Organizations should establish and pursue aims for improvement. Organizations should be supportive of national efforts to establish aims for improvement and provide local leadership in their communities to achieve those aims (see Chapter 3).
Organizations should become skilled at using and learning from quantitative information to measure progress toward quality improvement. The key goal should be to improve the performance of systems of care as a whole rather than improving parts of the system at the expense of the whole.
There should be a commitment to evidence-based health care with processes put in place to systematically reevaluate established practices.
Organizations should commit themselves to continuous improvement and the elimination of waste. Health care organizations should recognize that most quality problems are due to faulty processes, not individuals' failings. A clear link should be established between quality improvement and the elimination of wasteful processes.
Organizations should make a commitment to reduce error and increase safety. The health care industry should examine the possibility of establishing a national system for reporting and tracking errors. Changes in medical malpractice, tort, and quality oversight systems are also needed to create a climate in which errors can be more readily reported, analyzed, and prevented, while still providing fair and equitable compensation to victims of error (see Chapter 10).
Organizations should build long-term relationships with all stakeholders. Contracts with suppliers and other vendors should build quality improvement into long-term planning.
Organizations should commit themselves to fundamental change in their work environment, involving and empowering all employees. Employees should feel free to report errors and instances of improper care, as well as suggest innovations, regardless of their position within an organization.
While organizational culture is clearly an important factor in quality improvement, it is not necessarily easy to change. The organizational culture of a hospital, nursing home, or other organization is built up over years and is the product of decisions by a large number of actors. An organization that realizes the need to develop a strategy for quality improvement, but whose organizational culture is not supportive of innovation and risk taking, faces a difficult dilemma. In such a situation, only active and visible support from clinical and managerial leadership for the continuous improvement of quality of care and service is likely to bring about successful change (Laffel and Blumenthal, 1989).
At least some of the aims that an organization establishes should be highly ambitious. "Stretch goals," as they are often termed in other industries, make it immediately obvious that the current system is inadequate and that a new one is required. A less ambitious goal creates the temptation to simply stress the system to achieve marginal gains, gains that will probably be unsustainable over the long run. Not all of an organization's aims for improvement need to be stretch goals, but some such goals should be a critical element of the aim-setting process (Berwick, 1996).
Chapter 3 discusses the need for a national set of aims for improvement. One of the important tasks facing health care leaders is to translate these national aims into specific aims for their organization.
One example of a renewed focus on customer satisfaction in health care is increasing attention to waiting times as a key area for improvement. Long waits for appointments and tests frustrate patients and can lead to quality problems if patients are unable to see a physician or must endure long waits for test results. In 1996, the Institute for Healthcare Improvement in Boston assembled 27 health care organizations in a "Waits and Delays" project. The group met three times over 12 months to learn classic quality management principles and industrial design concepts. Participants also stayed in touch between meetings to swap ideas. The group's work has led to a dramatic turnaround in some cases. In just 3 months, a Catholic hospital in Illinois cut triage time in the emergency room from 45 minutes to no more than 15 (Nordhaus-Bike, 1997).
Customer focus is also leading health care organizations to redesign patient satisfaction surveys so that they can provide real guidance for improvement efforts. In 1991, the Henry Ford Health System began surveying internal and external customers regarding the barriers they experienced in accessing care. These data were used to guide the work of process improvement teams, which tried to address the identified barriers. One team, for example, focused on the availability of telephone triage and nursing-advice services and recommended upgrading phone systems and developing consistent advice guidelines (Antcil and Winters, 1996).
One of the most important tasks that leaders of health care organizations must undertake is the involvement of clinical staff in quality improvement efforts. Such involvement is critical if these efforts are to be successful. Past research has suggested that hospital leaders often intentionally narrow the focus of quality improvement efforts to business or service processes to avoid the appearance of management encroachment on physician autonomy in clinical decisionmaking. There is also evidence that physicians are often reluctant to participate in quality improvement projects due to distrust of hospital motives, lack of time, and fear that reducing variation in clinical processes will compromise their ability to vary care to meet individual patients' needs (Weiner et al., 1997).
One way of encouraging the involvement of clinicians in quality improvement efforts is to introduce the techniques of continuous improvement into their educational experience. A particularly interesting initiative in this area is the Community-Based Quality Improvement Education for the Health Professions (CBQIE-HP), a joint project of the Bureau of Health Professions/Health Resources and Services Administration and the Institute for Healthcare Improvement. CBQIE-HP will involve both students and practicing health professionals at 10 demonstration sites across the country. At each site, an interdisciplinary team will identify an aim for improvement in a specific area of health care and take action to achieve that aim (Bureau of Health Professions, 1997).
A key element of a system is that its performance depends as much on how its parts interact as on how they act independently of each other. Ackoff gives the example of a group of engineers who endeavor to build the best automobile by identifying which manufacturer makes the best engine, carburetor, brakes, and so on, and then putting these various parts together. Not only would such a car be unlikely to work well, it would probably not even run at all (Ackoff, 1981).
Berwick (1995) notes that this kind of "suboptimization" -- parts being improved without cognizance, and perhaps even at the expense, of the performance of the system as whole -- is quite common in health care. He cites a typical example of a clinical assistant in a pediatrics department who keeps a stack of tuberculosis test cards hidden away to prevent staff from the internal medicine department from "stealing" them. Such an approach, while benefiting the staff in the pediatrics department and solving their immediate problem, clearly can harm the operation of other departments and does not address the underlying problem of why the cards run out in the first place.
The challenge for health care organizations is to move beyond suboptimization to systemic improvement. In addition to understanding how systems operate, they must diffuse this understanding throughout their organization. They must bring people together across the boundaries of profession, job classification, and department so that everyone understands how their "part" interacts with the "whole."
One of the objectives of measurement is to identify, analyze, and control unintended variation in the delivery of health care services. The recognition and analysis of variation are fundamental to modern industrial thinking about quality measurement. All aspects of health care display variation. Laffel and Blumenthal (1989) cite the example of a set of patients with sepsis. The strength of each patient's infection and its responsiveness to antibiotic treatment varies, as do the underlying conditions that may affect the course of treatment. The particular mix of physicians, nurses, and support personnel also varies, as does the availability of diagnostic tests and the accuracy with which they are performed.
Clearly, there are many sources of variation that should not be controlled. It is often necessary to develop treatment plans that are customized to meet the needs and expectations of individual patients. Nevertheless, many quality experts believe that substantial quality improvement can be achieved by eliminating unnecessary variation in the execution of the processes by which these treatment plans are implemented. In the case of a set of patients with sepsis, Laffel and Blumenthal (1989) note that quality could be improved if technicians use the same techniques and equipment for obtaining, handling, and interpreting blood cultures and if nurses use the same techniques and equipment for measuring patients' temperature and applying wound dressings. If physicians choose to follow similar procedures for determining the source of infection and for selecting and modifying antibiotic coverage, it is likely that the hospital would be able to implement their care plans more efficiently and accurately.
Health care organizations seeking to bridge the gap between research and practice must create a climate that "enables and motivates innovation," including providing resources for innovation, promoting frequent communication across departmental lines, developing mechanisms for focusing attention on changing conditions, and creating structures that provide access to innovation role models and mentors (Van de Ven, 1993). This last element may be particularly important in the context of health care, where consultation with colleagues is a key avenue for the spread of medical innovations (Felch and Scanlon, 1997).
A number of health care organizations have used this kind of experimentation to test new approaches to care. A team at Park Nicollet Hospital in Minneapolis-St. Paul used the PDCA cycle to improve the process of evaluating possibly cancerous breast masses. The team developed a new procedure -- using a machine that allowed the radiologist to place a needle and do a breast mass biopsy in a single session -- and then tested it by submitting 100 women to both the old and new procedures to compare detection rates. Finding no difference, the team implemented the new process, which reduced the time period between first evaluation and definitive diagnosis from several weeks to 2 or 3 days (Blumenthal and Edwards, 1995).
The experience of other industries that have tried to address quality problems is that defects in quality are rarely attributable to a lack of will, skill, or benign intention among the people involved in the production process. In most cases, problems are built directly into a complex production process. Even when people are at the root of defects, the problem is generally not one of motivation or effort, but rather of poor job design, failure of leadership, or unclear purpose (Berwick, 1989).
