New research report separates re-engineering reality from rhetoric

More hindrances than helps identified

Although about 60% of U.S. hospitals are engaged in re-engineering initiatives, little research has been done to evaluate the content of the projects and the practices that impede or facilitate implementation, says John R. Kimberly, PhD, a professor of management in health care systems and sociology at The Wharton School, University of Pennsylvania in Philadelphia.

That knowledge gap is the focus of a recent research report by Kimberly and doctoral candidate Stephen Walston, MPA, FACHE. In Re-engineering Hospitals: Evidence from the Field, the two researchers analyzed surveys of 255 people at 14 hospitals.

The interviewees included executives, middle managers, physicians, staff nurses, and non-nurse staff.

"We had two goals," Kimberly explains. "First, we wanted to look at what really happens under the label of 're-engineering,' and second, we wanted to identify factors that helped or hindered the process." (See related story on first part of study, p. 55.)

Voices from the field: What works and what doesn't

In the second part of the research, Walston and Kimberly asked interviewees to describe their re-engineering experiences in detail to discover what factors contribute to or detract from successful implementation.

"As is typical in this style of research, we found more barriers than facilitators," Kimberly says. However, he adds, by identifying barriers, re-engineering professionals can then address them.

The study outlined the following factors that influenced the fate of re-engineering projects:

1. Lack of clarity and consistency of vision.

"Employees were perplexed, cynical, and angry when re-engineering visions drifted," he says. For example, if hospitals first identified cost as quality and then focused only on costs, employees chalked it up to managerial dishonesty or weakness.

2. Lack of planning for transition between planning, implementation, and continuance.

The study found the first transition problem occurred when consultants depart, usually after the planning phase. For example, the researchers cited a statement from one mid-manager: "When the consultants left, many groups disbanded, and it was hard to connect the planned changes with an ill-defined process for implementation."

Successful hospitals created a project team early in the planning phase responsible for organizing the planning and implementation processes, Kimberly explains. "At two of the more successful hospitals, the project team also had responsibility for quality and budgetary functions."

But even more difficult was the transition from implementation to a continued process of change. "Although most interviewed perceived re-engineering as a continual change process, many facilities ended their efforts, at least temporarily, after the initial implementation," he says. "Without continued and constant efforts, the organizations seemed to drift back to the old status quo."

To counteract this tendency, a few of the hospitals in the study actively linked their continuous quality improvement or total quality management programs with re-engineering. "One respondent called it 'TQM with steroids,'" Kimberly says.

3. Lack of training and preparation for change.

In addition to needing information about quality and the change process, the nurse interviewees said they needed training in managerial and delegation skills.

"Staff nurses and unit managers were assigned greater managerial responsibilities as a course of the re-engineering project but were given no additional managerial training," he explains.

For example, nurses who perceived themselves as technically proficient frequently lacked the management skills necessary to direct and delegate a team. "Because they were not able to delegate efficiently, they reported they were `working their butts off' trying to do more but accomplishing less."

Reinforcing that finding was one CEO's comment that a challenge of re-engineering was to find more intelligent and flexible nurses. "He did not seem to recognize that many of these skills are cognitively learned competencies and should be addressed prior to major shifts in responsibility," Kimberly points out.

He also discovered most hospitals underestimated the amount of initial training and retraining needed to perform clinical functions such as electrocardiograms and phlebotomy.

4. Poor communication methods.

Although re-engineering projects began with a communications strategy that includes newsletters, meetings, forums, and individual encounters, the study found that in many instances, efforts lagged as the project continued.

Yet, it's in the middle of re-engineering that managers and employees need communication the most, he notes. "They need feedback in order to validate or reconfigure their actions."

Honest communication is just as important as the timing.

For example, executives promised employees their jobs will be protected, but once implementation begins, positions are threatened. "One chief financial officer told us he did not think they had been totally honest about what was going to happen as he anticipated a large layoff, but they had not been allowed to even use the words layoff or severance [in the facility's communication efforts]," Kimberly says.

