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ANALYSIS

Various commentators have argued for interventions to improve processes in the delivery of health care by drawing attention toexperience and practice in other industriesfor example, airlines or vehicle manufacturing. A common and natural objection to thisline of argument is that health care is different, and so the potential to learn from othersectors is limited. We have sympathy withboth claim and counterclaim and explore inthis article some features of health care thatdistinguish it from other industries.

Background

The health service is increasingly looking tothe manufacturing sector for ideas to improveits processes.13 The BMJ, for example, haspublished articles drawing on lean thinking,the theory of constraints, and six sigma.4 5Within the NHS, the Modernisation Agencyand, subsequently, the Institute for Innovation and Improvement have championedthis way of thinking about the delivery ofhealth care. Their work,and that of Don Berwickand others at the USInstitute of HealthcareIm provem en t , h a sresulted in the identification of common systemsfailures in the healthcaresetting and provided clear, detailed prescriptions for overcoming such failures.68

Although this approach has resulted in

real improvements to patient care, it tends tofocus attention away from some of the mostdistinctive features of health care. Drawingon both health economics and medical sociology, we highlight some of these features bycomparing a hospital and a bottling factory.Hospitals are similar to bottling factories inthat they are built around a set of interconnected processes, and if these processes donot run smoothly, or if they are poorly coordinated as a system, the organisation willfail to deliver. But it is instructive to contrasthospitals with bottling factories in three key

respects: unpredictability, the professionalnature of their production class, and their

orientation to service rather than production.Inevitably, the features we draw attentionto reflect our own judgment; a recent seriesof papers on complexity science provides acomplementary perspective.9 10

Unpredictability

We take the notion of unpredictability tohave two components. The first is irreducible variability. Manufacturing philosophiessuch as six sigma teach the analysis andelimination of variability, and this theme isechoed in the writings of the NHS modernisers.11 Variability is a pervasive problem inall production environments, but factoriesdo at least deal with standardised inputs andso variability tends to be internally generated and controllable. In hospitals, on theother hand, since the patients response totreatment will always be to some extentunpredictable, the only way to eliminatevariability completely would be to eliminatepatients. Because of this, hospitals have to be

able to recognise atypical cases and suspendstandard operatingprocedures in dealingwith them. This sortof issue arises in othersettings, such as postoffices with automated

mail sorting and address reading systems.Some handwritten addresses are machinereadable, but a considerable proportion are

so nonstandard that the machine gives upand channels the letter to a human operative. Unavoidable variability does not constitute an argument against standardisationor even automation, but it does highlight theimportance of building exception handlinginto the system.

Task ambiguity is the second componentof unpredictability. Whereas the path of abottle through the factory can be mappedout in advance, in hospitals establishing thepatients diagnosis is an important part ofthe processing. Until diagnosis is complete,

it may be unclear whether a condition is lifethreatening or trivial, or even what organ

system is affected. Although UK referralscome through primary care, a general practitioners letter may be limited, incomplete,or unhelpful. This characteristic has morein common with garages than bottling factories. There is considerable formal similarity between the diagnostic tools deployedin health care and repair shop; indeed oneof the classic psychological studies of expertfallibility and the importance of structuredtools for diagnosis comes from a study ofcar mechanics.12 Successful repair shops arethus likely to have more to teach hospitalsabout fast, accurate, objective diagnosis thanfactory settings.

Professional nature of the production class

The professional nature of the productionclass in hospital has attracted the attentionof many observers. Despite the erosion ofmedical autonomy in recent years,13 doctors have far more freedom to exercise theirjudgment than assembly line workers andwill continue to do so into the foreseeablefuture. Some writers on hospital processesseem either to ignore the health professionsor suggest that hospitals can be deprofessionalised and an orderly scientific management system imposed. However, the reasondoctors enjoy professional discretion in theirwork is not bloody mindedness or politicalastuteness on the part of professional organisations but the nature of medical technology.14 The human body is complex, and

the ability of lay people (whether patientsor managers) to question medical judgmentis and always will be highly circumscribed.This makes running a hospital more akinto running a university: despite decades ofresearch on pedagogy, what makes a goodteacher cannot be completely codified; andsuccessful learning is coproduced betweenteacher and student, with the student havingan active role.