Processes in the health care industry are highly complex. Laffel and Blumenthal (1989) cite the example of a cardiac catheterization laboratory, where each case requires four individuals to carry out 50 separate activities. The activities of each individual are linked to those of the other three through an exquisitely timed series of interactions, handoffs, and dependencies. This process is only one of hundreds that a patient might be part of during even the most routine hospitalization.
A problem with complex processes is that they are frequently characterized by rework and waste. Tests are repeated because they are not performed correctly the first time. Requisitions have to be rewritten because they are lost or filled out incorrectly. Other industries that have sought to improve quality have identified the elimination of waste as an important part of improvement efforts (Womack and Jones, 1996). Berwick (1997) argues that "anything done in health care that does not help a patient or family is, by definition, waste, whether or not the professions and their associations traditionally hallow it." Process modifications that reduce waste and rework may simultaneously improve quality and reduce cost (Laffel and Blumenthal, 1989).
Given the complex nature of health care and medical practice and the multitude of interventions that each patient receives, it is not surprising that errors are made. Leape concedes that given the large number of interventions, health care personnel are operating at a high level of proficiency, but notes that even a success rate of 99.9 percent may not be sufficient. Such a rate would allow for two unsafe plane landings per day at O'Hare Airport, 16,000 pieces of lost mail every hour, and 32,000 bank checks deducted from the wrong bank account every hour (Leape, 1994).
A number of "high risk" industries, such as aviation and nuclear power, have made dramatic strides in reducing rates of error by using "human factors research," which tries to understand how and why human beings make mistakes in order to design work environments that minimize the occurrence of errors and limit their consequences (Leape, 1994). For example, concentrated solutions meant for mixing with intravenous (IV) fluid, not direct injection, could be kept in needle syringes without needles, with locks that fit only into IV bag receptacles (Stahlhut and Gosbee, 1996).
In response to growing public concern about health care errors, the American Medical Association has launched a major new initiative -- the National Patient Safety Foundation -- dedicated to ensuring that all patients in all settings receive health services safely (AMA, 1997). The Foundation will compile and disseminate data on the causes and constructive responses to errors. The Foundation is inspired by the example of the Anesthesia Patient Safety Foundation, which was established in 1985 to promote the development of knowledge and reduction of anesthesia injury. Whereas mortality from anesthesia was 1 in 10,000 to 20,000 just a decade ago, it is now estimated at less than 1 in 200,000 (Leape, 1994).
Many health care facilities are taking steps to reduce error. The LDS Hospital in Salt Lake City, Utah, has developed a computer system to identify, track, and reduce adverse drug events (ADEs), the leading adverse event experienced by hospitals. The system, which contains information from the hospital's computerized patient records, can check a physician's prescription against known drug allergies and test results and can flag potential problems. The system is even capable of recommending an ideal dose of medication to the physician. The implementation of this system has significantly reduced adverse drug events in the hospital and has given the hospital an invaluable database of information that it has used to design methods of preventing ADEs (Evans, et al., 1992; James, 1998).
Reducing error will also require a change in the way that health care organizations conduct themselves. In his testimony before the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, David Blumenthal (1997) noted:
The barriers to reporting error are not only internal, however. The very methods that are needed to root out error -- admitting it, measuring it, discussing it -- have the side effect of providing evidence of error, evidence that quality oversight organizations and plaintiffs' attorneys are eager to see (Belkin, 1997; Leape, 1997). Changes in medical malpractice, tort, and quality oversight systems are also needed to create a climate in which errors can be more readily reported, analyzed, and prevented, while still providing fair and equitable compensation to victims of error. Modern error reduction systems do not rely primarily on blame or punishment, since most errors are traceable to system flaws or inevitable human limitations that must be taken into account if safety is to be improved.
The dramatic changes that have taken place within the health care industry over the past few years have made the development of long-term relationships more difficult. Group purchasers -- both private and public -- have made it clear that they are unwilling to accept the kind of cost increases that prevailed in the 1980s. Health plans and providers are under enormous pressure to contain costs. Subcontracting, competitive bidding, and the rebidding of existing contracts have all become key strategies in this effort.
