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‘‘Learning’’ From Other Industries Lessons and Challenges for Health Care Organizations

Amer Kaissi, PhD

Although it is true that health care has several distinguishing characteristics that set it apart, analysts both within and outside the industry point to several similarities with other fields and suggest opportunities for health care to learn from other industries. Applications from other industries have been described in the literature, but the transfer of learning at health care industry level has not been examined. This article investigates health care learning from other industries in the recent decade, focusing on aviation, high-reliability organizations, car manufacturing, tele- communication, car racing, entertainment, and retail; evidence suggests that most innovative practices originate with these fields. The diffusion of innovations from other industries appears to start with a few early adopter organizations (hospitals and health systems) and influential other or- ganizations (The Joint Commission, Institute of Medicine, Agency for Healthcare Research and Quality, or Institute for Healthcare Improvement) pushing for the innovations. Once the trend becomes accepted, consultants and copying behavior seem to contribute to its spread across the industry. An important question to explore is whether the applications in the early adopter organizations are different (in terms of their effectiveness) from those in the rest of the industry. Another intriguing issue is to examine whether other industries learn from health care organizations. Key words: health care, innovation, knowledge transfer, learning

HEALTH CARE MANAGERS typically de-scribe their organizations as ‘‘unique’’ and ‘‘different’’ and rave about the distinctive aspects of working in an industry where

actions directly impact patients’ lives. 1

Man-

agement guru Peter Drucker 2

described

health care as the most difficult, chaotic,

and complex industry to manage and sug-

gested that the hospital is ‘‘altogether the

most complex human organization ever

devised.’’ 2(p118)

Although it is true that health care has several distinguishing characteristics

that set it apart, analysts both within and

outside the industry point to several similar-

ities with other fields and suggest opportu-

nities in which health care can learn from other industries.

In the last 10 years, a number of popular

books have stressed similarities with other

industries and recommended learning oppor-

tunities for health care organizations. In Why

Hospitals Should Fly? Nance 3

stressed prin-

ciples from aviation that health care organiza-

tions must instill as a foundation for safety.

Lately, Gawande 4

in The Checklist Manifesto

investigated the finance, construction, restau-

rant management, and aviation industries and

suggested that checklists can significantly

reduce errors in surgery. Whereas these books

have mainly focused on quality and patient

safety, others have addressed different aspects

of health care. For example, in If Disney Ran

Your Hospital, Lee 5

proposed ways to bring

the Disney culture of customer service to

health care. Christensen has argued that health care can

learn from other industries in implementing

The Health Care Manager Volume 31, Number 1, pp. 65–74 Copyright # 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Author Affiliation: Department of Health Care

Administration, Trinity University, San Antonio, Texas.

The author has no conflicts of interest.

Correspondence: Amer Kaissi, PhD, Associate

Professor, Department of Health Care Administration,

Trinity University, One Trinity Pl, # 58, San Antonio,

TX 78212 ([email protected]).

DOI: 10.1097/HCM.0b013e318242d399

‘‘disruptive innovations’’ that will result in

cheaper, simpler, and more accessible health

care services. 6

At the same time, other

examples have surfaced in newspapers and

news reports. Virginia Mason Medical Center

in Seattle has been praised for its efforts to implement ‘‘Lean manufacturing.’’

7 Boston

Medical Center has been admired for ‘‘keep-

ing the patient moving,’’ a concept borrowed

from airports and restaurants. 8

Massachusetts

General Hospital has implemented lessons

from the Ritz-Carlton in order to create a

‘‘patient experience,’’ 9

and Great Ormand

Street Hospital for Children in Britain has been celebrated by the Wall Street Journal

for collaborating with the Formula One racing

team Ferrari to improve patient handover

techniques from the operating room (OR) to

the intensive care unit (ICU). 10

However, it is not clear why health care

should adopt such innovations from other

industries. The previously mentioned exam-

ples assume that they lead to improved

performance, but there is little to no evidence

to support that argument. One might even

question how much ‘‘learning’’ is occurring

when health care organizations adopt prac-

tices from other industries without much

evidence to support their effectiveness. This

is especially true given that there are essential

differences that exist between health care

organizations and those in other industries,

such as providing a service that directly affects

life and death, legal requirements to stabilize

patients and provide charity care, 11,12

deal-

ing with nonemployed physicians, 13

and

operating in a highly regulated and complex

environment. 14

PURPOSES AND METHODS

The purpose of this article was to review

the evidence on health care ‘‘learning’’ from

other industries. Abundant examples of ap- plications from other industries have been

described in the health care literature, but a

comprehensive review and assessment of the

positive and negative aspects of this learn-

ing are still lacking. This article will contribute

to the health care management literature by

providing a thorough summary of the types

of innovations that health care organizations

have adopted from other industries and there-

fore can serve as a guide to better understand

what innovations work and what innovations do not work and under what circumstances.

