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Optimizing innovation in health care organizations.
Abstract:
In this article ...

There are many steps to consider when making the move to become an innovative health care organization. Take a look at the people and processes to have in place.

Subject:
Mathematical optimization (Health aspects)
Business creativity (Methods)
Business creativity (Management)
Health care industry (Innovations)
Authors:
Staren, Edgar D.
Braun, Donald P.
Denny, Diane S.
Pub Date:
03/01/2010
Publication:
Name: Physician Executive Publisher: American College of Physician Executives Audience: Professional Format: Magazine/Journal Subject: Business; Health care industry Copyright: COPYRIGHT 2010 American College of Physician Executives ISSN: 0898-2759
Issue:
Date: March-April, 2010 Source Volume: 36 Source Issue: 2
Topic:
Event Code: 200 Management dynamics Computer Subject: Health care industry; Company business management
Product:
Product Code: 9911437 Management-Creativity
Geographic:
Geographic Scope: United States Geographic Code: 1USA United States
Accession Number:
222549188
Full Text:
In the highly competitive world of health care, providing the latest in diagnostic and therapeutic technology is increasingly expected by information-savvy health care consumers. Successful health care organizations are obligated to embrace such technology and enable its use through availability of highly qualified professionals and effective reliable processes.

While providing such an environment can be difficult to achieve, the rewards engendered by public recognition, of an organization's critical differentiators have tremendous potential to impact that organization's success.

Creative, multipronged approaches to promote and facilitate innovation are required. Key requirements include an organizational commitment of appropriate resources to provide critical support, as well as the means to enable, and incentives to encourage adoption.

Those organizations that have supported such an innovative culture discover that this environment elicits added benefits, including enhanced patient safety and satisfaction, more effective communication, continuous process improvement, and a fully engaged clinical staff

Innovation defined

At first glance one might argue a culture of innovation should be considered the norm for all levels of health care. For example, in one author's specialty of surgical oncology, less than 50 percent of the procedures currently performed were learned during residency training.

Undoubtedly, this would be typical for many health care practices, implying that a more comprehensive view of clinical innovation is needed. Perhaps it would be more useful to embrace concepts that include, but arc not limited to, introducing "new, unique, or different" technologies.

Using an established technology to treat a new disease or in a different specialty might reasonably be considered innovative. So too would applying an established practice from another field, even one from outside clinical medicine.

A useful example is bringing the concept of "consumer centrism" into health care after it's been a standard practice for years in the business community.

It is useful to broadly divide health care innovation into process improvement activities (e.g., Total Quality Management, Lean, Six Sigma, etc.) versus technologic advances (e.g., device, drug, or procedure). Some innovations of course, are both process-enhancing and technical--such as electronic health records.

While it is easier and more familiar to most health care professionals to consider innovation in the context of a new device or procedure (e.g., robotic surgery) or a new medication (e.g., targeted anti-cancer therapies), the entire scope of quality improvement is deeply rooted in the concept of innovation.

'This can be appreciated when considering The Keystone Project and a related larger study that addressed the benefits of absolute attention to meticulous sterile technique during insertion of central lines. (1)

While the concept of sterile technique is certainly not innovative, unconditional insistence on its application coupled with staff empowerment to enforce appropriate processes was clearly so.

The resulting decrease in central line infections and the associated savings in both lives and revenue is testament to the innovative application of an otherwise straightforward process improvement.

Innovative individuals

Innovative health care organizations are populated with innovative clinical and administrative staff. Having the right people is critical. Any health care organization that undertakes the strategic decision to expand into new programs and endeavors must consider how to enlist or recruit the talent who will support this decision.

Presuming that an innovation program makes clinical and business sense, it is appropriate to begin with an evaluation of the capacity for existing staff to deliver/provide/support the program.

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In the case of health care organizations whose revenue is derived almost completely from patient care, there will be a limited capacity of existing staff to foster and manage innovation.

In these settings it might be better to adopt technologies developed and tested externally. Typically, one can identify a "champion" on the staff, who is motivated toward acquiring the technology for their practice, and provide to that individual the time and support for training and testing until an acceptable level of proficiency is achieved.

This champion can then bring the innovation into the organization and disseminate knowledge and skill to others who can practice the innovation for their patients.