In a competitive environment, universitiesface a similar challenge to hospitals, in thatsurvival depends on their customers assess

ment of a product that is hard to evaluateand setting expectations about the relative

Whats the difference between ahospital and a bottling factory?Effcen processes are essenal o good and cos effecve care. B healh servces

need o look beyond manfacrng for models, argeA Morton andJ Cornwell

The reason doctors enjoyprofessional discretion is notbloody mindedness or politicalastuteness on the part of theirprofessional organisations butthe nature of medical technology

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ANALYSIS

contribution of customer and provider tosuccessful outcomes is important. The literature on evaluation of teaching in highereducation15 16 may be a better resource herethan manufacturing quality measurement.

But hospitals differ from many other

professional organisations, including universities, in the intensive interdisciplinarity required in much clinical work, whichmay involve not just medicine but nursing, anaesthetics, physiotherapy, clinicalpsychology, and the legions of other professionals, para professionals, and nonprofessionals who staff the modern hospital.Hospitals are, and have to be, genuinelyinterdisciplinary: to provide surgery or toorganise discharge and aftercare, different professionals have to work together; tocare for patients with comorbidities, doctors have to work across specialty boundaries. Indeed, in this respect, hospitals mayresemble bottling plants (where engineers,marketers, and logisticians have to collaborate) more than universities, as in universities, cross disciplinary collaboration isoptional.

Cutting edge science, like patient care,does not respect professional or dis ciplinaryboundaries. In this respect, hospitals arelike the laboratories of a high technologyfirm, where chemical en gineers, physicists,computer scientists, and mathematiciansfind themselves forced to find a way towork together. Experience in this setting suggests that when multifunctional

teams are engaged in some sharedenterprisesuch as managing the patientjourneyhaving some sort of shared representation (such as a map of the patientpathway) may help facilitate cross profession communication but that it needs to

be complemented by data sharing, forumsfor informal interaction, and translation byindividuals who can engage with multiplecommunities.17

Service orientation

In hospitals, as in other service industries,18production means dealing with patients orcustomers directly. This makes a differencebecause patients care about subtle aspects ofdelivery19: are the staff aware of my needs?was I listened to and respected? Theseconsiderations can conflict with operatingefficiency if this is narrowly conceivedforexample, the formation of good workingdoctorpatient relationships may be compromised in a hospital that insists on mergingconsultant waiting lists for repeat outpatientappointments. However, the particular service mission of hospitals brings complexitiesnot found in most other service industries.For example, the organisation of the hospital has to accommodate patients visitors.Although these visitors are not the main customer, they can have an important role indelivery of care, interpreting what is goingon for the patient, arranging for the delivery of care after discharge, and acting as anadvocate.20

Law courts are similar in this respect:defendants, like patients, are typicallyaccompanied by anxious friends, relatives,and miscellaneous hangerson. Legal scholars have analysed the role of the friend in alitigation setting, whose role may range from

sympathetic supporter to semiformal legaladviser, and have attempted to clarify therights and responsibilities of both litigantsand judges and magistrates with regard tosuch friends.21 In clarifying the role of thevisitor in a hospital setting, it seems morenatural and productive to look to the legalliterature rather than manufacturing.

The presence of visitors is, however, anexpression of a more fundamental fact abouthospitals: they are the settings for some ofthe most important events in peoples livesfor the times of both greatest joy and greatestloss. The customers in hospitals are routinelyasked to undress, some are unconscious,most feel vulnerable, and many are distressed or fearful. They inspire strong emotions in staff: compassion, pity, admiration,or, sometimes, contempt.22 The organisedreligions are perhaps the only candidateorganisations that routinely touch so closelythe raw fundamentals of human experience.As they do with religious figures, patientsexpect personal authenticity and engagement from their healthcare providers andcan sense the disaffection and cynicism thatoverreliance on extrinsic motivators suchas financial and performance targets cangenerate.

