January 7, 2022 – Marisa Guerin, PhD Edited January 9, 2022
As regular readers know, since August 2021 I have been a patient in a Multiple Myeloma (MM) Cancer treatment program. It is going well, and I expect I will be like most MM patients – a person with a chronic condition that can be controlled for a long time with the right treatments. For family and friends with interest, I have been posting my personal journey of this cancer experience on a Caring Bridge site. However, I also periodically extract from those day-to-day stories some reflections that I think connect with larger issues that interest me.
In the case of today’s blog post, I am connecting with a long-time professional focus in my teaching and writing: namely, issues related to organization design. Organization design can be quickly summarized this way: In a unit with a specific mission, how are people’s roles assigned to manage various specialized responsibilities, and what established systems, structures, or processes ensure that their efforts are integrated for successful results?
Today, I’m writing about organization design from the relatively unusual first-person perspective of a cancer patient who is experiencing its effects in my personal treatment journey. This post takes a look at my adventures on a “clinic and chemo appointment day.” So, if you are curious about how organizations can be more effective as a result of how they are designed, read on. Or if you just like seeing the “color commentary” on what it’s really like to spend a morning in a cancer center, read the first half of what follows!
The Experience
The day's episode started with anxiety over whether our 11-year-old car would start, since Mike had needed a jump-start from a neighbor the day before. Whew, yes the car did start. We arrived on time: the appointment for labs was 9:30 am, appointment to see the doctor at 10, then chemo treatment at 10:30. A scheduler's calm and orderly vision! I sympathize with the lives of medical schedulers…how often must such eminently reasonable plans fall apart. As it turned out, our medical provider was unable to avoid an unexpected interruption, even though we ourselves were spared this time.
My first interaction is always with the lab unit, and it went smoothly. My name was called after several minutes of waiting, the blood was drawn efficiently by one of the team of 5 or 6 phlebotomists, and I noticed on my phone about 20 minutes later that the blood work results were posted to my patient portal, which means the doctor also had them. My experience of the lab work is consistent – the staff are friendly, very skilled, and efficient. It doesn’t take long, and if I have questions about the day’s tests, they get the answers for me right away.
After another short wait, I was called back to the clinical suite where my vitals were measured and Mike and I were led to the consulting room a bit before 10 am. I almost fell out of my chair when the doctor appeared at the door right at 10! I was all set to joke with him about being on time, an actual first, when he blurted out the sincerest of apologies: he knew we were here, but he was very late today and would be getting to us as soon as he could, but not for 45 minutes or an hour.
Well, ok, the courtesy of the alert was appreciated, and he has been late before…unexpected hospital round, or whatever. I don't mind that much, because I never have the feeling that he will rush me on account of prior delays. But then, (gulp) his next words: "I had to take my wife home unexpectedly earlier today, she works in a covid ward and felt very sick. I’ll be back soon." (Me, silently: AAAAAAghghghgh!)
When he arrived as promised about 45 minutes later, having given me and Mike plenty of time to muse on what our chances would be of going home with covid, he apologized again and did his best to be reassuring. He said that he and his wife had both tested negative the day before and it was more likely she had the cold/flu that is also going around these days. But he knew – and we knew – that we were all operating on hope right then. What could we do but trust his judgment? Onward....
The next challenge of the appointment was keeping him on track with reviewing my progress and planning the upcoming major treatment phases. Perhaps because everything was running so late or because they are so short-staffed there these days, he seemed to get “pinged” on his phone with urgent text messages every few minutes. It was distracting, but I actually appreciated that he was so responsive, getting off a quick answer to the latest text and returning to me. In my view, that could be my nurse someday on the other end, needing an urgent yes or no. But he did have to struggle to re-find his place in our conversation.
I resisted the urge to ask teasingly if he had ADHD. I didn’t do it because I am strongly confident that the much more likely explanation for my experience of this scattered and hyper appointment is to be found in two conditions: first, the doctor’s immediate situation that day of stress, over-burden, and his desire to live up to his own and the institution's values around patient care; and secondly, in the chronic situation caused by how the organization is designed, pressuring those same values. More on that below.
We managed to jolt from one thing to another and successfully got the schedules for my treatment worked out, and at least a few of the many questions I have were answered. Finishing up the appointment, I signed the release papers for the stem cell transplant next month, both doctor and I were relieved that the important planning had been done, and at 11:45 he dashed off to his next patient, for whom he was surely also late. I took a deep breath, looked at Mike, and said, “Well, that was at the high end of fractured and discombobulated, wasn’t it? Although it all worked out well enough at the end.”
Mike and I then went off to wait for assignment to an infusion suite for the chemo treatments, which happened by about 12:15 pm. The work in the infusion suite operates as a well-oiled process. There is no consistent person who connects with me personally, but there is a closely-coordinated team of about a dozen nurses and aides that I am beginning to get to know. The first step involves an aide getting my vitals and providing a drink and snack or blanket if needed. Then a nurse checks my side effects from the previous week, prepares and then delivers the pills and injections that are assigned for today’s treatment. Everything is tracked – the bar code on my wrist bracelet is linked to each medication and dose, and there is a second nurse colleague who comes in just specifically to check in advance if these meds are to be given to the person with the correct name and birth date. All data are entered carefully into my electronic record. Soon done, and Mike and I were home by 1 pm.
