Quality, that is. Has its day come and gone? There was serious question a few months ago over continuation of the Baldrige award on the grounds that it was no longer relevant. There was an article in, I think the NEJM last year suggesting that the quality movement had totally failed to produce any tangible results in healthcare. The measures of healthcare done by AHRQ and NAHQ are indeed static. Nothing is getting better.
One can (and I have) argue about the relevance of the metrics, but nothing is improving. Nothing. True, there are poster-child stories about this hospital or that doing something great, but the overall system is static. Why?
I think we have to go back to someone’s saying that a given system produces the results its designed to produce. If you want a different result, you have to re-design the production system. Healthcare was never designed to produce “quality.” P4P and other metrics were pasted on to an existing system with no provision for motivation. OK, some trivial financial rewards, but no hospital would go out of business because they failed to meet standards. No provider would lose business to a competitor who provides a better service or a lower price.
In the business world, if a competitor provides better or cheaper products than you, people will stop buying your product, and you’re out of business. So you work very hard to provide what your customers want at a lower cost than your competitor. Not true in healthcare. Pricing and purchase decisions are driven by small monopolies. Competition is for insured lives and not over price of procedures or convenience for patients.
When goods or services first enter the market, they command a premium price driven by innovation. The iPhone is a good example. The world was full of cell phones, but this was an entirely new concept in electronic communication. People bought it, and it was/is a high profit item for Apple.
Fast forward now to the point where that product has become a commodity. Generally speaking, prices come down. Dramatically. Competition is no longer about innovation, it’s about price, packaging, convenience, etc. Stuff gets cheap. Want to see a commodity? Copy machine paper. What brand does your company use? I’ll wager you don’t know or care. It’s all pretty much alike, so purchase decisions are made on price, delivery, etc. A certain basic quality is assumed--maybe even specified by standards.
Most of healthcare is a commodity today. All surgeons read the same journals, use the same instruments. Protocols drive family practice encounters. Want a mammogram? You’ll get the same exam with the same results, regardless of where you go. Where is quality in this system? Why would any provider or institution spend time or money pursuing better quality? There is no reward. It doesn’t sell. In fact, it’s difficult to define quality in a system like U.S. healthcare, beyond conformance to accepted practices.
We have been pursuing Quality as an end in itself, when it should be viewed as a tool to achieve a bigger market share. That would require the creation of a market in healthcare--real competition for goods and services, mostly on the basis of price. In such a world, everyone wins.
Tuesday, April 12, 2011
Friday, April 1, 2011
When he fell . . .
When he fell and couldn’t get up, the ambulance took him to the nearby University Medical Center. Did he have a stroke? “No, but we’ll keep him overnight.”
First was the overdose of sleep medication, so he didn’t wake up the next day. Then they overdosed his coumadin, causing GI bleeding that requires transfusion. What mistake will come today? The elderly and infirm lack resilience, so my friend may not survive.
When I needed help a few years ago, I suffered at home rather than call the ambulance that I knew would take me to that same hospital. But I had knowledge and a choice that my friend did not. My bleeding stopped, and the pain stopped, and I am alive today.
But why should survival depend on knowing enough to avoid healthcare? What must we do to convince institutions to pay attention and provide acceptable healthcare that doesn’t harm patients? The knowledge is there. No one deliberately tries to harm patients, but that is what happens all too often.
Barbara looked at me with anguish and frustration. “What can I do?” We both knew there was no answer. She is losing him. Not to accident or disease, but to carelessness within the system that is supposed to help him. Prescribing Coumadin is not rocket science, but it does require attention to detail. Secretly, I was glad I am no longer working in the healthcare sector and don’t have to take responsibility for these errors. I also wonder what will happen for me next time--when I don’t have a choice.
Maybe there will be a revolution in healthcare. Maybe we’ll stop paying for poor care, and doctors will pay attention to patients. Maybe I’ll win the lottery.
Monday, March 7, 2011
SR is PC
Social Responsibility, that is, is now Politically Correct. ISO has a new standard, ISO 26000: Guidance on Social Responsibility, that defines what it means for a company to be “socially responsible.” The standard strives to make social and environmental considerations part of decision making, and sustainability is a big part of this.
To accomplish this, the standard identifies seven principles that should be applied to seven core subject areas within the organization. The principles are: accountability, transparency, ethical behavior, respect for stakeholders, respect for the law, respect for norms of behavior, and respect for human rights.
The seven areas of the organization where these principles might apply are: governance, human rights, labor practices, the environment, fair operating practices, consumer issues, and community involvement.
I’m sure motherhood and apple pie are in there someplace. Much of this was written from a Western cultural point of view.
The first question is, will it sell? Altruism goes just so far, and without some regulation or competitive advantage, SR will have limited penetration. There is, indeed some evidence for a financial advantage. First, there is a correlation between “admired companies” and SR. Most admired companies (e.g. Apple) have an easier time hiring good employees, and, whether cause or effect, their employees tend to be more productive and more loyal.
A study done for BITC in 2010 showed that SR friendly companies outperformed their peers in the FTSE 350 index and recovered faster after the financial downturn. It stands to reason that companies with more efficient resource utilization will do better when resources become more expensive.
