Quality in Government

Is this an oxymoron?  Well, it kind of depends on how you define “quality” and who your customers are.  I work in the Office of Medical Services of the Department of State (DOS).  One customer group we deal with is DOS employees who want to serve overseas.  Our other customer group consists of job applicants with some medical condition that may prevent them from being hired. 

Those in the employee group have little clout as individuals, but as a group they are potent.  If enough of them become unhappy with our services, a directive comes down from above to “FIX THIS PROBLEM!!”  Once we understand what excites senior management, we fix that problem.  And then we fix it again, until it is so slick, we get kudos from customers. 

The applicant group is less powerful.  Some write their Congressman, and that gets attention tho not usually the desired result.  Some hire lawyers.  Again, attention but not usually the desired result. 

And then, a funny thing happened.  Five years ago, we adopted ISO 9001 as a management system.  Now, each of the 30+ sub-processes in MED has a written procedure about how they do what they do.  They know who their customers are and actively solicit input.  The most common metric is clock time, and “stuff happens faster now.” (A quote from an employee survey.)  One process in my office that routinely took 60 to 90 days now gets done routinely in 2 to 4 hours.  A few years ago, it took, on average, 11 months to hire a new employee.  Last month, we interviewed an applicant who applied only two months ago. 

If this still seems long to you, you’ve never dealt with OPM or applied for a Federal job.  If you do so, the person who wants to hire you may never see your application.  Some clerk in HR, who knows nothing about the job will decide how well qualified you are.  The office that has the opening will only see the top three names on her list.  For the rest, it’s a coin toss.

Are we truly worse that the civilian healthcare industry, as Paul Borawski suggests?  No.  We’re better, and I can prove it.  We collect HEDIS data every month from each of our 180 primary care offices around the world.  (Now there’s a challenge!)  Three times a year, we compare our data to the best US healthcare system results and discuss improvement strategies at the senior management level.  In general, we do well, although there are some special challenges in our system.  (Like getting a frozen vaccine to Ulaanbaatar.)  One thing we have that makes all this work is a culture of quality—the universal desire to do a good job coupled with the knowledge that senior management shares that goal.  Each quarter, we discuss errors, deaths, and complaints with those providers stationed in Washington.  I once received this email from a medical officer overseas: “Bob, we made the following mistake in our health unit this week.  Please discuss it at your next meeting.  I’d like to see what the group thinks.” 

How do you get there?  It takes leadership, consistency, and credibility.  It can be done in government. 

But Are we Happy?

Are software quality engineers really the happiest employees, as suggested by Forbes Magazine?

Is happiness related to occupation?  Or what does make us happy anyway. 

The country of Bhutan famously publishes a Gross National Happiness Index for the country and has a minister of happiness.  (Policies in Bhutan must pass a Gross National Happiness review.)  By definition, happiness in Bhutan includes the following goals:

1. Sustainable development
2. Preserve cultural values 
3. Conserve the natural environment
4. Good governance. 

I think good governance would not include prostitutes and parties in Las Vegas.  Mountain top mining in WVA would also probably fall out, so the US would probably not do well, but we are considering a measure of Gross National Happiness. 

But these are National goals, not individual, personal ones.  What makes individuals happy?  If it’s job related, I guess that would rule out wealthy wives who “never worked a day in her life.”  What about the money that allows some to live without working?  (Personal note:  Since my wife won’t read this, I can define “work” as an activity that someone else pays you to do.)  Numerous studies have concluded that a lack of money dissatisfies (makes you unhappy), but after a basic amount, more money doesn’t further enhance happiness. 

Health?  You would think so, but some sick people are also very happy.  Listened to an NPR interview  with a woman who sat at the bedside as her brother died of AIDS.  His last words were “I’m a happy man.”  Of course, you would then have to define what “health” means, and who is responsible for health.  Most would agree that air pollution (as a source of ill health) is the responsibility of the Federal government.  But the US life expectancy took a dip—first time ever—in 2011 due to obesity.  Now whose fault is that?  Health can certainly be a factor, but the correlation is missing.

Occupation and employment.  Some occupations are indeed happier than others.  Or maybe it’s just that happy people just gravitate to those occupations.  Employment is better than unemployment, and there are companies that are better places to work than others.  While we may be enjoy our job and be happy at work, these are factors on the fringes and probably not the defining factor for personal happiness.

It’s decision time!  Can I have the envelope please?  Happiness is . . . love.  It’s having someone to love and being loved in return.  In her poem, “The 5:32” Phyllis McGinley wrote:

“This hour best of all the hours I knew:” (while waiting at a suburban rail station)

“And a man coming toward me, smiling, the evening paper
Under his arm, and his hat pushed back on his head;
And wood smoke lying like haze on the quiet town,
And dinner waiting, and the sun not yet gone down.”

Q For Sale

What is this “quality” that we’re being asked to sell?  Using the word as a noun implies that it is concrete—a product that you can package and put on the shelf.  “I’ll have three pounds of quality, please.”  More frequently, it’s used as an adjective, as in “quality service” or “quality products.”  It’s common to see a mission statement profess to provide “The highest quality healthcare,” whatever that means. 

The term has become a slang expression, having no intrinsic meaning, and some organizations have dropped it.  “Quality” appears only once in a footnote on the Baldrige Award web site.  The American Society for Quality is now known as ASQ, and you won’t find a translation of those letters on their web site.  It is possible to go thru the ISO 9001 standards and remove the word “quality” entirely, without altering the meaning of any sentence. 

So then, what is it we’re being asked to sell?  What does “quality” look like, and why would anyone spend good money for it?  Perhaps it is an ethereal concept that we can sense or feel but cannot define.  More likely, it is an aspect of organizational culture, relating back to the concept of Total Quality Management.  Every employee has a compulsion to do whatever they do better than anyone else, anywhere.  But that’s not enough.  Employees must perform together to provide a service or product that is best in class.  But even that’s not enough.  They must do this reliably, every day, as a habit.  “This is how we do things here.” 

More than once, a Baldrige Award winner has been asked, “You just won this nice award, but what are you going to do on Monday, when you go home?”  Without exception, the astonished CEOs have replied, “We’ll do what we always do on Mondays. This is who we are.”

So, back to the original question: What is it that we’re selling? A concept?  Well no, it’s more like a culture.  Can you sell culture?  Can you impose a culture as an outside consultant?  No to both, but you can help senior management change the culture in their organization, assuming they see the benefits in doing so.  And that’s something we can sell.  AHRQ and others have demonstrated that you can create or improve a patient safety culture.  You can, of course have both—a safety culture and a quality culture.  They are not incompatible, but they are also not identical.  In either case, you have to work at it.  As Paul’s quote from Deming implies, “Success is not guaranteed.”  I like the quote from Paloma Herera (see last month), “First you must have a passion.  Then you must work very hard.”  That’s a formula for success in almost anything. 

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.