Fortune Cookie

What is the future of “Quality” in healthcare?  First, what is the meaning of “quality” in healthcare?  For most practical purposes, quality in healthcare means “doing what we say you should do” where the “we” means academics or organizations like NQF or AHRQ who pontificate on what should be done for the sick.  Certainly, there is not even a passive nod to what the customer wants.  Many argue about who the “customer” really is, or whether there is a “customer” in any meaningful sense in healthcare today. 

In the classic, historical sense, structuring your business to please customers would bring you more customers and take market share from competitors.  But that doesn’t happen in healthcare, at least not if you view the patient as a customer.  There is no competition for patients.  No hospital goes out of business and no doctor’s office closes because the office down the street provided better or cheaper service.  Even where the service areas for hospitals overlap, there is no price competition, because everyone gets the same price.  [That may not be strictly true, but it’s too complicated for a short article.  Just pretend for now.]

So, here comes ASQ with advice on how to do things better, faster, and cheaper, and guess what?  No one’s interested.  They’re not interested, because it doesn’t get you anything.  It’s not clear that the patient makes the purchase decision in most cases, but even where there is a choice, it’s not made on price.  It’s even against the law to offer discounts or forgive the co-pay for patients. 

That may be a bit harsh.  There are metrics that patients neither understand nor appreciate, but standard techniques from ASQ can help a hospital demonstrate compliance.  And passing muster on enough of those can get you a slightly higher reimbursement from some third parties.  But not more patients or a larger market share.  The bottom line is that doing well does not provide a competitive advantage in healthcare.

Is there a future for better, faster, cheaper?  Let’s hope so.  The biggest problem today with U.S. healthcare is that it costs too much.  Healthcare services in this country are too expensive—more so than any other country in the world.  We pay our doctors more, and we utilize expensive gee-whiz technology more than anyone else.  Somehow, that has to stop.  In a truly competitive environment, it’s possible to provide the same product/service today at a lower price than yesterday but still make as much money as you did yesterday.  However, the only reason you would do this is that someone else is doing it and will put you out of business if you don’t match their price.  Process improvement tools from ASQ could help, but only when the healthcare industry is prepared to use them.

Big Q, Little q

Just watched an interview by Paul Borawski with J. J. Irani or Tata Steel (India).  A couple of ideas that could be applied to healthcare, if we'd allow it.  Irani talked about "big Q and little q."  Little q is the quality of the product or service.  In his case, it meant how good was the steel?  This is where our emphasis has been for quality in healthcare:  wrong site surgery, hospital re-admissions, wound infections, aspirin for chest pain, etc.  All those metrics that various gurus have espoused as indications of quality in healthcare services.  We spend countless hours and dollars measuring these things and reporting the results to now-empty offices in Washington.  It's possible to look up how your hospital ranks on many of these metrics.  No one would argue that they are not important or desirable.  Catheter infections are costly.  Sometimes people die.  But somehow, there is this nagging feeling that we are chasing the wrong tail.  If we do better in all these little things, will healthcare overall be better?  Are these really the problems or are they symptoms of a more basic problem.

Which brings us to Big Q.  For Dr. Tata, that means quality in management.  How the company is run.  Asked which was more important, Big Q was an easy choice.  At one point, he said he would like all his suppliers to adopt the same quality management systems that his company was using.  For him, this meant adopting the principles of the Baldrige Award.  His point was that it needed to be a system of management, not a tool for improvement.  In other words, a way of running the organization.  The Baldrige principles constitute one approach, ISO 9001 is another.

For those who aspire to exceptional excellence, the Baldrige criteria are appropriate guides.  Indeed, the original concept was to identify examples of excellence for others to emulate and thus raise the quality of U.S. industry.  Over time, the award has expanded to healthcare, education, and government.  It has also become commercial, with a mini-industry of consultants to write the perfect application.  The number of healthcare applications has been increasing steadily, without visible effect on the healthcare industry as a whole.  It still costs too much money to be sick.

ISO 9001 has only recently made inroads in healthcare.  DNV healthcare became a serious competitor to the Joint Commission in 2008, primarily because of their focus on Big Q.  They require hospitals to become eligible for registration to ISO 9001 within three years of their original accreditation by DNV. ISO, of course, is not specific to healthcare.  It is a way of running the company--any company, including a hospital.  It is Big Q.  A recent book documents the effective use of ISO 9001 in a private group practice and in the global healthcare operations of the U.S. Department of State. 

If you have Big Q in place, other things will follow.  A management system allows control of the tiller.  Once the ship is headed in the right direction, quality becomes part of the culture and thus pervasive in all the activities on board.