In the following sections, we inspect

health care learning from other industries in

the recent decade (2000-2010). Although ex-

amples of transfer of knowledge have been

documented before that, we have observed

that the trend has reached its peak in the last

10 years. We elected to focus on aviation, high-reliability organizations (HROs), car manu-

facturing, telecommunication, car racing, enter-

tainment, and retail because evidence suggests

that most innovative practices originate from

these fields.

LITERATURE REVIEW

Aviation

The aviation industry has long been admired

by health care organizations, especially be-

cause of the dramatic improvements in safety

that it has undergone. 15

Helmreich 16

was

among the first to suggest that lessons from

aviation can help reduce errors in the OR. Of all the techniques that health care has

borrowed from aviation, crew resource manage-

ment (CRM) and team training techniques are

arguably the most widespread. Crew resource

management emphasizes developing skills in

briefing, inquiry, assertion, workload distribu-

tion, vigilance, and conflict resolution. 17

Appli-

cations of CRM to health care settings are widespread in the literature: from 2000 to 2010,

there were at least 35 discussion, review, or

research articles that deal with CRM application

in health care organizations. Substantial evi-

dence is also available on the application of

aviation-based simulation training in various

health care disciplines and settings. 18

Another important concept in aviation safety is the focus on systems and cultures,

rather than blaming individuals for failures.

In the last decade, health care organizations

started to borrow aviation concepts to change

66 THE HEALTH CARE MANAGER/JANUARY–MARCH 2012

their cultures and focus on system factors that

can prevent or trap errors before they reach

patients. 19

Moreover, increased attention to

nonpunitive error reporting systems has

been observed. 20

Other concepts and tech-

niques that have crossed over from aviation include checklists

21 and standardized tools

and behaviors, 22

among others. At a more

macro level, experts have called for the

formation of a public-private partnership

modeled on the Commercial Aviation Safety

Team to improve safety in health care. 23

Applications of CRM and other team

training techniques started in anesthesia but then spread to other ‘‘high-risk’’ health care

areas such as the emergency department, 24

the OR, the ICU, obstetrics and perinatal

services, and neonatal resuscitation. 25

Other

aviation-based practices such as improved

communication and standard protocols have

been regularly applied to hospital medication

administration processes. 26

The transfer of knowledge from aviation to

health care has not been immediately em-

braced by everyone. Randell 27

argued that

the comparison to aviation ‘‘is not always

useful, on the basis that (i) the type of work

and technology is very different in the 2

domains, (ii) different issues are involved in

training and procurement, and (iii) attitudes to error vary between the 2 domains.’’

Others have warned against the blind copy-

ing of aviation techniques by noting that

‘‘it is not sufficient to take aviation training

materials and simply delete ‘pilot’ and re-

place with ‘nurse’ or ‘anesthetist.’’’ 28

What these views seem to suggest is that a

solid understanding of the inherent differ- ences and similarities between the 2 indus-

tries is needed. A common argument is that

‘‘patients are not airplanes.’’ While advocating

for applications from aviation, Helmreich 16

has advised that the OR ‘‘. . .is a milieu more complex than the cockpit, with differing

specialties interacting to treat a patient whose

condition and response may have unknown characteristics. Aircraft tend to be more pre-

dictable than patients.’’ In Table 1, the simi-

larities and differences between health care

and aviation are summarized. 29

High-reliability organizations

High-reliability organizations are organiza- tions that function in hazardous, fast-paced,

and highly complex technological systems

while operating with no errors for long pe-

riods. 30

They include nuclear power plants, air traffic control systems, petrochemical plants, naval aircraft carriers, as well as commercial and military aviation (aviation was discussed separately because of the extensive evidence). The concept of HROs has been around for a long time, but its applications in health care organizations have started only around the year 2000, with the Institute of Medicine (IOM) (and the Agency for Healthcare Re- search and Quality [AHRQ] mainly pushing the idea).

