STEM

Paul Borawski asks why students aren’t flocking to Science, Technology, Engineering, and Math (STEM) as career fields.  The responses and his analysis focus mainly on how to improve the educational process in these fields.  Maybe it’s time to do a root cause analysis and a contrarian analysis of why anyone studies STEM, or anything else.

First guess is money.  People study fields where they can make money.  Yes, some do.  And many are happy doing that, tho 2008 brought a sobering reappraisal of careers in banking and finance.  However, salary is not on every employee’s top five list, and not every medical student wants to be an orthopedic surgeon.  For most people, once you make enough money, more is not a sufficient attraction to do something you don’t like.

Family tradition figures prominently but again not an invariable indicator.  If you grow up in the industry and hear conversations at the dinner table, you will at least have an interest in the field.

Talent or genetic predisposition is important in music, art, acting, etc.  Math and engineering; perhaps.  I’ll put personality into this category:”I like doing things that this field requires.”

  

Passion.  An inspirational teacher or mentor may be enough to create a college major and perhaps launch a career.   Some months ago, a young girl asked ballerina Paloma Herera for the secret to becoming a good dancer.  “There is no secret,” she replied.  “You have to have a passion, and then you have to work very hard.” So passion is required, but it’s not enough.

To some extent, we need to differentiate between a career and a hobby.  I know many people who are good at music or art but don’t depend on those skills for their income.

All of the above factors may push a student toward STEM, but what about the attractive factors that attract him to those fields?  On a survey, State Department employees checked that they identified with our mission and felt that they were making a positive contribution.  Meaningful work that is appreciated—but not very much.  Anyone want to be a Federal employee today?  Maligned and attacked almost daily.  Salary stagnant, and future benefits in doubt. 

OK, what about the STEM fields.  Are Science and Technology respected and valued?  When science says the world is getting warmer because of the release of CO2 by humans, does Congress respond with a carbon tax and other measures to reduce the burning of fossil fuels?  Do we embrace the science of stem cell research to relieve the disease burden of man?  When engineers (including quality professionals) offer tools and techniques to improve the efficiency of  healthcare services and thereby reduce costs, do we implement their advice?  In short, are STEM fields valued and respected in our society?  If not, how can we expect to attract students to careers where their scholarship is denigrated and their advice ignored?

What can we do?  One easy answer is to appoint and elect individuals who do respect STEM to positions responsibility.  Make that a litmus test for politicians: “If science dictates a politically unpopular stance, how would you vote?”  Blind acceptance is not required, but the facts cannot be denied out of hand.  Decisions must be made by rational process that conveys a message of respect for the STEM fields.  Then, students with the requisite talents and inclination will be attracted to fields where they can make a meaningful contribution to society. 

An Outmoded Concept

Paul Borawski offers examples of the good and the bad of 2011 in his recent post .  His use of the word "quality" highlights the abstract nature of that word--something the world is no longer willing to accept.  You have to be more specific and tell us what you mean by "quality" before we're willing to agree with you that "quality works" or that it has a rightful place in society.  What good is it?  What has it done for me lately?  The Institute of Medicine assessed the impact of their publications, "To Err is Human" and " Crossing the Chasm."  These two works sharply criticized the US healthcare system for its many failings and prescribed broad approaches for improvement.  Ten years later, nothing has happened.  Various quality initiatives in healthcare have essentially failed to address either the incidence of errors or the cost of the services provided. One can point to various initiatives or projects that have demonstrated small improvements, but nothing has spurred the industry to emulate these successes everywhere.  The reason for this general failure is pretty clear--money.  It's not that there isn't money to implement change, but that there is no financial incentive to do so.  There is no financial incentive for improvement.

Following that negative note, what were the discrete disappointments of 2011?  Paul cites the discontinuance of funding for the Baldrige award.  ASQ has a financial interest in the Award, and it's always disappointing to lose a client, so he’s hardly an impartial observer.  Beyond that, Baldrige was a concept that came and went.  Applications have diminished in the last several years, and the whole system has degenerated into a commercial enterprise, with consultants and writers to enhance your application and improve your chance of success.  The original concept of identifying a few examples of excellence for others to model has become a competition.  The ideas and criteria are still valid and still provide an excellent guide to excellence in any industry.  We just don't need shining examples any more.

