By Steve Friedland, Managing Partner

While the debate rages on over the macro issues that impact our health system as a nation, many believe that we have lost sight of the opportunities that exist at the provider and patient care level to dramatically change outcomes and lower cost.

Waves of improvement programs like CQI, TQM, six sigma and lean have swept through our healthcare system over the past few decades, only to be relegated to the list of past program buzzwords. Focus on the macro trends of automation and EHR, seem to be today’s panacea for delivering quality outcomes.  Regardless of whether your system is single payer, hybrid public / private or fee for service, the fact is that there are tremendous gains possible for positive patient outcomes, lowers costs and fewer defects by attacking problems from the bottom up.

Healthcare attracts the best people and we possess the world’s best technology. Sadly, we often lack robust and repeatable work processes at the patient care level, adding cost, increasing mistake potential and providing no value to the patient or payer.

Why is it so difficult to apply the innovation and discipline we use to develop new technology to the everyday work and care processes that occur at the patient level? Like many large organizations, health systems tend to operate in silos, with most people believing they are competent and efficient, if only those upstream and downstream from them would do their jobs correctly.  Problems are solved retroactively, after a mistake or complaint.

In many organizations, the most prevalent problem solving model is that management, believing they are smarter, instruct staff, perceived to be less smart, on what to do and then lament as systems break down and mistakes are made. Often, the person with the loudest voice, longest tenure or highest title gets their solution implemented without due diligence.  Isn’t there a better way?

There is a problem-solving model that we employ at Opus Solutions that relies on data and empowers front line staff to innovate. This bottoms-up approach is not new and is built from relatively simple concepts. However, it takes commitment and focus to be successful. The model begins with understanding the current state in detail, clearly defining every step in the process value stream while illuminating both defects and opportunities for efficiency gain. Step two is innovation delivered by staff that performs the work. Finally, after piloting and demonstrating efficacy, the solutions are implemented and made part of the current best practice or standard. Management facilitates the process, meeting directly with improvement teams and sending a clear message to staff that they are empowered, they are heard and they are accountable.

Sounds easy, but there can be several potential pitfalls. Many organizations either gloss over or completely skip step one, believing they have a firm grip on the current state problems that need to be resolved. Another potential failure mode is not paying enough attention to the change management required to create a true shared mission or vision. Culture develops more slowly than fixing broken work processes and many organizations struggle with the post-project coaching and communication needed for management and staff to truly collaborate.

However, for those organizations that understand and embrace the model, breakthrough performance gains are possible.


A case study:

Problem: The OR consistently struggles to have on-time first case starts, with Management, Anesthesia and Surgeons all having strong opinions on who or what is responsible.

Step 1 – Current state:

A team of staff that includes members from the entire OR patient flow continuum maps the current state. This takes several weeks and includes detailed time, motion and layout analysis. Data clearly indicates that over half of all patients present with an incomplete chart, requiring nursing to perform heroic measures to complete pre-admission testing (PAT). Data also reveals that a patient can spend up to 45 minutes during greeting, registration and wait time prior to arriving at PreOp. There is a high level of variability in the patient flow process with volunteers and clerical staff having little visibility to the needs of the clinical staff. Anesthesia and Surgeon are never sure if the patient will be wheels-in on time.

Step 2 – Innovation:

The team develops solutions and pilots them, documenting outcomes and sharing data with management. Creativity and collaboration are encouraged. Dozens of suggestions are vetted and several emerge as breakthrough innovations. These include a protocol to proactively review PAT for first case patients in advance to ensure they come with a complete chart. Another sends PreOp nurses to retrieve first case patients from Surgery Reception rather than wait for them, cutting the cycle time from 30-45 minutes to as little as 4 minutes. In addition, standard work is created to communicate patient-ready status to physicians, removing lack of communication as a reason for delay.

Step 3 – Management’s role:

Leadership is totally engaged and immersed in the process, reviewing data, encouraging innovation and providing the necessary resources to pilot changes without organizational delays. Leadership is committed to making the changes that prove successful for efficiency gain or defect reduction. Leadership also sends a clear message to the team and department that continuous improvement is expected and staff’s suggestions will be heard, piloted and implemented if appropriate.

The result:

  • On time first case starts are consistently over 95%.
  • Physician and staff satisfaction dramatically improved, plus
  • the addition of 1.5 cases per day with no new people, space or instruments.


We have the capacity to treat everyone and achieve lower costs with higher quality, regardless of payer mix. We simply need renewed focus on removing the waste and inefficiencies, especially at the care delivery level.



Steve Friedland is a Managing Partner at Opus Solutions, LLC. He can be reached at Connect with him on LinkedIn.