Guest Column

What Hospitals Can Teach Us About Performance


Last October, our daughter was born nearly five weeks early via emergency C-section. She spent 18 days in the hospital, and my three-week paternity leave gave me plenty of time to think about the parallels between the way hospitals and schools approach their work.

Elizabeth City, Richard Elmore and their colleagues make such a comparison into their central metaphor in the book Instructional Rounds in Education: A Network Approach to Improving Teaching and Learning. So, as a principal of a 480-student elementary school for three years, I've been wondering what we can learn about the delivery of medicine for getting results in education.

Consistency Guaranteed
I've settled on three ideas.
•  Treatment plans are highly directive. Our daughter was fairly healthy when she was born, but we realized immediately that hospitals donít take any chances. They follow strict protocols for virtually everything, and hospital staff members have no qualms about being directive and even downright bossy when necessary.

We didn't think our daughter needed to be in the neonatal intensive care unit for so long, but in hospitals, there is no pretense that the customer is always right. Best practices are encoded in well-defined procedures.

Over the course of our hospital stay, it dawned on me this rigidity is what ensures the desired outcomes -- healthy patients -- can be obtained with a high degree of consistency.

In education, seldom do we follow a sharply defined course of action for dealing with specific problems, yet we face the same problems over and over again, which leads me to ask, "Why not?"

•  Failure is not an option. The neonatal intensive care unit devotes an incredible level of support to high-needs patients. Whatever the baby needs, the baby gets, regardless of cost or hassle. We would consider anything less morally unacceptable. If the situation worsens, the interventions intensify. Our daughter didnít need any surgeries or other invasive procedures, but when her temperature dropped by one degree, she was immediately placed in a warming unit. The only time we had to wait for space to become available was when she was being moved to a less intensive level of care.

In education, resources (such as access to tutors, teacher-student ratios and learning time) are typically fixed, and the results are allowed to vary. In schools with a well-developed response to intervention model, the most intensive levels of support are given to the students who need support the most. However, schools are not typically designed or funded in ways that reflect a true "failure is not an option" mission. We do the best we can, but it's clear our results are allowed to vary considerably. Is this the best approach when we know the costs of failure?

•  The division of labor is interesting. Most of the people we interacted with during our stay were nurses, and it's clear the nurses do the vast majority of the work in hospitals. They use their own professional judgment in the day-to-day choices about patient care but are always bound by the doctor's care orders and hospital protocols. Doctors determine the treatment regimen but carry out little of it themselves.

In addition (as City and Elmore emphasize in Instructional Rounds), doctors consult with nurses and with each other in developing and adapting care plans.

In education, most decisions about what students need (by way of instruction, supports, accommodations and interventions) are made and carried out by teachers in isolation. We donít have a doctors-and-nurses division of labor. If anything, teachers are both doctors and nurses, and principals are most like hospital administrators -- responsible for everything that goes on but not involved in direct service to clients.

This has me questioning what it might look like to have, say, two or more teachers (perhaps with complementary areas of expertise) and several tutors working with a large number of students. The one-teacher/one-class model seems to be sacrosanct, but many teaching tasks could easily be done by staff with less training, freeing teachers to spend time planning and making decisions that draw more fully on their expertise. Teachers could check in and revise the plans -- the care orders -- as they go on rounds.

Any Similarities?
If you're interested in learning more about improvement in medicine, I highly recommend Atul Gawande's books and New Yorker articles, which are rife with potential analogies for how we can improve education. Gawande is a Boston-based surgeon who writes extensively on medicine and public health.

Education has plenty to teach medicine, too, so I'm not suggesting the solution to educational improvement is to imitate the medical profession. Schools and hospitals are both complex organizations working for the public good, but the economic, human resource and professional practice realities are drastically different. However, if we want to ensure all students learn at high levels, it's worth looking at the ways medical professionals get results for their patients.

Justin Baeder is principal of Olympic View Elementary School in Seattle, Wash. E-mail: