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Breaking the Rules for Better Care.

A few years ago, the Dean of the School of Business at the University of Leicester, Dr Zoe Radnor, tried to understand the reasons for the “bicycle book” that she discovered at an English hospital she was studying. All staff who arrived at work by bicycle routinely signed a register book at the front door. Hundreds of these registers, once full, had been collected and stored for decades in clearly marked boxes. “Why?” Professor Radnor asked. No one knew. The answer took some sleuthing. The first books dated from World War II—when rationing of fuel was the rule of the day, and when any staff who commuted by bicycle thereby earned extra food ration credits for saving on gas. Now, three-quarters of a century later, the bicycle book process remained alive and well, embedded in the organization’s brainstem, not its cortex. It was pure waste.1 Administrative burdens and complexity are alleged to be among the most costly forms of waste in US health care, at levels far exceeding those in other nations.2,3 Further, such requirements are said to detract from the care experience of patients and to drain time and morale from physicians and other staff, for whom they disturb value-added interactions.4 This Viewpoint describes an effort undertaken in a network of North American hospitals and clinics to explore the types and magnitudes of such waste at the front lines of care. The Leadership Alliance (Alliance), convened by the Institute for Healthcare Improvement, comprises approximately 40 North American hospitals, associations, and other care systems committed to delivering