencies, as Friedman reports in his enlightened work as a clear and conscientious customer for managed care. It is the leader's job to convert the customersupplied creative tension into focused and understandable aims for the organization.These aims provide people with a reason to cooperate. Benvick4provides some examples of these types of aims. Setting aims is necessary but not sufficient for good leadership. The habits of fragmentation are strong. Almost every paper in this issue mentions the importance of assertive-even courageous-leadership in insisting that old boundaries be crossed. McLaughlin (p 646), describing the difficulties in the ground-breaking community cooperation in Kingsport, Tennessee, describes the slowdown that followed changes in management of participating hospitals and emphasizes that leaders must "hang on against the buffeting winds of change." The Maine Medical Assessment Foundation learned to select its clinical leaders carefly, looking for characteristics (trustworthiness, respect, social skill, and more) that in combination are as rare as they are necessary. To some measure, we can all cooperate only so far as our leaders will. Cooperation requires remedial skill-building. Organizations do no not cooperate; people do. These articles strongly suggest both that cooperative behavior requires a specific skill base and that the skill base is underdeveloped in our health care workforce, beginning with (but not confined to) its 1eaders.The consequences of our own ineptitude in cooperating are frustration, confusion, backsliding, and, most costly of all, a slow pace. Kingsport paid those prices, and so did the Maine Medical Assessment Foundation, which had to tiptoe into open and trusting discussion among professionals
NOVEMBER 1995 JOURNAL
knowledge that matters most of all in the search for wholeness in our behaviors together is knowledge of people-psychology. Naive theories of motivation and naive approaches to communication produce naive and counterproductive behaviors. Read carefully the reports from Maine and Indiana and other good-hearted cooperative efforts, and you come to see that a particular view of people may underlie the very best examples we have so far of effective integrative work. Our failures, we think, may often have at their root a failure to understand each other. Until we address that, we may be trapped in improving fragments and forcing our customers to maintain and repair the whole. We find great encouragement in the articles in this issue of The Joint CommissionJournal. These are early efforts, incomplete and by no means yet what they can become, but we think they are headed in the right direction.These authors are students of cooperation, since they know that cooperation is the method for achieving what integration has to offer.
about their own performance. Making virtue of necessity, some of the authors here describe the role of "confidentiality" in sharing data and the importance of "respecting culture" and "understanding adult learning." All of these are important and inescapable considerations in the leadership of cooperation and change given our current low levels of ability to cooperate with each other. But we need to also recognize some of these sensitivities as, in part, flaws and bad habits, which we all might profitably unlearn if we can. The fear of each other is costly, and when we surrender to it we lose more than opportunities to improve--we lose dignity and pleasure in learning. Our information systems are not built to support cooperation. We measure our world in the terms famil-
iar to us-the terms of fragments. We have trouble understanding our total costs as a system of the whole (see Lee's frustrations in this issue), and we configure payment in ways that erode shared aims (as Reinertsen points out). Batalden, now at Dartmouth, has recently begun analyzing general accounting practices and searching for ways to track finance that show us the world as we must manage it-in terms of processes and systems, not elements and events. Until we cut better windows On
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References 1.WomackJI:JonesDT, Roos D: The Machrne That Changed the WbrU NewYork: Harper Perend, 1991. 2. N o l a n m : Integrating quai^ improvementand cost reduction. The Qyn(yLegerforHealthcareLe&rs 6(8):2-5, 1994.
do Our
enough
best together. Psychology is the root science of cooperation. In
the search for integration' measurement matters' engineering matters, and vision matters. But one cannot read these pages without coming to believe that the
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3. Senge PM: TheFiFhDiscipline: TheArt and Practice of the Learning Ogunhrtion. NewYoh Doubleday, 1990. 4. Berwick DM: Eleven worthy aims for cl~nicalleadership of health system ..form. / M A 272:797802, 1994.
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VOLUME 21
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