Wednesday, December 15, 2010

A Change in the Weather

Paul Borawski announced a project with ASQ and IBM to look at Social Responsibility--see what works and whether there is a business case.  We're left wondering exactly what "Social Responsibility (SR)" means and what "works" would look like.  For some, it means taking care of the homeless.  For others, it's reducing your carbon footprint.  For most of us, something in between, a consciousness of your corporate role in society.  Being a responsible citizen means not dumping pollutants into the environment, for example.  (Are you listening Shell, BP, Massey Energy, etc.?)  A business case could mean obtaining a platinum rating for your new building, new solar panels on your roof.  Efficient use of energy and other resources. 

One interesting aspect of all this is that the American Society for Quality is doing it.  Well, maybe ASQ is doing it.  They are not emphasizing what the initials stand for as they strive for a global presence and move out of strictly "quality" initiatives.  If you've followed my writing long, you know I think quality has become a slang word--no real defined meaning, something people invoke when they don't want to talk about other things, like cost. 

Just returned from a meeting of the Healthcare Division of ASQ, where there was considerable discussion about how to improve healthcare, but not much talk about quality.  It's process improvement, LEAN thinking.  The greatest improvement is needed in reducing the cost of healthcare, not improving quality, and that will be done by improving the processes of delivering healthcare services.

All this comes with a recent article in JAMA titled "The End of the Quality Improvement Movement" in which the authors posit that the QI movement has produced no measurable results in the past 40 years, at least not in healthcare.  Maybe it's time to change out thinking.

Maybe it's time to take the word quality out of our vocabulary and define more precisely what we are talking about.  So let's change our focus to SR or LEAN or Value Stream Mapping or some other way to reduce the cost of healthcare.  Your children will thank you for it.

Icon Under Attack

The deficit reduction committee has recommended canceling the Baldrige Award program as a way of saving money, and ASQ thinks this is a bad idea.  It’s worth noting her that ASQ is not a disinterested observer here.  They get paid for administering the program, so this proposal would mean a significant revenue hit for them.  What about the rest of us?  As Bryzinski remarked about the Wikileaks release of State Department cables, it would be “catastrophic but not serious.”   The Baldrige Award was launched at a time when U.S. industry was having difficulty competing in world markets because of the poor quality of their goods and services.  The Award sought out examples of excellence in hopes that others would emulate them and thus improve the overall quality of U.S. industry.  For many years, awards were presented in manufacturing, service, and small business.  Eventually, the list was expanded to include healthcare and education. 

Has it helped?  A recent study of NC hospitals by RAND suggests not. They found no change in the indicators created by NQF or AHRQ over the past 10 years.  This may be a bit unfair, because the Baldrige “Criteria for Performance Excellence” were not written to satisfy the NQF or AHRQ.  They were written to make business more competitive.  Since there is little to no competition within healthcare, one might argue that the Baldrige award is irrelevant. 

Furthermore, it’s not clear that we have a quality problem in U.S. healthcare.  For the past 10 years, it has been popular to bash our healthcare system and make derogatory comparisons with other countries.  Most of these articles cite criteria that have little to do with healthcare, per se, or relate more to governmental systems.  For example, prior to the recent healthcare reform legislation, we had an access problem in America.  There were 47 million people who did not have health insurance and thus had problems with access.  However, once they got into the system, the quality of their care was excellent.  We have arguably the best healthcare in the world.  If you have breast cancer, your chance of having that discovered and your treatment are better here than any other country.  An article last year in the Atlantic began with “If I lived in New Zealand, I’d be dead now.”  The reason was that the anti-cancer drug she was taking was not approved in New Zealand, or in England either for that matter.  England has its NICE committee to decide what healthcare the government will pay for.  This is similar conceptually to the “Clinical Effectiveness Committee” proposed for this country. 

For another example, look at longevity--life expectancy.  At the bottom end of the scale, this seems related to per capita income which presumably relates to access to healthcare among other factors.  Once you are out of the gutter, there are strange bedfellows.  I have never seen a statistical analysis to see whether being 16th or 17th is really different from being 10th or 12th.  One comes away with the feeling that life expectancy relates more to genetics, environmental factors (clean air and water)--but not to healthcare. 

In addition to breast cancer, one disease that does relate to healthcare is treatment for cardiac disease, and we do that better than anyone. 

At the time of the debate over health reform legislation, the two primary problems with U.S. healthcare were noted as access and cost--not quality.  The legislation largely fixed the access problem but did nothing to address cost.  Peter Orzag has spoken and written eloquently about this and the deficit reduction commission included Medicare expenditures in their plan for the future.  Our healthcare just costs too much. 

The Baldrige criteria were designed to make industry more competitive, but there is no competition in healthcare, only a network of local monopolies.  There is no question that the Criteria for Performance Excellence have improved the operations of hospitals and healthcare systems where they have been employed.  But it is doubtful that there has been any impact on healthcare in general.  Is this benefit worth the cost of a national award system?  As part of that debate, Congress should not ignore the industry that has grown up to help institutions apply for the award.  If it goes away, it will be missed, but the sun will still come up.  Catastrophic but not serious.