But innovation capable of transforming an organization is built largely around both technology-specific and process-improvement practices. In the latter, these skills are not acquired as a part of medical practice training and are frequently not present in clinical staff.

It is our experience that organizations that wish to foster a culture of innovation need to recruit skilled individuals to bring about this transformation. Qualified clinical practitioners will come most often from academia. As for process innovation managers/directors who are not clinicians, most will come from the private sector or with formal process improvement training beyond that found in traditional hospital quality departments.

A core group of staff with the knowhow to implement programs such as Six Sigma, Lean, and other transformational processes bring an organization the ability to examine every aspect of its systems, processes, revenue stream, and outcomes.

The value of this sort of information for health care cannot be overstated. It is fundamental to all strategic planning and decision making on behalf of the organization. In the future, it is likely that the viability of all health care organizations will be based in large part on their capacity to practice quality improvement innovation.

While innovation leaders were previously found most often in academic centers, recent experience reveals that academic medical centers have increasingly been training their own competition.

This situation has enabled a growing number of community health centers to provide tertiary and even quaternary clinical care resources and attract increasing numbers of uniquely qualified clinical staff. In fact, some of the most significant recent innovations in health care (e.g., minimal access surgery, interventional cardiology etc.) nave originated from people based primarily in community health care settings.

If recruiting outside clinical staff is necessary to support a new program, efforts need to be carefully planned. Cursory evidence supporting an individual's capability may require only brief review of their curriculum vitae (GV). But a CV can sometimes be misleading.

Particular attention should be paid to aspects of experience that are highly indicative of an orientation toward clinical innovation including:

* Area of research interest

* Level of research activity, especially over the long-term

* Grant support

* Peer-reviewed publications

* Service on local, regional and/or national organizations engaged in clinical innovation and system improvements

Another kind of "right" person for an innovative health care organization will be support staff required to facilitate and shepherd innovative activities. This includes people in research and development and quality improvement offices,

Ideally, there is a cooperative give-and-take relationship between the research offices and the clinical staff- This greatly facilitates the ability to identify opportunities and bring them to fruition.

Skills of the ancillary support staff needed to enable clinical innovation include expertise in all aspects of protocol development, activation, performance, data collection, monitoring, and reporting of clinical trials as well as the federal regulations that govern these activities in patients.

The lack of qualified individuals with knowledge and skills to oversee and enforce clinical research practices can, and has, threatened the reputations of some organizations. For this reason, it is appropriate to have one highly qualified professional with administrative authority and responsibility for these institutional functions. This individual and his/her team should be given broad authority for the organization, staffing, and operations of the clinical innovation enterprise.

Additional research and development personnel necessary to support the clinical staff involved in innovation require the existence of a formal protocol office with research and data coordinators, clinical protocol nurses, and administrative support.

It is the clinical protocol office that is the institutional mechanism responsible for guaranteeing that the institution will conduct its clinical innovation activities according to "Good Clinical Practice" (GCP) Standards. While full discussion of the elements of GCP are beyond the scope of this article, they emanate from the U.S. Code of Federal Regulations (CFR), Title 21 and Title 45 and are designed specifically to ensure the protection of human subjects who participate in clinical research.

Institutions that undertake innovation through clinical research also must have these activities reviewed, approved, and monitored by an "Institutional Review Board" (IRB). The IRB is charged under FDA regulations to perform these functions to protect the welfare of human subjects participating in an institution's clinical research programs. Significantly, federal regulations mandate that this board be completely independent of the institution for which it performs these functions.

Departments devoted to quality improvement in truly innovative organizations avoid the tendency to take technology and embed it in unchanged care delivery processes. Instead, they connect and rearrange knowledge.

Process innovation can involve revolutionary or breakthrough improvement in broad, cross-functional processes or it can entail continuous or onetime improvement in smaller processes such as those often connected to TQM or Six Sigma initiatives.

Skills of the ancillary support staff needed to enable clinical innovation based on focused attention to systems and process improvement include expertise in all aspects of quality improvement:

* Quality planning and design

* Measurement strategies

* Assessment and current state mapping

* Improvement tools and techniques

* Project management

* Process control

These individuals focus upon process innovation through sequential testing on both a small- and large-scale basis to determine merits prior to widespread organizational adoption. They play an essential role in providing guidance and support to clinical staff who have often not until recently been adequately exposed to process improvement tools and techniques applied successfully in industries outside of health care.

