Healthcare improvement can't happen without better management.

Healthcare is steeped in the scientific method tradition. Placebo controlled double blinded studies are front and center of evidenced based medicine. But research has lagged far behind in management science. Very little evidence exists for the best management practices in healthcare. This has left a void which has been filled with a soup de jour of management practices most of which are ineffective. My study of now 167 organizations around the world has identified a universal flaw. Healthcare is stuck in 20th century management system. The same system that bankrupted GM. It is characterized by top down management practices that smother the people that could actually change the system. The people that do the work every day, nurses, technicians, etc. have the answers to the problems but the antiquated management system does not allow front line workers to address problems and solve them. A few bold organizations are pushing back on 20th century management. UMass Memorial Health Care has come back from the brink of financial disaster (3) by applying a management approach first introduced by Toyota. It is working. Cost and quality has significantly improved. In the past two years since starting the program, management has instituted over 20,000 ideas from the front line staff which has helped reduced cost per patient day by 2–5% at its four hospitals while improving quality in both outpatient and inpatient areas. Major improvements have occurred at San Francisco General Hospital as well as others (4). The difference is a management approach that begins with defining a set of competencies for managers and executives based on a set of principles. For example, one of the competencies I see in the successful management approach is a daily “status sheet”(5). Middle managers have a dialogue each day with front team leaders. This involves a set of questions that are open ended and intended to uncover the problems the front line workers are experiencing. For example, the morning “status sheet” at San Francisco General Hospital is a dialogue between the middle manager and the nursing lead. The conversation is scripted by standard work and includes questions related to the most important potential problems nurses may encounter that day. This could include a discussion regarding patients at risk for falls that day, or the disposition of a frail elderly patient. This management competency is based on a fundamental principle of respect for every individual. The middle manager respects the opinion and knowledge of the front line worker to identify and solve problems. By handing the power to the front line worker to solve problems the manager empowers her team members. She also unleashes the creativity of the team. Imagine the impact of unleashing the creativity of the millions of