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42 PRACTICE MANAGEMENT The Science of Healthcare Delivery: 10 Thoughts on the Future Structure of Healthcare Organizations By Laura Dyrda T here is much focus on lowering the cost of healthcare today without lowering quality. How can providers strike the right balance? e science of healthcare delivery offers a roadmap to success. Alok Sharan, MD, co-director of WESTMED Spine Center in Yon- kers, N.Y., and James Weinstein, DO, CEO of Dartmouth-Hitchcock Medical Center in Lebanon, N.H., penned an article in the Journal of Bone and Joint Surgery discussing the science of healthcare delivery for orthopedic surgeons. e article focuses on applying scientific meth- od principles to healthcare delivery structure and organization. Dart- mouth-Hitchcock includes a Master of Health Care Delivery Science program evaluating these principles and supporting the individuals who will lead their organization through the change in healthcare from a volume- to value-based system. Here are the key thoughts for re-designing healthcare delivery: 1. e U.S. healthcare system needs to transition from a supply-in- duced demand to a value-based system. Business school students quickly learn how important value creation is for their future organiza- tions; organizations that can't create value fail. In healthcare, the orga- nizations that create the most value will be able to respond to demand by providing the right care for the right patient at the right time using only the necessary resources at a reasonable cost. 2. e science of healthcare delivery depends on creating systems and subsystems within systems that all work together toward a common goal. "According to basic system-engineering principles, for any system to work optimally, it is critical that each component work efficiently individually and that collectively, the parts work together in an efficient manner, toward a common goal or purpose," the article states. e cur- rent U.S. healthcare system isn't well designed and depends on loose social systems with artificial barriers preventing the most efficient com- munication and care delivery. 3. Independent physician practices traditionally dominated health- care delivery, which led to fragmentation, high costs and inconsistent quality of care. However, the healthcare system is moving more toward value-based care and asking providers to assume more risk. As a result, the healthcare delivery system will be redesigned to optimize patient care and experience. 4. As healthcare providers collaborate more for care, the traditional de- partments will change. Instead of focusing on specialty-specific depart- ments — such as the department of orthopedic surgery — departments will focus on the problem — such as arthritis care or spinal disorders — so all specialists are part of the same team and department. 5. Healthcare is currently a complex adaptive system. Complex adap- tive systems include individual "agents" who self-organize but don't have a central point of control. When leaders try to control them with centralized direction, such as with pay-for-performance initiatives, the direction fails because agents within the system develop work-arounds. As a result, committed leaders of departments are finding new ways to influence their system and persuade providers to make a change. 6. Standardization is important to build a strong system, but shouldn't come at the expense of employee satisfaction. Many healthcare organi- zations are moving toward self-direction with more independent deci- sion-making for employees. e most progressive institutions are train- ing employees on the mission and values of the organization instead of focusing on bureaucratic rules to encourage individual contributions to the team. 7. Physicians are thought to have the biggest role in a patient's health- care, but there is a new focus on patient experience that includes several other touchpoints in the process. For example, the patient's experience is shaped by their ability to schedule the appointment, interaction with front desk staff, nurses and ability to pay the bill. Additionally, patients oen need care from multiple providers — imaging, therapy and physi- cians. It would be easiest for the organization to have the patient work with individuals in each department for care, but patients become con- fused and upset; it's easiest for the patient to have one person, such as a care coordinator, to manage their care. 8. New reimbursement methods like bundled payments value team- work instead of independence, which is a shi for many physicians. In orthopedics, the successful bundled payment programs utilize team- based approaches, but figuring out savings distribution remains a chal- lenge and could require additional organizational redesign. 9. e transition to value-based healthcare systems will require strong leadership and change management to develop a sustainable model for the future. e leaders will need extensive knowledge and experience with health information technology, as these systems will drive innova- tion in healthcare delivery going forward. 10. ere are high fixed costs in healthcare which can throw a wrench into a hospital's efforts to lower costs. Traditionally, providers didn't have their financial incentives aligned with care delivery, but new data gathering capabilities allow providers to track care and costs. Pay-for-performance models are beginning to align those incentives more closely. n