31,32 General applications from

HROs are similar to those from aviation and include a focus on safety systems, error re- porting, and simulation training.

33 Specifically,

nuclear power plants represent a successful model to emulate. It is suggested that this industry represents a better analogy for an- esthesia than aviation because of its high levels of complexity.

Car manufacturing

Up until 2010 when news of grave accidents

and major recalls broke, Toyota was widely

recognized as one of the most successful

companies in the world. Through relentless dedication to continuous quality improvement,

it was famous for the quality of its cars and its

focus on employee safety and well-being, as

well as its efficiency and high profit margins. 35

At the heart of these remarkable results is

the Toyota Production System (TPS), which

emphasizes frequent rapid problem solving

and work redesign, with the goal of ‘‘deliv- ering to customers exactly what they need,

when they need it, every time, defect-free,

in a safe environment at the lowest cost

without waste.’’ 36

In the last 10 years, this philosophy started

to gain a following among health care or-

ganizations with an increasing number of

hospitals and health systems adopting a ver- sion of TPS as their systematic approach to

enhancing quality and improving efficiency. 37

Lessons and Challenges for Health Care Organizations 67

Once widespread across several industries,

TPS became known as Lean Systems, Lean Man-

ufacturing, or just Lean. Several early adopters

of ‘‘Lean health care’’ emerged. 37-40

As these

success stories became publicized in the health

care literature, numerous organizations started

to learn and implement Lean principles. A

recent review of the literature between 1999

and 2009 (which almost coincides with the

time frame of this assessment) illustrated

Table 1. Summary of Similarities and Differences between Health Care and Aviation

Similarities

Complexity Complex procedures and processes with a series of critical steps that must occur to ensure the safe outcome for the patient/passengers.

Time-critical events Time-critical event flows and actions. Unpredictability Element of unpredictability (for aviation, unexpected weather events, and other

external operating conditions; for medical, patient response to treatment). Rare deviations Most days have normal procedure and process flows, but a variety of deviations

may occur requiring urgent response; some of these deviations are extremely rare. Lengthy training Highly trained professionals involving many years of training a team of professionals,

with a gradient of authority present in the team. Often a single person is designated as the final authority for the safe outcome of the flight/procedure/process. As an industry, the practices result in highly visible public safety implications.

Differences

Personal risk The pilot’s fate is tied to the fate of passengers; in the doctor-patient relationship, only the patient’s safety is at risk.

Public perception Passengers are not often aware of the errors that pilots make. Medical errors are more frequently visible to the patient or their family.

Litigation Doctors are more often the principal target of litigation when errors occur in medicine. This impacts how voluntary reporting systems are used: NASA’s Aviation Safety Reporting System effectively results in immunity for the reporter in most cases and is very widely used by pilots. Doctors are often reluctant to report errors in their systems because of the potential for litigation.

Level of training and roles

Most surgical procedures are performed by 1 surgeon (with resident, etc, assisting) resulting in a single high-authority figure. Air carriers are 2-crew, the captain and first officer trade the ‘‘pilot flying’’ role on alternate flights. The other pilot role is ‘‘pilot monitoring,’’ and their job is to catch and report errors. This yields a high probability of catching errors.

Authority structure within team

Flight crew authority gradient is improving over time with crew resource management adoption. Medical teams are generally autocratic, with even more extreme authority gradient in some developing countries, so there is little opportunity for error catching because of crosschecking.

Culture of standardization

Pilot culture generally accepts standard operating procedures (SOPs), with disciplined use of procedures and checklists; medical culture values extreme level of knowledge, judgment, and expertise but is resistant to imposed SOPs, rigor, or discipline.

Oversight Pilots’ performance is subject to random checks by Line Check Airmen, regulatory observation, recurrent training and checking, and flight operations quality assurance performance data gathering. Doctors are subject to less formal oversight and less frequent mandatory ongoing training.

Labor unions Pilots are represented by labor unions in many parts of the world, so feedback or discipline due to errors is often done with the union as intermediary. Health care workers are sometimes members of unions, but these unions do not usually act as intermediaries in incidents involving patient harm.

Litigation If a pilot violates the federal aviation regulations (FARs), they are subject to the provisions of the FARs, which are federal laws. Litigation is a potential consequence of medical error, but very few errors committed by health care workers are a direct violation of the law.

