Form Follows Function: Designing the New Healthcare Delivery System
Richard P. Shannon, MD

Never in U.S. history has the subject of healthcare costs been so visible or so contentious. While few Americans can truly appreciate what $2.6 trillion dollars or 18% of the GDP really means, more and more perceive the double-digit increases in premiums and their attendant social costs. Stop for a moment to consider how much money $2.6 trillion represents: spending at a rate of $1000 every 5 seconds, it would take 412 years to consume. Not only does the rising cost of healthcare deprive working Americans of wage increases and the associated social mobility that once was the American dream, it also has driven unacceptable social tradeoffs. School and library closings in local communities are attributed directly and appropriately to rising healthcare costs. While these impacts are real and increasingly recognized, another variable in the healthcare cost equation—the value of the services rendered—should command at least equal attention. Most Americans might pay more for healthcare if assured of associated value and, increasingly, a demand for greater value is driving a focus on quality that actually should make healthcare cost less.

Value in the U.S. healthcare system has been diluted by visible waste like over-utilization, lack of price transparency, and failures both in delivery of care and care transitions. Estimates suggest as much as half of all healthcare spending brings little or no value to patients. Over the last decade, and long before the recent debate over the Patient Protection and Affordable Care Act, a series of pioneers embarked on a precarious journey to transform the delivery system using principles borrowed from other, more reliable American industries. The application of these improvement principles has brought remarkable benefits and lower costs to medical care. The concepts are empirically simple. High-performance healthcare requires continuous improvement. Continuous improvement requires continuous learning. Continuous learning means identifying and solving problems in the course of work. Solving problems requires disciplined skills and a common language for communicating new learning.

Surprisingly, these rational and inarguable reforms, cloaked in the guise of work redesigns and applied at the point of care, have not been widely embraced or adopted, leading to islands of excellence, amid a sea of prolific opportunities for improvement. Most of this success has eluded the medical literature as medical scholars debate the merits and legitimacy of the science of continuous quality improvement. This intransigence and skepticism has led to insufficient and ineffective communication of these lessons to the medical community as a whole.

These stories—many of them personal sagas—are both compelling and inspirational in conveying what is humanly possible through disciplined problem solving. The new knowledge is sowing seeds of transformation in American healthcare. Naida Grunden, a consummate storyteller, has faithfully and reliably recounted the pioneering journeys of the agents behind these changes.   In a previous volume titled, The Pittsburgh Way to Efficient Healthcare, Grunden chronicled a regional Lean effort in southwestern Pennsylvania that aimed to provide patients with only the care they need, at the optimum time, in the most appropriate setting and with the highest possible quality. The accounts are at once personal yet highly professional, simultaneously capturing case histories and human emotion. The improvement processes and work redesigns are elegant in their simplicity; they underscore the transformative power of human capital and demonstrate the importance of tapping the knowledge and experience of all healthcare workers in the pursuit of habitual excellence.

On the heels of this important work comes another contribution from Grunden focusing on the importance of both work and space redesign in the healthcare delivery system. In Lean-Led Hospital Design she and co-author Charles Hagood illustrate why the application of Lean thinking to the design of healthcare facilities is a critical complement to delivery-system redesign. Their work brings new meaning to the 19th century American architect Louis Sullivan’s heuristic that form must follow function. Just as Sullivan applied this thinking to skyscrapers, Grunden and Hagood describe the critical reasons for permitting function to govern structure in the design of hospitals and clinics. In this natural extension of Grunden’s decade-long study of applications of Lean principles to healthcare delivery, she and Hagood show that transformation of healthcare and perfection of its processes often requires transformation of the space in which care is given. They guide us through the ways Lean is contributing to both.

To those of us who aspire to better, higher quality healthcare, the authors also create innovative music to accompany and advance the cause of defect-free delivery. Even as we have applied Lean principles to medical practice as a means of improving the care we deliver, we often have been constrained by the walls and fixtures in the spaces where we work. That work redesign and elimination of waste now informs space redesign is a truly hopeful sign that our first principles are taking hold.

Wonderful examples abound throughout this book and the underlying Lean concepts are articulated in ways both highly readable and readily absorbed. Some of the most telling examples come in the attention given to waiting areas and lobbies, which for all their modern splendor, sentence patients and families to countless wasted hours and offer grand, if mute testimony to healthcare’s yawning inefficiency. What if patients never waited? What savings could be realized in building costs if healthcare facilities didn’t require these space-hogging rooms? Grunden and Hagood offer ways to supplant endless waits. They give us ideas about work redesign and complementary space redesign that are the essential ingredients for that seemingly elusive state of patient-centeredness in healthcare.

The book is a must read for all healthcare CEOs and board members whose hospitals and clinics are contemplating building campaigns. Before borrowing for construction, these executives should pledge adherence to the brilliant, to-the-point concepts the book describes. These ideas are the moral equivalent of the legal debt covenants bond issues require.  No project should be considered “shovel ready” without embracing and applying them.

Dr. Richard Shannon is the Frank Wister Thomas Professor of Medicine at the Perelman School of Medicine and Chairman of the Department of Medicine of the University of Pennsylvania Health System.

Dr. Shannon’s pioneering work in patient safety has been featured in the Wall Street Journal and ABC’s “20/20″, and he has served as a mentor for the IHI 100,000 Lives campaign. His work on patient safety was recently a centerpiece for the PBS feature entitled “Remaking American Medicine.” He also sits on the Governor’s Special Panel on Patient Safety and is a member of the Technical Advisory Group of the Pennsylvania Healthcare Cost Containment Council. He has served as a consultant to the Delmarva Foundation, The Safest in America Consortium, Blue Cross/Blue Shield of Massachusetts, the New York City Business Group on Health, and the US House of Representatives Committee on Energy and Commerce.

Dr. Shannon first came to Penn in October of 2006 as Vice Chair for Clinical Affairs and shortly thereafter was named Senior Vice Chair by Dean Arthur Rubenstein. In August 2007, Dr. Shannon was appointed Chairman of the Department of Medicine. Dr. Shannon received his BA from Princeton University and his MD from the University of Connecticut School of Medicine. He did his training in internal medicine at Beth Israel Hospital, his cardiovascular training at Massachusetts General Hospital, and was the Francis Weld Peabody fellow and associate professor of medicine at Harvard Medical School before becoming the Claude R. Joyner Professor of Medicine at Drexel University College of Medicine and the Chair of the Department of Medicine at Allegheny General Hospital. Both Harvard Medical School and Drexel University College of Medicine have honored him with numerous teaching awards.