That’s the experience. Here’s the analysis, starting with my conclusion.
The Analysis
My doctor succeeds in managing all that comes his way and in retaining a strong and positive patient relationship because he is so sincere, responsive, and medically competent, and because he works at this really hard. I appreciate that greatly, but on his own behalf, I suspect he will face burnout one of these days unless he realizes that personal effort cannot trump the side-effects of the organization design in a complex system. In my view, the lab and the infusion suite have integration methods that are well suited to their work, but the clinic in which the doctors and nurse practitioners work does not. The result is that the burden for pulling it all together falls excessively on the doctor and does not center the experience or needs of the patient.
A few well-implemented changes might bring the clinical visit part of the cancer center process into line with the evident efficiency of the other parts of the system. But this would require that the powers-that-be (I'm guessing that's the physicians) would be willing to implement a different solution to the problem of integrating work in the clinical suite, versus in the lab or infusion suite. I wonder if they realize that you can organize differently in each of the various parts of a cancer treatment process? More likely, they are not even conscious of this as a question. Here’s how I’m thinking about it.
The Problem: Size and Expertise Drive a Trade-Off in Value Propositions
The challenge starts with the fact that highly specialized medical centers are not organized around patient experience in the first place; that's not their essential competitive advantage in the healthcare marketplace.
A large academic medical system collects expertise and technology. In the case of a cancer center, that’s a huge list, and I only know parts of it: oncologists, nurses and nurse practitioners, chemotherapy pharmacists, laboratory analysts, regulatory and insurance compliance protocols, infection assessment units, links to high tech radiology, imaging, pulmonary and heart functioning units, administrative tracking and billing, and who knows what all. Don’t let your eyes glaze over…yes, it’s an overwhelmingly complicated system.
What’s important to know is that the value proposition -- that is, the competitive advantage -- that would drive a medical system to acquire such a range of expensive resources is very compelling. Patients will come from far away or will arrange for second opinion consults in order to access the latest and best research and technology. There is a good reason for the presence, scattered across the US, of top-line medical centers.
However, because of the primacy they must place on deep expertise and latest technology, there are two value propositions that a large, complex, expert system cannot honor with the same depth of focus. One is the proposition of efficiency driving lowest cost (found only in a few innovative pockets of US health care), and the other is the proposition of customer intimacy, which means organizing resources around the primary value of the patient experience. Smaller community hospitals, linked to academic research centers for consultation support, are in a much better position to ensure that the patient has a sense of their own centrality and importance. In such institutions there is a higher likelihood that the caregivers and patients will develop a network of personal relationships that in itself has healing value.
So from the start, we see that a big medical complex is stuck with the challenge of designing its operations so that it can deliver on the promise of top line medical care, but without totally falling short of its obligations to manage costs and to be at least reasonably patient-focused. It has to balance these objectives through the way it is designed to function.
Integrating Structures are the Key to Complex Work Among Specialists
Of the various elements of organization design, I think the key one that is relevant to this case is what is called the "integrating" function. An integrating process, structure, or role is the point at which the work of the specialists in a unit is coordinated so that errors are avoided and the process is completed as efficiently as possible. Each of the three cancer center units I interacted with on this particular day had some form of designed integration -- two of them work well and one, not so much.
Each of these units -- in fact, every part of a health care system -- has a specific primary task that must be accomplished very, very, well, with critical consequences if there are errors. Some of these tasks are repetitive and standard in the extreme, and excellence means not a single deviation from what is known to be the correct procedure. In departments of this type, such as the blood draw lab, consistent results can be achieved using integrating structures such as protocols to follow, quality tests to implement, and data reports that can be audited. Tested protocols and relevant data tracking are very basic and useful integrating methods; we see them appear again and again as a foundation for integrating the work in other departments, too, like the tracking process used in the chemo infusion suite.
But a further integration structure is in evidence in the lab and in the chemo suite: they also use a form of human resource integration that is common for airplane crews and operating room staff and many other team processes: intensive standard training for a team of interchangeable members.
When a nurse or airplane crew member arrives for work, their co-workers count on the fact that they have the exact same training, will follow requisite procedures exactly, and will exercise trained, independent judgment only in the circumstances that deviate from expectations. By communicating well, keeping track of their overall progress and dealing quickly with anomalies, a rigorously trained team provides an excellent integrating structure for a service that is mostly, but not always, standard in delivery. An integrating team is higher up the ladder of integrating mechanisms that might fit the work of a specific department; it accomplishes more than protocols and data sharing.
A Hiccup: Some Medical Work is not Technical, but Adaptive
A hiccup appears when we think of the work of the clinical unit, where the doctors and nurses diagnose, meet with, and plan treatment with patients. What is the hiccup? Clinical medical work is not primarily technical! Technical work refers to tasks that science and engineering have studied to determine what is the best way to do something effectively and reliably. It applies to drawing blood and delivering chemo drugs. Technical work is very powerful; it’s what gets rockets to the moon.
Adaptive work is what we call the challenges that face us when the human element is critical. In addition to technical knowledge, a professional who is doing adaptive work needs good judgment and emotional intelligence and interpersonal skills. Technical skills might have gotten rockets to the moon, but lack of adaptive ability caused the Challenger disaster.
Why is this relevant in today's case? When I meet with my doctor as a cancer patient, his adaptive skills are primary. The technical know-how of my doctor about the disease and its treatment is a given, but the primary interaction happening is not all that rational and practical. Instead, a cancer doctor is facing someone who is anxious, who wants to understand a complicated health situation, who is struggling with competing emotions about having cancer, who has a whole range of expectations of their doctor and their treatment, perhaps most of them unrealistic.
The relevant skill and talent of the doctor in this situation, which my doctor demonstrates in high degree, is his or her willingness and ability to connect personally with the patient, to hear and understand what the patient is concerned about. The skilled physician has to do something that is quite difficult: to balance a compassionate, containing empathy with a realistic, medically-sound set of responses. I am confident in my doctor and appreciative of him because I recognize how hard he works at the adaptive part of his role.
Adaptive Work Requires a Human Integrator
How does this detour through technical and adaptive work connect with the argument I am making about organization design? It is this: for a doctor managing any given health diagnosis in the clinical setting, or for the primary care physician in general, the doctor is the single person point of integration between the medical system and the patient as a human being, a body and spirit in need of healing arts. A single person integrator is even higher up the ladder of sophisticated options for coordination of work, beyond protocols, data bases, and teams.
The patient's interaction with the primary physician, extended over time and multiple visits, weaves a level of integration in the complex care focused on the patient that CANNOT be replicated by a team of a dozen interchangeable people. With real effort and commitment to close communication, it may be possible to achieve the necessary level of integration among two or three people, if the doctor works with close partners – a physician assistant, a nurse practitioner, or other specialized medical professionals – who can help him or her to carry the load of being point person and integrator.
In the situation I faced today when the doctor was unexpectedly delayed, such an integrator-partner might have been able to triage the priorities for the patients on the appointment list for the morning, and perhaps might have been able to answer or work with the more practical issues like sorting out the schedule and orders. The doctor then could focus on the most central conversations and personal check-in with the patient that really do have to start with him.
I haven’t seen this work in practice, and I think it is because the clinical unit is not organized to operate this way. In my case, it appears that the role of the doctor-partner is being staffed in the same way that the chemo infusion team is staffed. There appear to be a number of similarly-trained, interchangeable nurse practitioners who are on call to respond when I send a question via the patient portal or make a phone call about how to handle a side-effect. The nurse-practitioner who responds is the one assigned to the doctor on that day or that shift, not a someone assigned to the doctor and certain of his/her specific patients in an ongoing way. That is the design difference.
From my perspective as a patient, one consequence of this design focus on doctor support rather than patient support is that I feel disconnected from these members of the clinical team; the only one that I know is the doctor, whom I see briefly every few weeks. I have no idea who the nurse practitioners are, since there are a lot of them and I don’t actually meet them face to face, only via text or phone when I have questions. If the doctor is available (not on vacation, for example), this system works well enough to ensure that responses sent to me have been vetted by the doctor, but it does nothing to relieve the burden on the doctor, who remains the single knowledgeable point of contact about my case.
I suspect that the assigned nurse-practitioner role is intended to help the doctor in various implementation tasks related to patient care follow-up, and I’m sure it does that very well. But what it doesn’t appear to do is help the doctor with the patient-centered integration that is contained in his role; in fact, they may be quite unaware that this is even an element of the work. It is apparent that "patient-centric" is not a design criterion for how this unit functions. That assessment is not a criticism; tradeoffs have to be made, and they may have good reasons for preferring the current system. However, my consulting experience tells me that most of the time the busy people in a stressed system haven’t had the time or the concepts to think about how to improve things. They move mountains to cope amazingly well, which is an accomplishment in itself -- but not one that can be sustained indefinitely.
I can tell from my experience of my doctor over the last six months that he is very smart, knowledgeable, and a good thinker about my multiple myeloma disease, but I can also see that he is relatively earlier in his career than others in the department. He hasn't finished growing into the practiced skills, or gained the seniority needed, for full mastery of the boundaries and support systems that could enable him to keep his critical expertise and attention better focused. Organization design is important, but it is also up to the people in the system to apply it well. Given the status of the oncologist in a cancer center, it may be within the power of his role to influence a more effective way of operating.
I am early in my cancer journey. Maybe by the time I’m another six months in, I’ll have a more useful and proper analysis to offer. In the meantime, these are my interim observations of a day in the life of a medical center in the time of covid. I'm grateful that it all works as well as it does. I totally salute the excellent people who care for me! And I hold hope that their already very-good system can get even better over time.