Outside authority Pilot procedures have an original authoritative source with the aircraft manufacturer (OEM, or original equipment manufacturer). The medical community is a group of peers, generally without a single authoritative source of procedures and standards.

68 THE HEALTH CARE MANAGER/JANUARY–MARCH 2012

around 40 articles related to Lean in health

care. 41

Of these, 8 were empirical studies that

examined the implementation of a Lean proj-

ect to various health care settings. The review

concluded that there is weak evidence be-

hind the assertion that Lean techniques lead to performance improvement in health care.

This conclusion is in line with the views

of many experts who are skeptical of the

transfer of car manufacturing principles into

health care. It is suggested that ‘‘Lean thinking

has been applied, largely uncritically, to the

hospital sector.’’ 42

Some observe that there

is limited literature on the failure of Lean techniques in health care, which may suggest

a publication bias, 4

whereas others warn that

these principles have been applied in health

care with no theoretical foundation. 43

Other observers have taken a more flexible

approach and propose that Lean techniques

can be successfully implemented in health

care but that ‘‘cultural and practical barriers likely will have to be overcome.’’

37 Just like

with aviation, the argument is that ‘‘people

are not automobiles.’’ At a deeper level, a

serious organizational barrier is that health

care organizations have fragmented units

that operate as autonomous silos, although

Lean tools emphasize that the entire work-

flow with cooperation of multiple operating units must be improved. Other challenges

include the fierce adherence to physician

autonomy in health care, which contrasts

with the standardization of practice advocated

by Lean. 44

These barriers and challenges

notwithstanding, and despite the recent failings

at Toyota, recent evidence suggests that the

health care industry is moving toward more widespread application of Lean principles.

Telecommunication

In the mid-1980s, Motorola, the multina-

tional telecommunication company, devel-

oped Six Sigma, a quality improvement concept

that focuses on error reduction by establishing aggressive goals.

45 Although Six Sigma was first

applied to manufacturing processes, Motorola,

GE, and other companies have extended the

applications to customer service. Therefore,

several experts started calling for the appli-

cation of Six Sigma in health care. In 1998,

Mark Chassin, 46

a nationally recognized expert

in health care quality improvement declared:

‘‘We can learn a good deal from industries that

are working toward the Six Sigma goal. Let’s try it in health care and see how close we can get.’’

Soon after the Chassin 46

article, applica-

tions of Six Sigma in health care started to

proliferate. Between 1999 and 2009, around

124 studies relating to Six Sigma appeared in

the health care literature. Of these, 26 were

empirical studies using statistical methods

to evaluate the effectiveness of Six Sigma projects in health care settings.

41 Similarly

to Lean applications, the review demon-

strated that there are significant gaps in the

literature and very weak evidence that Six

Sigma actually improves quality of care.

The implementation of Six Sigma in health

care has also been fraught with skepticism

and concern. One reason is the fear of health care executives to completely overhaul their

existing quality improvement initiatives. Other

barriers include the nursing shortage, govern-

mental regulations, long-standing professional

group silos of nonemployed physicians in

hospitals, and the risk of Six Sigma being

used in only marginal projects. 47

Other industries

Although not as extensive as the previously

mentioned applications, examples of transfer

of learning from other industries have also

been documented in the health care literature.

As previously mentioned, to address com-

munication failures in patient handovers from surgery to the ICU, surgeons at Great

Ormond Street Hospital for Children in

London got inspiration from an unlikely

source: the pit-stop techniques of the Italian

Formula One racing team Ferrari. Using ex-

pertise from car racing, the new handover

protocol focused on leadership, task allocation,

rhythm, standardized processes, checklists, awareness, anticipation, and communication.

As a result, technical errors, information hand-

over omissions, and duration of handovers

were reduced. 48

Lessons and Challenges for Health Care Organizations 69

In a recent article, experts called on health

care organizations to learn lessons from mass

retail to streamline layers in the supply chain

and use purchasing volume to reduce prices.

They used examples of in-store health clinics

and low-cost generic drugs as examples to be followed to cut costs in health care.

Other more straightforward examples

have included the application of hotel-style

room service in hospitals. Practices such as

meal delivery within 30 to 45 minutes, a

restaurant-style menu, tray assembly on de-

mand, scripting, and waitstaff uniforms have

been successfully implemented to allow pa- tients more control over their food choices.