These individuals must be equally proficient in coaching and team building and possess strong communication skills. To be successful, their work depends on their ability to build on the accumulated knowledge of the organization and its people in making meaningful change and advancing innovations.

Encouraging innovative ideas

Physician executives can play an integral role in bringing innovative ideas to their organization by regularly monitoring the basic and clinical literature as well as routinely networking with key professional associations. Moreover, physician executives are often in the best position to engage their clinical colleagues in innovative program identification and process improvement.

Merely "bumping into" innovation is far less likely to be successful than when an active, intentional, and well-delineated strategy is in place. One component of such strategy involves the physician executive enlisting the input and support of clinicians not generally accustomed to practicing innovative thinking.

This can be accomplished by a structured dialogue where the staff member is asked initially to describe in detail how they do their particular job and to consider how in the perfect world they might do that job better.

It is useful to engage in such a discussion in the same venue that the clinician delivers their care; this not only displays a sincere interest on the part of the physician executive but increases the ease with which the clinician can demonstrate the issue at hand. That simple interaction may be all that is necessary to allow these highly trained individuals to properly frame their issues. Depending on the circumstances, the results are often remarkably innovative, challenging conventional thinking and current delivery processes.

When functioning optimally, an organization's quality and safety program will go beyond routine monitoring of clinical practices/programs into in-depth evaluation of those processes from both a patient's perspective, as well as that of clinical staff

The data provide a wealth of information to justify and guide "innovative" process improvement. Quite commonly, processes thought to be optimal have often evolved without solid justification and, once evaluated, are in fact shown to provide less than ideal care.

The physician executive can strategically use this information to weave various quality care teams through the fabric of the traditional medical staff executive committee. A physician executive may assist in creating the framework in which the "right" group of individuals can engage in dialogue designed to light the innovative spark.

Brainstorming sessions may be useful opportunities for diverse clinical specialties to opine on possible organizational innovations. While formal brainstorming consultants may be used, such sessions are well within the capabilities of a properly prepared physician executive.

Successful brainstorming sessions require both preparation on the part of the facilitator and clear delineation of "rules-of-the-road" to the participants. Such rules include awareness that no idea is bad and that all (sincere) comments are important.

This session should allow delineation of the "sandbox" wherein innovation can occur, followed by identification of specific opportunities and projects. These sorts of sessions are best performed off site where participants are free from the distractions of phones and pagers. It is the facilitator's paramount responsibility to keep participants focused.

It should be understood by all participants that detailed descriptions of ideas is not the goal of these sessions. Rather, they are aimed at defining the "universe of opportunities" for innovation within a division, a department, or an entire organization, identifying specific projects, and enlisting the appropriate team to bring them to fruition.

By the session's end, specific projects will be identified and prioritization should be given to different ideas, often through affinity voting or some other quantitative tool. Appropriate stakeholders should be determined who are charged with creating the development plan with appropriate milestones, timelines, metrics and budgets. Here is the time for more detailed description and clarification.

Another useful activity to help drive innovation, but which has lost some of its luster in recent years, is the classic grand rounds meeting. In these conferences clinical cases are presented to the diverse members of the clinical staff and are discussed in some detail. While tumor boards and other specialty specific conferences have proliferated, the broader audience, characteristic of grand rounds type presentations is less common.

The physician executive should organize grand rounds and might choose to moderate such conferences, since in addition to facilitating innovative thought, they are also useful opportunities to engender organizational camaraderie and communication. These have the added benefit of providing continuing medical education (CME) credits.

Innovation "summits" are another venue to more thoroughly vet ideas in a broader context to both clinical and administrative audiences. Generally, such summits involve didactic presentation of varying "in practice" or proposed innovative clinical programs or processes with some opportunity for discussion.

Innovation summits provide an opportunity to review progress, consider modification or expansion, and clarify future plans. In addition to a focused analysis of a clinical innovation, summits may stimulate a related idea in other individuals and disciplines.

Unfortunately, the expanding time constraints on the busy clinician today are such that doctors have little time to monitor the literature and/or network with their particular professional association/societies.

Innovative health care organizations recognize this and not only encourage such activity out facilitate it. This generally requires ready access to the professional literature either through a well stocked hard-copy and electronic medical library or, less likely adequate institutional support for staff subscriptions to the top tier journals.

