This issue of the Journal of Healthcare Management contains more plot twists than an episode of Game of Thrones. In particular, the articles swing back and forth between two distinct aspects of health system operations—one internal, one external. The internal aspect relates to how policies, procedures, and operations can be aligned to create high-reliability care processes that routinely function free from errors. The external aspects include the influence of social determinants on patient care outcomes, irrespective of a health system’s effectiveness. Reconciling the impact of internal and external forces on care outcomes is one of the largest challenges a healthcare leader faces.
In her interview for this issue, Christine M. Candio, FACHE, talks about how St. Luke’s Health Corporation works internally and externally to meet care needs in the St. Louis, Missouri, area. She explains how committees comprising both internal and external stakeholders are used to improve care. As the president and CEO of St. Luke’s and a 2019 recipient of the Gold Medal Award of the American College of Healthcare Executives (ACHE), Ms. Candio exemplifies the leadership skills at the organizational, local, state, and national levels that can support significant improvements in healthcare delivery.
The theme of attending to the dynamic external environment is also addressed in this issue’s column on diversity and inclusion. Robert S. Chaloner, FACHE, describes how Stony Brook Southampton Hospital interacts with a patient base that changes dramatically through the course of the year. He emphasizes that meeting people on their own terms and being sure employees humanize their interactions in an individual’s space are critical to compassionate care. People possess diverse talents, backgrounds, and ways of life—and all are valued at Stony Brook Southampton Hospital.
In his column on managing risk, M. Michael Shabot, MD, FACS, FCCM, FACMI, of Memorial Hermann Health System, looks at creating an internal environment with zero error rates. Further, he explores the power of zero as an organizational imperative. For too long, many health systems deemed zero errors as either impossible or prohibitively costly. Dr. Shabot proposes the high-reliability organization (HRO) model as a potential means for achieving the aim of zero errors.
ACHE’s annual Richard J. Stull Student Essay Competition in Healthcare Management encourages future healthcare leaders to identify and describe important issues and developments in their chosen profession. The winning essays are published in JHM. Marisa S. Polonsky, the 2019 graduate division winner, goes further into the topic of HROs’ roles in quality and safety. The University of Iowa College of Public Health student discusses barriers to adopting the HRO model in healthcare. With that said, I will point out that analogies comparing healthcare organizations to HROs such as nuclear power plants and the aviation industry frequently fail to consider the wide variety of activities and outcomes hospitals strive to achieve. Nuclear power plants and airlines carry out a relatively limited set of activities that can be highly routinized. Although many hospital operations share these characteristics, other aspects introduce variances and systemic shocks that are difficult to overcome.
One highly variable set of features that extends beyond a hospital’s own influence includes the social determinants that prevail in the community. The 2019 undergraduate division winner in this year’s Richard J. Stull Student Essay Competition in Healthcare Management, Andrew W. Peeler of Auburn University, puts forth three strategies that health systems can use to extend their efforts to improve their patients’ social determinants. No spoilers here, but I will note that all of the approaches require collaboration to succeed.
Moving on to the research articles in this issue, the topic swings back to the internal hospital environment—but with a twist. The article by William B. Rouse, PhD; Mary D. Naylor, PhD; Zhongyuan Yu, PhD; Michael J. Pennock, PhD; Karen B. Hirschman, PhD; Mark V. Pauly, PhD; and Kara M. Pepe uses simulation techniques to model different transitional care plans and their cost-effectiveness. The policy flight simulator they developed takes a fascinating approach to healthcare innovation. The next step is to see if the simulation results can be replicated in real life.
The final article in this issue swings back to the social determinants topic. Laura Gottlieb, MD; Caroline Fichtenberg, PhD; Hugh Alderwick; and Nancy Adler, PhD, take an approach similar to Peeler’s, and then build on it to look at the incentives and challenges that different engagement models have as parts of their design. I especially like their discussion of integrating social determinant information into the patient care process to create a more holistic plan. Without better information on the social determinants that individuals experience, the true cost of bad environments will be hard to assess.
I hope this issue provides a valuable overview of two critical aspects of organizational operations: discrete process design and environmental challenges. Successful leaders will need to be able to deal with both of these chaotic domains. However, as Petyr Baelish said in season three of Game of Thrones, “Chaos isn’t a pit. Chaos is a ladder. . . . The climb is all there is.”