At the same time, however, a number of health care organizations, understanding the need for long-term partnerships, are attempting to build lasting relationships with their suppliers. The Group Health Cooperative of Puget Sound health plan, for example, has a policy that it will not contract with any vendor that does not have a quality improvement plan in place. Group Health's Supplier Quality Certification Program rates suppliers in a number of areas, such as proactive and continuous quality improvement initiatives, innovative solutions to customer requirements, women and minority business support, and environmental commitment (Group Health Cooperative of Puget Sound, 1995). The Employer Health Care Alliance Cooperative in Madison, Wisconsin -- a health plan purchasing cooperative for employers -- has a key aim to identify of "quality, cost-efficient" providers for the purpose of entering into a long-term business arrangement (Employer Health Care Alliance Cooperative, 1997).
It is not always easy to bring individuals from different disciplines, departments, and organizations together, but when it happens, the results can be dramatic. At Henry Ford Hospital in Detroit, an orthopedic surgeon convened a group of physicians, nurses, social workers, discharge planners, and health plan administrators who were involved in the care of joint replacement patients to look at ways to improve the process of care. Within a year, the team had redesigned the care process and had begun treating one surgeon's patients under the new protocol, which emphasized standardized preoperative tests and increasing patient education about their expected recovery program. After a few months of tracking the first surgeon's patients, all three surgeons adopted the new care plan. These changes reduced the length of stay from an average of 7 to 10 days to an average of 5 days and increased patient satisfaction (Blumenthal and Edwards, 1995).
Relationships between administrators and clinicians are under strain. The rapid pace of change within the health care industry is straining the relationship between administrators and clinicians. While surveys of physicians reveal that most are broadly satisfied with their work, many are frustrated with key aspects of their practice, especially their perception of a decrease in professional autonomy, a decrease in control over clinical decisionmaking, unreasonable delays in compensation, and the growing burden of paperwork. In some cases, the tension between plans and clinicians has entered the legislative arena in the form of debates over health system regulation.
Estrangement between administrators and clinicians leads to a number of problems. It creates morale problems among clinicians that can adversely affect interpersonal relationships with patients and the recruitment of new individuals into the profession. Estrangement also makes it harder for administrators to involve clinicians in quality improvement efforts, which is widely recognized as a critical factor in their success. Administrators and clinicians need to develop new ways of working together that allow potential conflicts to be identified and resolved before they begin to damage the relationship.
An important aspect of fear is employee concern about job security. In an industry undergoing convulsive change, many employees fear that their jobs could be eliminated at any time. In such a climate, some employees may view quality improvement initiatives as a means of identifying which jobs are to be eliminated. While the significant overcapacity that exists in the inpatient hospital sector suggests that downsizing will probably continue, managers must find creative ways to respond to this concern if they are to succeed in involving employees in improvement efforts.
Another set of barriers to effective empowerment that must be surmounted are those that exist between disciplines, professions, and departments within health care organizations. The distinction drawn in many facilities between "administrative" and "clinical" quality improvement efforts (see discussion above) is one such barrier, as are hierarchical relationships between administrators, physicians, nurses, and paraprofessionals. Other industries struggling with quality problems have found that excessive deference to authority can occasionally prove fatal. The investigation of a crash of two 747s on a fog-shrouded runway in the Canary Islands found that one plane had a very good, but overly strong-willed pilot. John Nance, an airline pilot and safety analyst, noted that "His crew perceived him as so senior and so omnipotent that they weren't willing to tell him when he was doing something wrong. They just assumed that he must have known what he was doing" (Belkin, 1997).
A third barrier to empowerment is that large sectors of the health care industry, such as skilled nursing facilities and home care, are still characterized by low wages, high turnover, and high injury rates. This is particularly true of paraprofessionals. Of the 2 million health care paraprofessionals in the United States, over 600,000 of them are earning wages below the poverty line (Home Care Associates Training Institute, 1997). High levels of turnover make it difficult to tap the institutional memory and expertise of workers to make improvement in quality.
The challenge that health care leaders face is to eliminate these barriers and to cultivate a climate where all employees feel free to suggest innovations. In many cases, employees with good ideas remain silent because they assume that they will not be listened to. Effective health care leaders must find ways to engage the creativity of all of their employees, not just clinicians. The experience of health care organizations that have empowered employees to use their imagination and creativity is that the result is not only technically successful projects, but a sense of enthusiasm and enjoyment among the staff (Berwick et al., 1990). Chapter 13 contains a number of examples of employers in the industry who have found ways to engage employees in quality improvement efforts.
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