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ANALYSIS

Conclusion

Although hospitals do have some things incommon with bottling factories, there aremany ways in which they are different. Buthospitals are not unique. As we have seen,for practically all of the dimensions of com

plexity discussed here there are natural comparators in other industries. We suggestedmail processing for ideas about exceptionhandling; repair shops for ideas about diagnosis; universities for ideas about evaluation;science laboratories for ideas about interprofessional collaboration; courts for ideas aboutaccommodating friends and family; and theorganised religions for ideas about the provision of comfort. We hope our reflections willbe a stimulus for a creative search for alternative comparator industries and organisationsfrom which lessons can be learnt rather thana reason for resisting change. And certainly,none of this means that process improvement is impossible or impractical. Indeed,because the stakes are so high in hospitals itis important to get the processes right. Afterall, the worst that can happen in a bottlingfactory is a few broken bottles.a Mrn lecrer, Operaonal Research Grop, Deparmen

of Managemen, London School of Economcs and Polcal

Scence, London WC2A 2AE

J Crnw drecor, pon of care programme, Kngs Fnd,

London W1G 0AN

Correspondence to: A Morton .morton@lse.c.uk

accepted: 30 May 2009

PiCtuRE Quiz

Unusual computed tomographyfindings in a patient presentingwith acute abdominal pain

1 This patient has mesenteric ischaemia.

2 The computed tomogram shows portalvenous gas and pneumatosisintestinalisthat is, air within the liver

and bowel wall, respectivelyand someintra-abdominal fluid. These signs areconsistent with bowel ischaemia.

3 The most common cause of acutemesenteric ischaemia is thrombosis orthromboembolism within the superiormesenteric artery. Atherosclerosis andcardiac arrhythmias are the greatestrisk factors.

4 Surgical resection is the main treatmentfor bowel infarction. In this case,however, the patient was managed

conservatively

CASE REPORt

Fever in the vaccinated returning traveller

1 Having excluded malaria, the symptoms described in a traveller returning fromthe Indian subcontinent suggest a diagnosis of enteric fever. Paratyphoid maybe the more likely diagnosis because she received the typhoid vaccine and isrelatively well.

2 Blood, stool, and urine cultures should be undertaken. The diagnosis of entericfever relies on recovery of the pathogen from the patient; however, a diagnosis

of presumed enteric fever should be made if cultures are negative but theclinicopathological presentation is consistent with this disease.

3 Prompt initiation of empirical antibiotics after discussion with a microbiology orinfectious disease consultant. Antipyretics should be given as needed and carefulattention paid to adequate rest, hydration, and electrolyte balance.

4 Patients must be counselled on meticulous hand hygiene and proper sanitation.Patients should be advised that their carrier status, and that of close contacts, willbe assessed in the community. Decisions regarding exclusion from work or schoolshould be made by those experienced in public health medicine.

5 Enteric fevers are notifiable diseases, and it is the statutory duty of doctors inEngland and Wales to notify forthwith the person responsible for epidemiologicaldata collection at the local Health Protection Unit. Medical practitioners in Scotland

and Northern Ireland have similar duties.

ANSWerS To eNdgAMeS, p 465. For long answers use advanced search at bmj.com and enter question details

Contributors nd sources: AM s a management scentst

who became nvolved n hosptal management through

an Engneerng and Physcal Scences Research Councl

funded project, DGHSiM, amed at modellng watng

tmes for electve care. JC s a medcal socologst wth

many years experence n healthcare management and

regulaton at the Audt Commsson and the Commsson

for Health improvement. She s an ndependent healthcare

consultant, specalsng n qualty of care and patentsafety. Stmulated by dscussons wth JC, AM had the

dea for the paper and took the lead n wrtng. AM s the

guarantor.

We thank Gwyn Bevan, Steve Allder, Katherne Morton,

Charles Bruce, and Mchel Looyens for helpful dscussons

and feedback.

Competing interests: AM has no competng nterests.

JC drects the Pont of Care programme at the Kngs Fund,

a programme to mprove patents and famles experence

of care n hosptal.

Provennce nd peer review: Not commssoned;

externally peer revewed.

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Cite this as:BMJ2009;339:b2727