5. Lack of administrative support and involvement.

Most of the hospitals in the study had a single individual - a chief executive officer, chief financial officer, or chief nursing officer - who championed re-engineering, Kimberly notes. "Yet when this champion did not have authority over all of the hospital, and the top executive did not understand or support the re-engineering process, power conflicts ensued," he says.

For example, at one hospital, the chief nurse officer was the key patron of re-engineering, and each department was directed to develop cost reduction recommendations. Subsequently, nursing developed a patient-focused plan to incorporate many services, including respiratory therapy, into service units; however, when the nursing redesign team presented its plan to the hospital's steering committee, members discovered respiratory therapy had already obtained approval for its own plan. The plan called for laying off a number of part-time respiratory therapists, providing a fixed number of inpatient therapists, ranking all inpatients according to the severity of their need for respiratory therapy, and providing care only to the sickest patients as far as the fixed hours would allow.

"Nurses were astonished and angry because respiratory therapy was allowed to exempt itself from a coordinated re-engineering process as well as the fact that its solution would pass a great amount of work back to nursing," Kimberly explains.

Variations of this scenario were repeated frequently throughout the interviews, he adds. Another often-cited administrative directive that caused increased cynicism and damaged trust was the "sacred cow" phenomenon.

"At first, hospitals would promise there would be no sacred cows - no areas would be exempt from re-engineering examination," he says. "But in reality, almost every hospital exempted certain areas."

For example, one major vendor, who was also a major donor, was excluded, along with a physician who was deemed too powerful to challenge. In another case a specialized service area generated too much revenue and was declared off limits.

6. Lack of measurement mechanisms.

Only four hospitals established specific, measurable goals and instituted mechanisms to track their progress, Kimberly points out. For example, a West Coast facility set three main goals that Kimberly characterizes as 50-50-50. "They wanted to reduce the number of employees by 50%, increase the time a nurse spends in a patient's room by 50%, and decrease ancillary turnaround time by 50%," he explains.

Such measurable goals helped to "galvanize the organization to make and maintain changes," the study found.

But for most of the hospitals, measuring and monitoring was a barrier that often impeded successful implementation.

"Every hospital in the study developed some type of tracking mechanism that illustrated each project, completion dates, and expected results," he says. "However, employees reported they lacked either access to information or felt inadequate information was available." Executives, mid-managers, and physicians also concurred that the "process fails on the measurement side."

This inability to measure progress also created a perception that outcomes would not be sustainable. "One associate administrator felt documenting cost savings was extremely difficult, and he was not certain if all their projections were real savings or just 'paper savings,'" Kimberly explains.

The study also found that vague perceptions and anecdotal stories filled the void of concrete data. For example, half-way through a re-engineering implementation that cost millions of dollars, executives at one large hospital in the Southwest seriously considered returning to centralized services," he says. "When asked why, they said the quality of services had deteriorated, patients and physicians seemed to complain more, and things were not as good as they should be."

Why the lack of measurement monitors? The study pinpointed a well-known re-engineering lament: We're so busy planning and doing we don't have time to measure.

7. Poorly defined roles, responsibilities, and relationships.

"Mid-managers, in particular, noted their new positions were vaguely defined, and authority was not matched with new roles," he says.

Especially problematic were partially decentralized services such as medical records, phlebotomy, and admitting. "When only portions were transferred to nursing control, managers were given responsibility but did not have authority to change the quality and training levels," he says.

"Therefore, when the quality of medical records, blood draws, and admitting verifications declined, no one felt responsible to resolve the problems."

Mid-managers also felt stymied when they changed their roles, but administration remained in the old mindset.

8. Inadequate physician involvement.

Twice as many physicians and executives mentioned this, Kimberly notes. "On the one hand, hospitals consistently invited medical staffs to participate, but executives frequently reported obtaining little or half-hearted physician involvement," he says. "On the other hand, physicians reported that the work to which they were invited was either trivial or outside their expertise."

Failure to obtain physician involvement at the beginning of the project almost guarantees more work later, he adds.

"After one hospital spent three months developing its clinical practice protocols without extensive physician involvement, the medical staff rejected it and insisted they begin again," he explains.

Kimberly's final advice, based on study findings, is that all eight of these factors must be managed as a total package. "Each of these things is connected and affect the other," he says.