Recently, many hospitals and health systems

have joined the trend of creating a ‘‘customer

experience,’’ just like Starbucks or Disney has

done. Especially after the publication of the

book If Disney Ran Your Hospital, some

pioneering health care organizations have

shifted from a narrow focus on customer service to engaging ‘‘patients on an emotional,

physical, intellectual, and, yes, spiritual level.’’ 5

Hospitals are introducing hotel- and spa-like

amenities such as waterfalls, fireplaces, gar-

dens, aquariums, larger windows, more natural

light, private rooms, better waiting areas, re-

duced environmental stressors, and calming

music. Models such as ‘‘Planetree’’ that stress ‘‘healing, nurturing environments’’ have been

adopted by numerous hospitals. 51

Table 2 pro-

vides a summary of the practices and their in-

dustry, as well as the evidence and the methods

of transfer, as discussed in the following section.

DISCUSSION

Several applications from other industries

to health care organizations have been de-

scribed. These applications can be thought

of as ‘‘innovations’’ 52

diffusing across indus-

tries at first (car manufacturing to health

care, for example) and then within the same

industry (across hospitals, for example). The

first issue to consider is how the innovations are transferred from one industry to another.

The case of health care organizations imple-

menting the TPS can provide a good under-

standing of that development. Executives at T a b le

2 .

S u

m m

a ry

o f

T ra

n sf

e r

o f

P ra

c ti

c e s

In d u s tr y

P ra c ti c e s

M e th o d s o f T ra n s fe r

E v id e n c e

A v ia

ti o

n C

re w

re so

u rc

e m

an ag

e m

e n

t/ te

am tr

ai n

in g /s

im u

la ti

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sy st

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/c u

lt u

re /e

rr o r

re p

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in g

In st

it u

te o f

M e d ic

in e

(I O

M )

re p

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, Jo

in t

C o m

m is

si o n

/A g e n

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fo r

H e al

th c ar

e R

e se

ar c h

an d

Q u

al it

y (A

H R

Q )

c o n

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an ts

/t ra

in in

g M

ix e d

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h -r

e li a b

il it

y o

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st e m

/c u

lt u

re /e

rr o

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p o

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g IO

M re

p o

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Jo in

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m is

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n /A

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in g

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it h

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—

70 THE HEALTH CARE MANAGER/JANUARY–MARCH 2012

Virginia Mason Medical Center first became

interested in TPS when they heard about the

benefits of the approach from local business

executives in the Seattle region. Once they

became convinced of the value of TPS, the

hospital chairman, president, and other key leaders went on a 2-week visit to Toyota

factories. 37,39

Around the same time in the

Pittsburgh area, hospitals, major insurers, and

corporate and civic leaders joined efforts to

form the Pittsburgh Regional Health Initiative,

a nonprofit community consortium focused on

‘‘perfecting the health care system.’’ As the

former Alcoa (a global producer of Aluminum) chairman was recruited to help spearhead the

effort, health care executives came in contact

with Alcoa’s own adoption of TPS. 34

As a

result, several health systems started learning

from Alcoa’s experience and implemented TPS

in their own organizations. 36,38

A similar situation

took place at the University of Michigan Health

System, where contact was established with General Motors (GM), an expert in both Lean

and Six Sigma approaches. This collaboration

resulted in GM providing University of Michigan

Health System with facilitators for initial Lean

projects, helping with training coaches, and

giving access to GM’s own training materials. 40

In brief, the pattern of initial diffusion of TPS/

Lean innovations seems to be collaboration between health care executives and other local

business executives, which results in transfer

of knowledge across industries.

A different method of innovation diffusion

appears to take place in the case of patient safety practices from aviation and HROs. The

main precursor for that trend was the pub-

lication of the IOM 31

report that estimated that up to 98 000 people die each year in

the United States because of medical errors

and that noted that ‘‘health care is decades

behind other industries in terms of creating safer systems.’’ The report called on health

care organizations to derive lessons from

aviation and HROs. Soon after, powerful or-

ganizations in the health care arena, such as

The Joint Commission and the AHRQ, started

pushing for practices such as CRM, team train- ing, simulation, and other safety practices.