Innovative institutions also recognize the value of providing financial assistance for key staff to attend national meetings for presentations of cutting-edge clinical and scientific information. Beyond fostering an innovative orientation for attendees, these meetings support staff licensure and related CME requirements and provide a positive inducement in clinical contracts.

It is necessary to monitor this process; this does need to be tracked to ensure time is well spent and not merely paid vacation time. One useful way to minimize such misuse is by tying support to a required clinical presentation of the events activities subsequent to the clinicians return. This has the added benefit of providing CME for the rest of the staff as well.

Clearly, for busy clinical staff to succeed in conceiving, creating and delivering innovative programs, more than merely bringing the right people together and fostering dialogue is required. This is particularly true if those same clinicians do not see ready evidence of now such innovation can be realized and how it will improve their or their patient's lives.

In other words, getting them involved requires somehow vesting them in the whole innovative process. There are numerous means to encourage this, ranging from creating formal salaried positions (i.e., medical directors) and incentive-based compensation to non-financial means such providing resources, continuing educational support, and other non-monetary enticements.

Interestingly, these non-monetary motivators are often highly attractive to even the most jaded clinical staff members if they have an interest and passion for learning about and creating the means to improve the human condition.

Implementing innovative ideas

Innovative ideas should be assessed for their value from both the clinical and the business perspective. While clinicians are essential to building the clinical case for most kinds of health care innovation, the decision to move forward requires the input of administrative staff who understand the financial ramifications of adapting that innovation.

The decision-making process must provide sufficient analysis, based on all aspects pertinent to the revenue systems of the institution, to justify the business case for the innovation. This dual approach to evaluation is critical to guard against the adoption of non-sustainable innovative processes, no matter how attractive to the clinical staff and how appealing they may appear to administrative staff.

Assuming an innovative idea makes both clinical and business sense, most clinicians don't have the training, experience, or time to bring an innovative idea to fruition. So it is imperative that the physician executive foster an environment that is both conducive to innovation and its implementation. These opportunities require the ability to understand all aspects of the clinical application(s) of the innovation, and the ability to manage highly complex challenges to its implementation. Such innovation is generally categorized as:

1 Proven but new to the organization and/or individual practitioner

2 Relatively proven (e.g., moderate support in the literature) and new to the organization and/or individual practitioner

3 Unproven and new to the organization and/or individual practitioner

For #1, the task of introducing the innovation is somewhat less onerous but necessitates appropriate attention to credentialing requirements and monitoring of outcomes; outside standards for such outcomes may already be established and can be adapted to the organization.

Innovation identification and adoption of this level was demonstrated recently when laparoscopic cholecystectomy and subsequently minimal access surgery was rapidly introduced to medical care.

For #2, the same credentialing mechanism applies but this level of innovation also necessitates a determination by the organization as to whether a standard IRB protocol is required. This will of course depend on a number of factors, including the level evidence in support of the innovation.

Finally, for #3 careful attention to universal standards of clinical investigation following all human rights protection rules is essential. Until recently, this level of research innovation was limited almost exclusively to the academic environment; this paradigm too has undergone substantial evolution. Based on the number and complexity of patients currently treated in community health care organizations, this pattern is likely to expand.

Contractual consideration of clinical staff remains an important component in facilitating innovation implementation. While academic health care institutions have more experience with this concept, even these organizations are "all over the map" on how they deal with this area of innovative support. Issues to consider include financial arrangements to the level of partnerships and intellectual property protection, personnel, laboratory support, and others.

The degree to which such inducements are provided is an important strategic decision but well worth the time and effort. Proper attention to delivering this relationship can be used to encourage rather than restrict such activity.

It is important for an institution to have or create policies that govern ownership of intellectual property and the distribution of any proceeds that may emanate from same. The best policies balance the rights of the institution with the rights of staff members responsible for producing ideas (inventions) that can be reduced to clinical practice.

The best example of this is in innovation that rises to the level of an invention suitable for protection by a patent, trademark, or brand. Significantly, protection of an invention is not restricted to new products or devices; in these cases, the potential upside for both the institution and the staff member can be considerable and mandates that policies be designed to share the benefits derived from the innovation. Good policies can be highly motivating to staff with the inclination toward clinical innovation; bad or unequal policies will stifle this.