 Don Berwick/s departure from CMS should be on most people's list of disappointments.  A victim of Republican ideology, he brought credibility and stature to the position.  Not everyone agreed with all of his ideas, but then, not everyone agrees with me either.  I hope that's OK.

Paul cites the high point of his year as going to a meeting in China.  Maybe that's a sad commentary on the real absence of anything good. 

Meaning of Quality in HC

Paul Borawski asks us to “raise our voices for quality” in November, and eleven other months.  The implication is that such actions would make various processes “better.”  What does that mean for healthcare? 

The healthcare gurus talk about quality as if it is some mysterious aspect that transcends price or adherence to standards—something we must have and so we cannot talk about price, for example, without fear of losing quality.  In most industries, the definition of quality is determined by the customer, and price is usually an important consideration.  Adherence to standards is also important, but that is assumed, particularly in healthcare or other highly regulated industries.  States grant licenses to providers and to institutions (hospitals, surgery centers, etc.)  Medicare grants authority to institutions to perform and charge for certain procedures.  Patients, in general, trust those regulatory mechanisms to ensure a certain standard of care.  Price is not an issue.

The issue of trust was also mentioned in a subsequent ASQ piece from Coca-Cola.  Part of their definition of quality is a product consumers can trust.  Dependable, consistent.  This is what made Holiday Inns successful, and in HC, we depend on regulatory agencies to ensure trust. 

Those regulatory agencies (e.g. Medicare) typically delegate their authority to proxy organizations, like the Joint Commission or DNVHealthcare.  Does it work?  Well, partly.  The accreditation organizations ensure that healthcare organizations comply with their standards, including a consistent standard of care.  But again, price is not a factor.  Also, individual providers are not involved in the accreditation process.  The state medical boards that regulate providers only take action in cases of grievous or flagrant abuse of ethical standards.  Doing a poor job is allowed, and price is not an issue.

The biggest problem with US healthcare today is that it costs too much.  Quality is good, but the price is too high.  In any other industry, price would be part of the definition of quality for goods and services.  For some things—commodities—price is the defining characteristic.  For example things like paper clips or gasoline are purchased by price.  It’s really tough to sell a “better” paper clip.  Oil companies struggle to convince us that their gasoline is somehow better, but most people don’t really believe it.  Customers vote with their feet or pocketbooks, and they buy the cheapest product that meets their needs.  Except for healthcare.

Prices in healthcare are fixed by Medicare and other payers.  Patients don’t have a lot of skin in the price game and don’t usually have much choice about where they get healthcare.  Most healthcare in the US is provided in a monopolistic environment—strong local hospitals have a monopoly on healthcare services in their region.  The price may not be exactly secret, but it is also not public.  I know exactly how much I’m paying for gasoline when I pull up to the pump, but not when I enter the hospital. 

Why would a hospital (or physician) want to lower their prices?  Why would you want to charge less than you could be paid?  They wouldn’t.  And don’t.  Patients don’t know or care how much they’re paying and wouldn’t opt for a lower cost alternative if they had a choice.  There are exceptions to this rule, of course.  Those without insurance come to mind, but they are a dwindling group.  Those with high deductible insurance also have skin in the price game, but they are also a small group.   The other area where price matters is elective procedures, such as plastic surgery.  Insurance doesn’t pay, so patients do shop by price. 

For the vast majority of healthcare services, however, price is not an issue, and this is a major reason for the high cost of healthcare in the US.  We could fix that by price competition.  If we define quality as meaning price, then quality would improve as prices come down.

Success from Failure?

These thoughts were inspired by a conversation between Laurel Nelson-Rowe from ASQ and Terry Woychowski, VP for Global Quality at GM. 

The auto industry has a long and controversial relationship with healthcare, so it’s not clear that they have anything to teach us, particularly in the policy arena.  Historically, they used health benefits as a bargaining chip and eventually discovered that healthcare was costing them more than the steel in their cars.  Hard to put that genie back in the box.

