Erik-Jan Wilhelm's Profile

Hi Theo,

I face the same kind of problems in my organization. We actually have design rules for these situations, as soon as the number of employees exceeds a certain quantity a management position is created. I find this quite frustrating. It takes away initiative and ownership and makes it hard to reach any synergy goals that come with two merging organizations like yours. I was thinking: isn’t this the time for you to totally redesign your laboratory organization? Can’t you rearrange processes and put in a totally different type of steering? At this time I am experimenting with a matrix structure inspired on the Spotify model. See: https://labs.spotify.com/2014/03/27/spotify-engineering-culture-part-1/ Because you are in a totally different environment I have no idea if this might work for you. It is actually a hell of a job to make this work in my environment and on a much smaller scale. What might be interesting to look at is if you can make a division between people responsible for the outcome of the laboritories and those responsible for managing teams of professionals.

Our organizational models are so old fashioned and not fueling inspiration. I find great inspiration in the Buurtzorg model of Jos de Blok. A 350 million euro company with about 9.000 employees and no management. Best employer for many years in a row. And we keep on designing our organizations like the Romans did 2000 years ago. I would recommend taking a lot of time to look around in the laboratory world and other industries all over the globe for inspirational examples. Get people with lots of other background involved, you need some out of the box thinking.

See you on sunday or at the flight to Boston, Erik

Thanks for your suggestions. I do agree with number 2 and 3. Especially paying for the bundle might be in place to add more value in the chain of prostate care. Number one, patient’s freedom of choice is something I am experiencing a growing difficulty with. I think it should go hand in hand with number 2, full medical transparency. But even with full medical transparency if freedom of choice leads to significant worse outcome it is time to act (like in the London Stroke Care case). My personal opinion is that freedom of choice is the lesser one if the patients quality of care/life is at stake, as is the case in this example.

Thanks. I think you are right, although it will be very disappointing to start out with three centers, knowing that Martini is handling almost the same volume as the whole of The Netherlands.

An interesting dilemma. Your first three options in the end all seem to be pricing strategies. Of course you should keep a sharp eye at the costs of your business, cut waste, but in the end cost cutting is not a strategy, as we learned from Porters strategy paper. It will leave you in a race to the bottom. And working for a healthcare insurer that is in a cut throat prize competition, it is not a place were you want to end up.

So you should really focus on your price relative to your outcomes for your patients. In other words add value. Focus on quality of care and better outcomes that matter to your patients. Measure outcomes, proof you are delivering better quality and healthcare plans are more then willing to pay higher prices for better outcomes. From a payers perspective, if you know nothing about outcome, you can only look at the price.

I really think you should see this. It is an incredible example in the field you are working in, only in the Netherlands. This Organization is now giving care to over 80,000 people a year and with about 10,000 employees (mainly nurses), and management consists of only 1 director and almost no staff. Voted best employer of the year for 6,7,8? years in a row. Very strict organizational rule.Teams not bigger than 12 and they brake up to form new autonomous teams.

https://www.youtube.com/watch?v=SSoWtXvqsgg

https://www.youtube.com/watch?v=BeOrNjwHw58

http://journal.aarpinternational.org/a/b/2013/06/Buurtzorg-Nederland-Nurses-Leading-the-Way

I don’t know if it will solve your problem, but I think it might inspire you (it inspired healthcare over here)

I don’t know how the lean review group is organized, but while reading your assignment I reached the same conclusion as you did in your final paragraph. It seems that there is no commitment to the outcome of the review because the ‘subject’ the Orthopedic Department does’t feel they were involved. If you only confront departments with the outcome of this process without involving them they will feel judged. If you try to impose the outcome on this or any other department you will create your own resistance. I would not go that way if I were in your shoes. You need to take them serious from the beginning. There is not only one truth. The situation you are working in is far too complex for that. Change will only come with acceptance. I think you really need to think hard about how to select people being part of this review group. Even the name doesn’t really sound inviting. Involve various members of this department. Don’t make it all about efficiency, but make it about the patient. I would most certainly include patients (who had undergone the procedure) in the process. Or those that are on a waiting list. Get this group trained in some lean principles, so they are empowered to look at their own work processes. Even the biggest criticasters of change or management principles (I am thinking about the doctors now) might surprise you if you give them responsibility in improving service.

Two examples from my own practice: we confront healthcare providers with our data to benchmark them and there is always a discussion about validity etc. They feel judged and not helped. If we give our data to GP’s to discuss it amongst themselves in their own effort to learn and get better it does work. Something I tried recently and didn’t work out: I had a group working on how to improve their work. But the group only consisted of employees actually doing this job. So the reverse situation from what you described. They didn’t come up with any new ideas. The conclusion was more or less that what they were doing was perfect. I think this result was all about not putting togheter a more diverse team.

