HEALTH CARE MANAGERS typically describe their organizations as "unique" and "different" and rave about the distinctive aspects of working in an industry where actions directly impact patients' lives.1 Management guru Peter Drucker2 described health care as the most difficult, chaotic, and complex industry to manage and suggested 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 similarities with other fields and suggest opportunities 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 opportunities for health care organizations. In Why Hospitals Should Fly? Nance3 stressed principles from aviation that health care organizations must instill as a foundation for safety. Lately, Gawande4 in The Checklist Manifesto investigated the finance, construction, restaurant 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, Lee5 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 "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 "keeping 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 examples 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 practices 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 dealing with nonemployed physicians,13 and operating in a highly regulated and complex environment.14

PURPOSES AND METHODS

The aviation industry has long been admired by health care organizations, especially because of the dramatic improvements in safety that it has undergone.15 Helmreich16 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 management (CRM) and team training techniques are arguably the most widespread. Crew resource management emphasizes developing skills in briefing, inquiry, assertion, workload distribution, vigilance, and conflict resolution.17 Applications 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 evidence 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 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 techniques that have crossed over from aviation include checklists21 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 embraced by everyone. Randell27 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."27 Others have warned against the blind copying of aviation techniques by noting that "it is not sufficient to take aviation training materials and simply delete 'pilot' and replace with 'nurse' or 'anesthetist.'"28

What these views seem to suggest is that a solid understanding of the inherent differences and similarities between the 2 industries is needed. A common argument is that "patients are not airplanes." While advocating for applications from aviation, Helmreich16 has advised that the OR "[horizontal ellipsis]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 predictable than patients." In Table 1, the similarities and differences between health care and aviation are summarized.29

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

High-reliability organizations

High-reliability organizations are organizations that function in hazardous, fast-paced, and highly complex technological systems while operating with no errors for long periods.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 Research 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 reporting, 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 anesthesia than aviation because of its high levels of complexity.34

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 "delivering 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 organizations with an increasing number of hospitals and health systems adopting a version of TPS as their systematic approach to enhancing quality and improving efficiency.37 Once widespread across several industries, TPS became known as Lean Systems, Lean Manufacturing, 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 around 40 articles related to Lean in health care.41 Of these, 8 were empirical studies that examined the implementation of a Lean project to various health care settings. The review concluded that there is weak evidence behind 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 workflow 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 multinational telecommunication company, developed 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 application 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 Chassin46 article, applications 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 demonstrated 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, governmental 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

As previously mentioned, to address communication 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 expertise 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 handover omissions, and duration of handovers were reduced.48

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.49

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 demand, scripting, and waitstaff uniforms have been successfully implemented to allow patients more control over their food choices.50

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, gardens, aquariums, larger windows, more natural light, private rooms, better waiting areas, reduced environmental stressors, and calming music. Models such as "Planetree" that stress "healing, nurturing environments" have been adopted by numerous hospitals.51Table 2 provides a summary of the practices and their industry, as well as the evidence and the methods of transfer, as discussed in the following section.

Table 2. Summary of Transfer of Practices

DISCUSSION

Several applications from other industries to health care organizations have been described. These applications can be thought of as "innovations"52 diffusing across industries 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 implementing the TPS can provide a good understanding of that development. Executives at 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 publication of the IOM31 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 organizations in the health care arena, such as The Joint Commission and the AHRQ, started pushing for practices such as CRM, team training, simulation, and other safety practices.25,53 For example, AHRQ established the HRO network 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 Administration, 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 organizations, 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 outcomes, 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 services. For example, the previously mentioned Pittsburgh Regional Health Initiative now offers 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 (at considerable expenses) prepackaged CRM and other team training approaches. Consultants began to sell health care-tailored team training, and several standardized team training 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, developed by the Veterans Health Administration.30 Helmreich and Sexton61 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 process of being recognized, acknowledged, and formally mandated, a number of consultants emerged from 'under rocks' offering packaged programs that promised to cure all an organization'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 Improvement) 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 improve performance in early-adopting organizations 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 practices even if they do not improve performance.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 legitimacy concerns.63 It will be important to assess whether the same applies to the innovative 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 industries 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 practices 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: Management Lessons From Mayo Clinic," Berry and Seltman65 claim that lessons of organizational efficiency and interpersonal relationships learned at the Mayo Clinic can be applied to any organization in any industry.

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