Everyone would view GM as a product company.  Well, almost everyone, and maybe that’s one of their problems.  Some years ago, I looked at a new Honda, and the first thing the salesman did was take me into the shop area and introduce me to the service manager.  I bought a Honda.  I remember a survey of Ford Taurus owners which showed that buyers loved the car—until they had a problem, and then they hated it.  In other words, it looked good, but the company didn’t furnish the service to keep it running.

So, it’s a mission thing.  Are you selling cars or selling transportation?  Many years ago, Cunard line was going bankrupt.  Unthinkable!  So they sold a major interest to a hotel company, and the rest is history.  They had focused on driving ships across the Atlantic.  Now, they have become a vacation destination.

Mr. W. promised to build cars that performed as advertised and lived up to expectations.  To the extent that the customer defines quality, I wonder what new car buyers expect and how GM is addressing those demands.  Mr. W doesn’t seem to understand that building good cars isn’t enough.  They buy transportation or a status symbol, and in any case, service is part of the equation.

So what’s the message for healthcare?  I liked his comment that bankruptcy “clarified the mission for GM.”  Perhaps some healthcare institutions need to fail.  Price competition might do that, as institutions lose market share because they can’t meet a competitor’s pricing.  That would certainly get the word out that we’re serious about reducing healthcare costs.  For starters, how about an RFP from Medicare for total hips.

I also liked his comment about engaging every employee in defining their role in the GM mission.  That helps make the mission part of the organization’s culture.  How many hospital employees even know the mission of their institution?  How many healthcare institutions have a realistic mission that doesn’t include world peace or community health, etc?  Or something equally silly, like providing “the highest quality healthcare.”  What does that mean?  How would you measure it?  If you don’t have a realistic mission, how can your employees help you achieve it? 

Maybe that’s the lesson from GM.  Have a mission and get everyone on board to achieve it. 

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.

When does it end?

In reviewing Paul Borawski's brief comment about quality at Ford, I was intrigued by one concept mentioned by Mr. Fowler of Ford:  quality must focus on the entire customer experience.  To paraphrase another sage, "It ain't over 'till it's over."  Now there's a new concept for much of healthcare.  How do patients get to your office?  Is it easy to find?  On a public transportation route?  We once surveyed patients coming to a clinic in our building, and 85% said it was difficult to impossible to find. At one time, there was a sign at the main entrance, "Hard hat area.  Do not enter."  The response of our executive officer was, "We have signs!  What's the matter with those patients that they can't read signs."

Beyond directions, how about instructions.  What to bring.  What to eat/drink.  Does this work?  Do you know?  Is the process of getting into your system so easy that it never fails?

Some other thoughts from my surgery center days: 

What about the experience within your system?  How do your customers feel about that?  Don't forget that family members are customers also.  Are they kept informed? An analysis of calls coming in to the pre-op area showed over 95% were looking for a patient.  "Is Mrs. Smith there?"  With computer screens everywhere, it didn't take much to create a patient locator system so any employee could find any patient, tell when they arrived at that location, and how long they were likely to stay.  The calls stopped.

And the exit.  Which way to turn out of the parking lot.  When my wife had cataract surgery, the center gave chits for 2 hours of free parking.  Unfortunately, the procedure took 2 hours and 20 minutes.  Somehow, I found that extra $5 for 20 annoying.  The center had no idea and was not at all interested.
I received a thank-you note from a family once because our maintenance employee changed a tire for them so they wouldn't be delayed going home.  How did he know?  Are employees tuned to signals of a need in patients or families?

How was the trip home?  Did you know there is a high incidence of vomiting in children when the car turns the first corner on the way home? 
In some ways, ambulatory surgery foists the burden of post op care on the family rather than hospital nurses.  Sometimes, the family needs guidance in what to expect and how to deal with it.  Take pain pills before the pain starts.  How long will it take to recover?  Go back to work?  Managed expectations.  Surgeons frequently have an overly optimistic view of the post op period.  Collect data.


The biggest hurdle to managing total customer experience is taking responsibility.  Make it your job.  If providing care is not part of your mission, be there to provide resources or inform those responsible.  Learn from the Ford experience; it ain't over 'till it's over.