Fixing healthcare from the inside: teaching residents to heal broken delivery processes as they heal sick patients.

There is a marked gap between the potential of medical science to treat illness and injury and the performance of the health care system in which hard-working, intelligent, well-trained people put that science to work. Care is available to too few, and costs and risks of injury are too high. This is avoidable. Experience in Boston, Pittsburgh, Salt Lake City, Seattle, and elsewhere indicates that quality can be raised-while risks and costs are dramatically reduced-by applying lessons from the highest-performing industrial organizations to designing, operating, and improving health care processes. What are these lessons? Improve sick processes with the same approaches used to treat patients. Specify "normal." When problems in quality, safety, efficiency, responsiveness, and the like occur, quickly determine exactly what is abnormal and determine what might be causing them. Develop a "treatment plan"-process changes that will eliminate or counteract the causal factors. Run the process (or a facsimile) with a modified, watching for gaps between actual and expected outcomes. When gaps occur, do a new work-up, diagnosis, treatment plan, and test. Lessons in designing, operating, and improving processes can be taught just as medical expertise is developed. Teach basic frameworks didactically; then, provide hands-on experience in applying those principles to real problems. Start with simple well-bounded situations that can be practiced frequently, with rapid feedback and close mentoring before advancing to more complex, less well bounded situations that occur less frequently and provide less immediate feedback between action and outcome. Incorporate development of process improvement skills into residency training so that deepening expertise within specialties is complemented by greater skill at integrating functional knowledge into well-integrated care processes.