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Key to health care is “adaptive design”


image: © Nieves

Donna E. Shalala, chairperson of the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing at the Institute of Medicine, contributed an article to the September 2009 issue of the American Journal of Nursing on the crucial role of nurses in meaningful and effective healthcare reform.

The article reached out to healthcare professionals for “innovative ideas that address important nursing issues, such as the nurse shortage and regulatory and reimbursement barriers to nursing, and which can help transform the way Americans receive care.”

In Part III of our series on the future of nursing, (read part I about Nurse Educators and part II about NPs) we hear from physician and enlightened patient, Dr. John Kenagy:

“I’m a physician who didn’t understand what nurses really did until I fell off a tree and broke my neck. As a patient, I saw nurses and other staff going the ‘extra mile’ to get me what I needed. The ‘system’ often didn’t help, and sometimes got in their way.

“After a great recovery, I returned to practice. I also became a healthcare executive determined to make a difference in ‘the system.’ And I made another discovery: We executives tried to fix the ‘big’ problems—like quality, safety and productivity—while everyone at the frontline continued to struggle with the small problems that then became the big problems.

“My next stop was unexpected. I became a Visiting Scholar at Harvard Business School. I studied transformational companies like Toyota, Intel and Southwest Airlines and found they had a different mindset. Instead of solving big problems in meetings, they solved small problems as close to the work as possible. Then the big problems went away.

“As a researcher and advisor, I tested those concepts at the point of care. This is what I learned from nurses: Hospital nurses spend one third or less of their time with patients. The rest is spent documenting, validating, clarifying, hunting, fetching, waiting, meeting, etc.—doing all the things it takes to get patients what they need. It’s necessary, but it’s not patient care. Nurses are problem-solving the system, not the needs of patients. And so the problems keep recurring. How often are you looking for a wheelchair, or missing supplies, a lab report or a doctor, even in the most ‘wired’ hospitals?

“Frontline staff knows how healthcare really works. For the last 10 years, I have accessed that knowledge by engaging frontline staff in real-time, systemic problem solving that changes the system as part of everyday work. The patients get what they need and, most importantly, the problems don’t recur and the systems improve. The method is called ‘adaptive design,’ and it’s the subject of my new book, Designed to Adapt: Leading Healthcare in Challenging Times. In the future, working adaptively, staff and management will just focus on getting patients exactly what they need at continually lower cost. That’s what nurses should really do. And that’s the only way we will fix healthcare. I believe the frontline is the key to healthcare transformation.”

For more information on Dr. Kenagy, his new book and adaptive design, see his Website at

What are your innovative ideas for the future of nursing? We know you have many. Write your comment below or email us at

Dr. John Kenagy knows healthcare as a physician, executive, scholar, advisor and patient. After receiving his MD with distinction, he trained in General and Vascular Surgery, and is a Fellow of the American College of Surgeons with board certification in General and Vascular Surgery. In addition to 20 years of experience as a vascular surgeon, he has been Chief of Surgery and Chief of Staff, and held management positions including Regional Vice President for Business Development for a multi-state, not-for-profit healthcare delivery system. He earned a management degree from Harvard University’s Kennedy School and was appointed a Visiting Scholar at Harvard Business School from 1998 to 2002. Dr. Kenagy’s Harvard research and teaching focused on disruptive innovation healthcare strategy and the unique management methods of highly resilient companies. He founded Kenagy & Associates, LLC to bring these capabilities to healthcare with the concept of Adaptive Design®. Dr. Kenagy’s contributions have been widely recognized by leading publications such as the Harvard Business Review and the Journal of the American Medical Association. His article “Service Quality in Health Care” was named the Best Health Care Management Article of the Year. Forbes magazine named Dr. Kenagy “the man who would save healthcare.”

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2 Responses to Key to health care is “adaptive design”

  1. Nicole, RN

    This is an interesting viewpoint of the role of hospital nurses and overcoming barriers to patient care. Working in the hospital setting, I’m well aware of the barriers that nurses are faced with on a daily basis that hinder patient care to some extent. I’m hoping this gentleman is not too idealistic in his opinions because I think the mindset of recognizing problems early and making changes to prevent them from happening again already exists in the hospital setting. Sure, it depends on the hospital, the management, the funding, etc. but I think medicine is one of those professions that is changing so rapidly that quality improvements initiatives are/have been around. I do agree with his school of thought that you must attack the small problems which will snowball into resolving or preventing of some larger issues. I also feel as though as much as researchers and executives are trying to do for the future of nursing, each nurse has to do their part by putting the patient first amidst a hectic day that may have barriers. If these barriers exist and prove to be a detriment to care, nurses have to take responsibility for reporting these problems and suggesting means of improvements. Not to discredit the validity of the article or his viewpoints, but I oftentimes think the most valuable players in making innovative changes are the ones directly involved in the issues, and in this case that would be nurses- those providing direct patient care.

  2. Thanks, Nicole – I apologize for the slow response – this just slipped by me.

    You and I are very close together in our thinking. Those close to the patient have to be part of the solution because they have information that no one else has. Adaptive Design is a management method that makes identifying barriers to care and solving them easy and routine.

    Rather than move information up to isolated decision-makers, we seek to develop very sophisticated decision rights close to information at the point of care. The challenge in this work is not getting RN’s engaged – they love Adaptive Design. The hard part is changing the “data up/implement down” organizational structures and mindsets that dominate in healthcare management. I think we are on the same page.