“Circle of continuous misery”!*

10 February 2021

Arnout Orelio

Everybody is clear on the fact that we need to improve healthcare! If this pandemic made one thing clear, it is that there are limits to the quality and quantity of care we can provide to our community with our current system and processes. So, let’s start or continue, depending on where you are at, changing healthcare for the better. But, how to solve all those problems, that keep emerging, in a sustainable way?

As a process improver for the past 25 years, I have continually sought out the available ways to improve in healthcare. I hoped for a culture of continuous improvement, with the accompanying effective approach to problems by healthcare providers themselves, aimed at ever better quality for patients. The approach, as I learned from the many excellent organizations I visited. An approach based on the world-class principles formulated by many quality thinkers, such as Dr. W. Edwards Deming, et al., and known today as the Lean management philosophy.

However, from further analysis of what was happening in healthcare at the time, including interviews with healthcare leaders and providers, a different model emerged: “The circle of continuous misery!”

“’Circle of continuous misery!’ Ouch, spot on Arnout!”
— Esther Veenstra, Healthcare Manager

What problem are you working on?

If you want to improve, you need to know what the problems are. It seems very clear right now what the problems are in healthcare. You can’t ignore them anymore. However, the solvability of problems is greatly determined by your thinking and therefore by how you define your problems. Einstein said about this, “You cannot solve problems with the same thinking with which you caused them.” So, what is the prevailing thinking in healthcare?

When my colleagues and I started in 2005 with our efforts to help healthcare providers to improve, we researched what problems existed or were experienced within the sector. To our amazement there seemed to be few (different) problems. The biggest and recurring theme was money: “We have to cut costs”; “Healthcare is no longer affordable”; and so on. [Interestingly, we all hear a lot of that, still.]

We had carried out a small desk research to better understand the problems that were prominent in healthcare, at the time. We counted the subjects of the articles in the Zorgvisie** – Newsletter. The result: 80% of the articles were about money (including reorganizations and mergers driven by money); 10% were on (non-)quality, such as the intervention of the Healthcare Inspectorate and 10% were on other subjects. We came to the conclusion that budgets and efficiency were the most important goals. And “cost cutting” was the main instrument. Several conversations with executives confirmed this picture.

So, what are consequences of making budgets and efficiency the goal? It mostly starts with defining your problem as “not making enough money”. The “logical” approach to this problem is cost cutting. If, who want to cut back costs, you limit the budgets. As a result, you limit possibilities for healthcare professionals to care for patients. The quality of your services goes down. Patients and/or the regulators will complain and report on this. Subsequently, the quality problems will be “solved” by sharpen current or draw up extra (external) rules, controls, registrations and procedures. These all result in more work for the healthcare providers and thus extra costs. This making healthcare more expensive. And so, you have to cut costs, again and the circle continues, spending more and more time and money on “paper” quality and less on patients. The “circle of continuous misery” is born.

You need to and can break this circle by following it in reverse order, providing quality care for patients as your starting point. Next step: everything that does not contribute to providing quality care for patients, you eliminate. This will reduce the need for budget and therefore have a positive effect on the financial health of the organization. Higher quality and healthier finances reduce the need for (external) rules, inspections and registrations. Now you’ve entered a circle of continuous improvement instead of misery.

What circle of “improvement” are you going through in your organization? And how does that affect the safety, quality, accessibility and cost of the care you provide?

* This article is based on: A. Orelio, Lean Thinking in Healthcare (2023), Introduction.

** “Zorgvisie” is a Dutch medium, including website, magazine and newsletter, focused on healthcare.



4 Comments on "“Circle of continuous misery”!*"
  • Bob Emiliani
    10 February 2021Reply

    Hi Arnout. Nice article. Leaders have no right to impose "circle of continuous misery" on workers, yet, being disconnected from the actual work, that is the (ab)normal outcome. As you say, "...everything that does not contribute to providing quality care for patients, you eliminate." And this is part of the problem because not knowing the work (leaders failing to participate in kaizen), they think everything contributes to providing quality care for patients. Furthermore, top leaders are money-managers and to them the budget is the important thing, which always leads to continuously wrong decisions. Doing things in the "reverse order," as you rightly suggest, is beyond their ability to understand due to deeply-rooted preconceptions, traditions, and habits. I see exactly the same thing in higher education and also when I worked in industry.

  • Arnout Orelio
    11 February 2021Reply

    Well said Bob! These "deeply-rooted preconceptions, traditions, and habits" are among the most persistent that "... not contribute to providing quality care for patients." Revealing them and helping leaders replace them with more effective ways of thinking and behaving, is the big challenge. And because I can't wait for higher education to solve this, I will one leader and one preconception at the time. It will take a while, I guess ...

  • sikis izle
    25 April 2022Reply

    Wow, this paragraph is nice, my younger sister is analyzing these kinds of things, so I am going to convey her. Chang Derenthal

  • Arnout Orelio
    25 April 2022Reply

    Thanks for the complement Chang! I'm looking forward to hear from her.

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