Unfortunately, institutional policies in this area are also all over the map. This is especially problematic for institutions that have not traditionally engaged in the sort of innovation capable of producing new ideas, products, devices and processes.

The strategic decision to foster a culture of innovation in any clinical institution should recognize the possibility that the fruits of that enterprise will produce discoveries sufficiently unique, attractive and capable of being practiced to warrant a level of protection afforded to intellectual property. Equitable policies provide substantial motivation to engaged staff as well as serve to attract new talent into an organization that practices innovation under these policies.

An innovation implementation plan should include all elements related to goals, timelines, staffing, budgets, and strategies for continuous monitoring and improvement. But beyond these essentials, it is valuable for the plan to include a communication and education component.

With rare exception, clinical innovation will require communication to a broader audience that includes physicians (colleagues, referring), support staff(nursing, administration), department heads, board members, the public, and others. This process will have begun by targeting a more limited group as a natural consequence of building the clinical and business case.

But once the plan is activated, communication devoted to the innovation must be of adequate scope and schedule to thoroughly involve the broader target audience whose participation and support will ultimately determine the success of the innovation.

Successful implementation of new innovation necessitates a comprehensive training/education strategy as well. For example, support staff must be adequately trained and sufficiently comfortable with all aspects of a new diagnostic or therapeutic innovation prior to bringing this to the patient's bedside.

Equally, support staff must be adequately consulted and trained on any clinical process innovations likely to redirect their routine practices in care and delivery. Only through a comprehensive, structured education program is this likely to occur.

Finally, successful implementation also depends on monitoring adoption and utilization of the innovation and its effect on the outcome targeted for its use. A particularly effective way of assessing the value of any innovation is to know the baseline data prior to introduction of the innovation and to continuously monitor its impact in a prospective fashion by regularly analyzing predetermined outcomes, process, and structure measures in real time.

Using such an approach will optimize all aspects of patient care affected by the innovation, as well as ensure consistent performance, staff acceptance and continuous process improvement.

Table 1

Advantages of Clinical Staff Innovation

* Improved quality outcomes, processes and structure

* Enhanced patient safety and loyalty

* Creation of critical differentiators

* New revenue streams

* Enhanced organizational reputation

* Enhanced fund-raising/philanthropy

* Significant key to enabling institutional strategy for growth

* Enhanced relationships with key constituents (pharmaceuticals; specialty interest patient groups; other organization/association collaborations)

* Requirements for Clinical Staff Innovation

* Motivated core clinical and support staff

* Additional staff - Professional

* Additional staff - Support

* Additional infrastructure (e.g. Protocol office; Institutional Review Board, certified process improvement specialists)

* Rigorous adherence to multiple federal and state regulations not inherently familiar to clinical staff

* Skill development and training on robust improvement techniques and tools

* Collaboration between clinical and admistrative staff

Mechanisms by which Physician Executives Can Encourage Innovation

* Develop/implement an innovation strategy

* Network with diverse clinical staff

* Facilitate the clinical staffs access to innovative information

* Enhance organizational continuous quality improvement process

* Regularly engage clinical .staff in structured dialogue (in practice care setting)

* Perform "brainstorming" sessions

* Organize regular "grand" rounds conferences

* Organize innovation "summits"

Issues o Consider Regarding Clinical Staff Innovation

* Does the innovation make clinical and business sense?

* Not efficient if practiced sporadically

Not efficient if the organization attempts to engage all staff regardless of interest and/or capabilities

* Need, for specialized training and credentialing (e.g., Human Subjects

Protection)

Need for uniquely Qualified "support" personnel

* Need for substantially increased capacity for data collection and analysis

Reference

(1.) Pronovost F and others. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med, 355:2725-2732, 2006

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By Edgar D. Staren, MD, PhD, MBA, Donald P. Braun, PhD, and Diane S. Denny, MHA, FACHE

Edgar D. Staren MD, PhD. MBA is senior vice president for clinical affairs and chief medical officer at Cancer Treatment Centers of America. Zion, IL

Donald P. Braun PhD is vice president for clinical research at Cancer Treatment Centers of America. Zion, IL

Diane S. Denny MAH, FACHE Is vice president for quality, patient safety, and clinical innovation at Cancer Treatment Centers of America. Zion, IL
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Copyright 2010 Gale, Cengage Learning. All rights reserved.