In my post below, I invited students of all persuasions to write in with questions and comments and promised a weekly response. (Also, I answered some immediately.) Let's decide that Wednesday is Student Day and, I will try to have a more extensive response to one or two questions on this day each week.
Andrew Calvin asks:
I know residencies are increasingly incorporating systems improvement curricula, and it seems some academic medical centers are starting to recognize systems improvement work as a valid career path (in addition to the clinician-researcher and clinician-educator). In terms of university faculty promotion the clinician-educators have struggled to quantify and prove their worth to their departments (vs. the more easily quantifiable publication record for the clinician-scientist), and I'm wondering how the "clinician-systems improvers" (not even sure if that's the right term) can get fully recognized for their contribution and justify their academic promotion to their university department. Perhaps that's outside your area of expertise but I'm curious to your take given your unique vantage point. How do these people get recognized/promoted/etc by the hospital, whether it's an academic hospital or not?
Are you noticing an increased activity level in SI work from your clinical staff, in particular from MDs? From your perspective, do you think there is a large or growing demand in both the academic and private sector for those SI-focused clinicians? Do you see an increasingly diverse group of clinicians getting involved in this type of hospital administration (MDs, PharmDs, RNs, RTs, etc)?
How does an SI project work between a hospital administration and a university department that staffs it - who typically is in charge? What sorts of backgrounds/training/experience have you seen that seems to help these individuals?
It is my impression that the academic promotion system is lagging behind the needs of the profession on this front. As you have seen from several posts on this blog, there is a real and extensive need for people to be engaged in system improvement study, planning, and implementation. The techniques of service and industrial process improvement that have been used for years in other service and production industries have not yet been fully incorporated or appropriately modified in a great number of hospitals.
I believe there are serious structural and/or sociological reasons for that in medical communities. First among those is that medical students, residents, and junior faculty generally do not get professional recognition for having strong interpersonal skills or engaging in teamwork. In academic medicine in particular, you are trained to be decisive and act as an individual in the clinical setting, and you receive professional recognition in the research arena for the work you do as an individual. Systems improvement activities, in contrast, require an ability to interact well with others at a personal level and to create teams to accomplish mutually agreed upon goals.
Second, in many hospitals, there is a divide between the administrative people and the medical staff. They come from different backgrounds, have different training, and find personal satisfaction in different ways. In some sad places, the relationship between the two groups is downright toxic, with MD considering administrators as intelligence-deficient and administrators considering MDs as stuck-up egotists. Even when the relationship is exceptionally good, the difference in perspectives and approach to problem solving can get in the way. (A friend of mine once said that doctors use inductive reasoning and administrators use deductive reasoning -- dunno, maybe she was right.)
But what does that have to do with academic promotion? Well, if your department or division chief does not see the value of your time spent in system improvement research, planning, or implementation, you are rowing upstream with regard to academic promotion if you have made that a cornerstone of your time on the faculty. If he or she does see the value, then you will have mentoring and support to use that aspect of your time towards either the research or teaching professional advancement path.
What's the strategy then? In choosing a hospital, find a place where these activities are strongly encouraged by the academic leaders. Then, design a career path that enables you to design and publish academically sound research studies in the field. Our Triggers group, for example, designed their program from the get-go as an academically sound experiment, and they fully intend to produce peer-reviewed journal papers on the subject. So did our Team Training group.
I cannot speak for how quickly academic medicine more broadly will endorse system improvement as a field. Perhaps you would more wise to term your activities the "science of care," but even then I see somewhat slow acceptance in some quarters. But rest assured, these activities are crucial to the future of the health care field. This is being driven by cost pressures on the industry and by a public that is ever more knowledgeable of the outcomes delivered in a hospital, as contrasted with its reputation. You will not go wrong by studying, experimenting, and implementing programs in this arena.
On your final question, who is in charge of a given system improvement activity in a hospital? The best administrators know that a program will not work unless there is a medical champion. The smartest doctors know they need a strong administrator to help. So, the most effective programs occur when a medical champion teams up with an administrative leader to garner the best of their respective learning and teaching styles and to tap the experience and skills of both disciplines. (Usually, the MD is deemed to be in charge, but it is actually a co-chairmanship.)
In saying this, I do not mean to leave out others. The Lean program described below is based on a multi-disciplinary team -- MDs, administrators, front-desk staff, medical and technical techs, respiratory and physical therapists -- as inclusive a group as possible to study, design, and implement change. Whether as part of a Lean process or more generally, everyone has something to contribute, and your job as MD leader is to be extremely respectful to people who, frankly, you often wouldn't talk with (and -- admit this now -- sadly, not even notice!) in the course of your daily activities. My best ideas often come from the clerical staff, housekeepers, transporters, food service people, surg techs, and lab techs -- those hard-working and extremely devoted people "on the ground", closest to patients, who are excellent observers of the human condition, and who are watching what is really happening.
So, by all means, pursue this arena. Look for a hospital where you will get strong support from your academic chief of service. Then, look for allies on the administrative side. Show respect to all those who work with and around you. Trust me, you will get noticed, and you will find yourself busier and more engaged than you would have ever thought possible!