By Thomas H. Lee, MD
What brings teamwork to life? A subtle but essential enabler is competition—the push to improve. That push comes from knowing someone else out there is better; that someone else out there is staying up late and working weekends, trying to improve; and that someone else might take your market share or embarrass you if you don’t meet patients’ needs better or more efficiently.
This description of competition may not sound pleasant, but healthcare needs the pressure of that “fear factor” to ensure patients’ access to high-quality care. Competition rewards learning and improvement; it punishes standing still. It rewards teamwork; it punishes dysfunction.
The implication for healthcare leaders and boards is that, if they want their organizations to thrive in a competition-driven marketplace, they should create teams that do the same. These teams should be organized around groups of patients with similar needs and consist of multidisciplinary groups of clinicians who can meet those needs. But having the right mix of personnel, with everyone practicing at the top of their license, isn’t enough. These teams also need the right tools, the incentives to improve, and the intangibles that result from real competition.
The most basic of these tools is information. Teams need data on what they are trying to improve: patient outcomes, and the costs required to deliver them. “Hard” clinical outcomes (e.g., death, clinical complications) are of course most important, but are often similar among competitors. Thus, “softer” patient-reported outcomes that capture functional status and the utility (or disutility) of care are important targets for measurement, improvement, and differentiation—a major reason patient experience data is becoming an emerging focus for healthcare. Similarly, some organizations are starting to analyze the true costs of care so that the impact of care redesigns to enhance efficiency can be understood.
A second major tool is connections among team members. Co-location of personnel is the most powerful catalyst for coordination. Clinicians who do not know each other, or who pass each other unrecognized in the hallways, will have a more difficult time collaborating. The impetus to improve group performance is greater if clinicians are meeting formally on a regular basis to review cases and data, and the risk of chaos is reduced if those clinicians run into each other and have informal interactions in their daily work lives.
Creating the sense that the team is something real, a true group with a shared purpose, is a valuable goal. Interdependency develops among clinicians who know each other, who see each other frequently, and whose work is exposed to each other. This socialization contributes to quality and employee morale. In short, connections among team members are an antidote to chaos for patients and a balm against burnout for clinicians.
A third major tool is concentration of volume. Teams need a critical mass of patients to justify their existence. The decision to channel patients toward a team usually means that other clinicians are no longer performing some services—often a politically challenging proposition. But teams that have high volumes tend to have higher quality, and the reduction in overhead by cutting back on duplication is one of the most powerful cost-saving steps organizations can make.
The strongest incentive for high-performing teams is market share. No teams (or organizations) can be successful without patients—and if they have patients, most organizations can figure out how to make finances work, regardless of their payment model. The implication is that organizations should strive to create conditions in which their most important teams can compete for patients locally, regionally, and beyond. One key step in this direction is to participate in the “Centers of Excellence” programs run by major payers and employers.
This step usually requires participation in bundled payment programs—fixed payment for episodes of care. These financial incentives can generate profit through efficiency, but efficiency can be difficult for most organizations to identify and track due to lack of accurate and consistent cost data.
Organizations should not become mired in uncertainty about their surplus or deficit at any given bundled payment rate. Regardless of the initial dollar amount, bundles give organizations the focus to support real teams and to help those teams measure costs and become more efficient. If organizations are running deficits despite their best efforts at efficiency, they can push for higher rates in the next round of negotiations. In the long run, the organization of the team and the search for opportunities to lower costs while improving outcomes matter more than any individual contract’s terms.
Financial incentives should be complemented by nonfinancial incentives—the most powerful of which is transparency, with outcomes that matter to patients. Collection and publication of outcomes data doesn’t just help consumers choose where to get their care; it also helps the clinicians who are being measured learn from their competitors and strive for improvement.
Something happens to individuals and to groups who want to be winners. They push themselves in ways that go beyond the term “hard work.” They live in fear of failure. They feel that whatever their current level of performance might be, it isn’t good enough.
To have a great team that wins market share in healthcare, organizations need more than branding campaigns that proclaim them to be “world class.” These teams need to be hungry to become better, as reflected by patient outcomes, and then work relentlessly to improve their efficiency. The team members need to feel like their professional pride is based on belonging to a group whose performance is as transparent as that of a major-league sports team.
This team culture already exists in some parts of healthcare—transplant programs, for example—where public reporting of outcomes and bundled payments has become common over the last few decades. The best programs tend to be the biggest because volume moves to the programs that deliver the best outcomes. Some of these programs have financial gain-sharing programs for clinicians, but if these clinicians are asked what motivates them, they always bring up two things—patient outcomes and the respect of their peers.
That dynamic can only be achieved through real competition. “Pretend” competition, in which organizations simply proclaim their teams to be the best, produces business as usual. Instead, to have great teams that are even greater next year, organizations should embrace real competition now.
Thomas Lee, MD, joined Press Ganey as chief medical officer in 2013, bringing more than three decades of experience in healthcare performance improvement as a practicing physician, a leader in provider organizations, a researcher, and a health policy expert. As CMO, he is responsible for developing clinical and operational strategies to help providers across the nation measure and improve the patient experience, with an overarching goal of reducing the suffering of patients as they undergo care and improving the value of that care. In addition to his role with Press Ganey, Lee continues to practice primary care at Brigham and Women’s Hospital in Boston. He received a BA from Harvard College and earned his MD/MSc from Cornell University-Medical College and Harvard.