It is a good thing you write blogs about it on your website. If you do the same thing within your organization it might be a great platform to share your dilemmas and get people involved.

Good Luck, Erik

I really enjoyed this dilemma. Hard to come up with any sensible solutions not knowing the local situation. Made me think about the Breakfast at Paramount case, even though I am not sure your hospital offers the same experience that makes people want to wait before being able to park their car. I will give it a try. About the neighborhood not being cooperative, isn’t there anything you have to offer as being part of that community? Can you get them involved? Can they be made part of the solution? If you can get them involved, would they for example be willing to rent out their driveway during day time when they go to work to your staff as part of their commitment to your hospital? Maybe you can organize a town hall meeting with the neighborhood and invite them to think with you about possible solutions. Can you make a deal with patients and Uber? We pay for (part of) your trip or you get credits/discount. Or can you set up some kind of taxiservice yourself, with volunteers for example? Maybe it is possible to separate visitors and patients? Avoid peaks in visiting hours by widening them or skipping visiting hours during peaks. Can you make staff carpool as much as possible? And last but not least, what struck me is that there is a physician lot, would the be willing to give it up for the greater good of your patients needing to park?

A very interesting strategic challenge indeed. There is a lot to be said about medical tourism. For my company as a payer for healthcare it is sometimes a blessing, for example if there are waiting lists for a procedure here and in another country our clients can be helped right away. But I also see a steep downside, in communication, in offering integrated care, liability, follow up costs and the lack of transparency. In my eyes it might complicate new bundled payment methods as well. It most certainly will make it harder for us to represent our clients. On the other hand it might be a solution as well for the case I wrote about prostate care. Why would you prevent patients to travel if the outcomes are significantly better elsewhere? The strategic upside for your company is interesting not only being a healthcare provider but being part of an insurance company as well.

Thank you for your reaction Steve. I find your personal perspective on the connection between prevalence, experience and travel distance very interesting. It seems that healthcare adapts slowly to some new circumstances.

I totally agree on your remarks made about the Martini Klinik. Besides concentrating volumes, there is a lot to be learned from them. I was very lucky to be able to visit them last year and meet with most of their medical staff. I was really impressed. It is a culture of learning and improving. I will never forget what one of the founders of the clinic said: ‘this culture started with breaking down the specialist’s ego’. Only after that there could be a culture of transparency and learning.

The way they keep track on outcome, discuss these outcomes directly with as a result a much steeper learning curve for new specialists joining the team, is an example for healthcare providers on both sides of the ocean. It also raised the question to me: why is this not the standard for the rest of Germany?

Thank you for the article. I do agree that minimum volumes are not always the panacea for quality in outcomes. In this particular case we are talking about elective care in a region half the size of the state of New York with 17 million habitants. I don’t think the dilemma of improving the quality of low volume hospitals is a consideration. With all prostate care concentrated in two centers the maximum traveling time will be about an hour and a half. There is no need to leave any volume behind in other hospitals.

There is a lot of discussion (read confusion) about the minimum volume needed for this procedure. The Dutch Urologist Society (which is not a scientific body) uses 20 procedures a year per hospital location as the minimum volume. The minimum volume set by the European School of Oncology is 50 operations per hospital location. http://www.eso.net/images/ejc.pdf These norms say nothing about the number of procedures preformed by an individual specialist.

Intuitive surgical, the producer of the Da Vinci robot, sets a minimum standard of 250 operations per urologist a year being able to use this equipment independently. And for a significantly less complex procedure like a colonoscopy the European Guidelines for Quality Assurance use 300 procedures per specialist as minimum norm. http://www.kolorektum.cz/res/file/guidelines/CRC-screening-guidelines-EC-2011-02-03.pdf

Actually we are looking for the optimum and not the minimum volume. Using a volume between 200 and 250 procedures a year in line with the Martini Klinik as a best practice and in analogy with the guidelines for colonoscopy and the use of the Da Vinci robot.

An interesting article in the NEJM about the relation between volume and outcome on prostate cancer http://www.nejm.org/doi/pdf/10.1056/NEJMsa011788

Thank you for your comments. Concentrating prostate care in only two hospitals is exactly what we are proposing. The only way to make sure that urologists have enough experience is if they conduct this procedure 200 – 250 times a year. Even if they use the Da Vinci the only way to deliver quality is in experience which means quantity. With about 2500 cases a year and an group of expertise needed of around 6 urologists that leaves room for 2 centers. Your right, waiting lists might become an issue in dedicating urologists only to these procedures. It makes the pool of experienced specialists smaller. Considering taking care to peoples home you are making an excellent point. The total patient journey with diagnostics and follow-up takes about 10 years. Only the actual operation, which takes two days, we want to concentrate at two hospitals. In a survey by the Dutch Prostate Association 91% of the responders were willing to travel further to a hospital with more experienced specialists.