25,53

For example, AHRQ established the HRO net-

work to provide health care organizations

with a forum for learning about promising

practices and identifying new and innovative

ways to implement research findings. Early

adopters such as the Veterans Health Admin-

istration, Kaiser Permanente, and Vanderbilt University Medical Center, among others, started

sending their clinical teams to attend training

courses, as well developing their own courses

‘‘in-house.’’ 54-57

Another method of diffusion of innovation

that is also worth mentioning is health care

organizations’ hiring of executives who have

worked in other industries. For example, Henry Ford West Bloomfield Hospital in

Michigan recently hired a former Ritz-Carlton

executive as its chief executive officer. The

newly built hospital boasts private rooms,

a chef, a concierge, and weekly classical

concerts, all concepts imported from the

hotel industry. 58

The second issue to examine is, once the innovation is brought to the industry by early

adopter organizations, how does it spread to

other organizations in health care? In the

case of TPS/Lean, once the initial phase of

adoption was underway by a few organiza-

tions, an influential organization jumped ship

and endorsed the trend. The Institute for

Healthcare Improvement, an independent not-for-profit organization, published in 2005

a powerful white paper that proposed that

‘‘adoption of lean management strategies—

while not a simple task—can help health care

organizations improve processes and out-

comes, reduce cost, and increase satisfaction

among patients, providers, and staff.’’ 59

As a

result, the TPS/Lean trend started to gain ‘‘legitimacy’’ in health care. Lean (and Six

Sigma) consultants started offering their ser-

vices. For example, the previously mentioned

Pittsburgh Regional Health Initiative now of-

fers education and training courses in TPS and

Lean. 60

Many health systems implemented

these new approaches by hiring consultants

and/or by copying successful early adopters in their markets.

Similarly, for innovations from aviation and HROs, health care organizations, hoping to

catch up with the new trend, started purchasing

Lessons and Challenges for Health Care Organizations 71

(at considerable expenses) prepackaged CRM and other team training approaches. Con- sultants began to sell health care–tailored team

training, and several standardized team train- ing curricula emerged: MedTeams (adopted from US army rotorcraft safety experience),

TeamStepps (developed by the Department of Defense Safety Program in collaboration with AHRQ), and Medical Team Training, devel-

oped by the Veterans Health Administration. 30

Helmreich and Sexton 61

likened the surfacing

of team training consultants in health care to what took place in aviation several years ago: ‘‘After CRM had gone through the pro-

cess of being recognized, acknowledged, and formally mandated, a number of consultants emerged from ‘under rocks’ offering packaged

programs that promised to cure all an orga- nization’s ill.’’ They cautioned that some of these packages may be ill suited for hospital

staff and other medical teams.

Implications

In summary, the diffusion of innovations from other industries appears to start with a few early adopter organizations (hospitals and health systems) and influential other organizations (The Joint Commission, IOM, AHRQ, or Institute for Healthcare Improve- ment) pushing for the innovations. Once the trend becomes accepted, consultants and copying behavior contribute to its spread across the industry. An important question to explore is whether the applications in the early adopter organizations are different (in terms of their effectiveness) from those in the rest of the industry. Institutional Theory suggests that innovative practices that im- prove performance in early-adopting organi- zations are legitimized in the environment.

Ultimately, these innovations reach a level of acceptance where failure to adopt them is seen as ‘‘irrational and negligent.’’ At this point, other organizations will adopt the new prac- tices even if they do not improve perfor- mance.

62 For example, in the early 1990s,

hospitals that have adopted Total Quality

Management principles early on were driven

by efficiency concerns, whereas those that

adopted it later on were mainly driven by le- gitimacy concerns.

63 It will be important to

assess whether the same applies to the inno-

vative practices described in this article. To

take this a step further, Institutional Theory

can be used as a basis for developing a model

of transfer of innovations from other indus-

tries to health care. More specifically, we plan

to assess coercive and mimetic isomorphism forces that affect health care executives and

organizations when decisions to adopt prac-

tices from other industries are made. 64

Another intriguing issue is to examine

whether transfer of learning happens both

ways: do other industries learn from health

care organizations? In their book: Manage-

ment Lessons From Mayo Clinic,’’ Berry and Seltman

65 claim that lessons of organizational

efficiency and interpersonal relationships

learned at the Mayo Clinic can be applied

to any organization in any industry.

In conclusion, innovative practices have

been imported from various industries to

health care organizations in efforts to ad-

vance patient safety, enhance quality of care, reduce waste and inefficiency, and improve

customer service and satisfaction. Although

several success stories have been documented,

serious questions remain about the value of

these imported practices in improving the

performance of health care organizations.

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