But it isn’t always so obvious. Take farming. You’d think that a farmer would not want 25% of the fertilizer he buys to get washed out into the Chesapeake bay. However, the American Farm Bureau Federation (“The Voice of Agriculture”) is suing the EPA so farmers can continue to do exactly that. A 2003 report on the bay said the nation’s largest estuary continues to decline because of over-fishing and pollution. (Much of that pollution is due to farm run-off.)
But what about healthcare? What does SR mean for healthcare? What about your carbon footprint? Is your building LEED certified? OK, how about Energy star certified--that’s feasible. Are alll the light bulbs LED? (CF’s are old hat now.)
How do patients get there? Employees? I worked in a hospital once where all employees were required to pay commercial rates for parking at work. Once visited a hospital that started its own bus line to bring in patients. The more you think about this, the more ideas come to mind. Perhaps that’s the real value of a new standard.
And patient care processes. Applying LEAN principles can help with more efficient use of resources which reduces the carbon footprint as well as costs, while pleasing patients at the same time. Here’s one place where a quality professional can help--what tools to use where, and help getting started. Another, of course, is conformance to the ISO 26000 standard.
The ancient oath of Primo non nocere, or First do no harm, was intended to apply to harming patients. It could be expanded conceptually to include society in general. Genichi Taguchi is quoted as suggesting that a “service demonstrated good quality if its production and use caused little to no harm to society.” Read that again and think broadly of the environment.
First you have to care. The rest is easy.
To accomplish this, the standard identifies seven principles that should be applied to seven core subject areas within the organization. The principles are: accountability, transparency, ethical behavior, respect for stakeholders, respect for the law, respect for norms of behavior, and respect for human rights.
The seven areas of the organization where these principles might apply are: governance, human rights, labor practices, the environment, fair operating practices, consumer issues, and community involvement.
I’m sure motherhood and apple pie are in there someplace. Much of this was written from a Western cultural point of view.
The first question is, will it sell? Altruism goes just so far, and without some regulation or competitive advantage, SR will have limited penetration. There is, indeed some evidence for a financial advantage. First, there is a correlation between “admired companies” and SR. Most admired companies (e.g. Apple) have an easier time hiring good employees, and, whether cause or effect, their employees tend to be more productive and more loyal.
A study done for BITC in 2010 showed that SR friendly companies outperformed their peers in the FTSE 350 index and recovered faster after the financial downturn. It stands to reason that companies with more efficient resource utilization will do better when resources become more expensive.
But it isn’t always so obvious. Take farming. You’d think that a farmer would not want 25% of the fertilizer he buys to get washed out into the Chesapeake bay. However, the American Farm Bureau Federation (“The Voice of Agriculture”) is suing the EPA so farmers can continue to do exactly that. A 2003 report on the bay said the nation’s largest estuary continues to decline because of over-fishing and pollution. (Much of that pollution is due to farm run-off.)
But what about healthcare? What does SR mean for healthcare? What about your carbon footprint? Is your building LEED certified? OK, how about Energy star certified--that’s feasible. Are alll the light bulbs LED? (CF’s are old hat now.)
How do patients get there? Employees? I worked in a hospital once where all employees were required to pay commercial rates for parking at work. Once visited a hospital that started its own bus line to bring in patients. The more you think about this, the more ideas come to mind. Perhaps that’s the real value of a new standard.
And patient care processes. Applying LEAN principles can help with more efficient use of resources which reduces the carbon footprint as well as costs, while pleasing patients at the same time. Here’s one place where a quality professional can help--what tools to use where, and help getting started. Another, of course, is conformance to the ISO 26000 standard.
The ancient oath of Primo non nocere, or First do no harm, was intended to apply to harming patients. It could be expanded conceptually to include society in general. Genichi Taguchi is quoted as suggesting that a “service demonstrated good quality if its production and use caused little to no harm to society.” Read that again and think broadly of the environment.
First you have to care. The rest is easy.
Wednesday, February 9, 2011
Speaking and Listening
If you were granted five minutes with any individual or group to improve healthcare in the U.S., where would you go and what would you say? With so little time, you’d want to find the fulcrum--the leverage point to amplify your message. Perhaps a physician group, for they order the tests and procedures that make our healthcare the most expensive in the world. Perhaps hospital administrators. Those tests and procedures are done in their facilities. Would you “raise your voice” and implore them to inject “quality” into their healthcare practices? What does “quality” look like? How much does it weigh?
Used to be that quality meant statistical analysis of assembly line output. Then Deming pointed his finger at management. Today, we hear about process improvement, LEAN, and TPS. Then, there are dashboards and Six Sigma and myriad other tools. So which is the magic bullet? The key to success.
Rene Dubois, the shepherd of the French anti-smoking efforts talked about the variety of initiatives his group had done over many years to achieve a notable and unlikely success. Someone asked what was the most important factor--the key to success, and he replied, “You have to do it all.” There is no shortcut. Managers must be nimble and skillful in selecting the right tool at the right moment. This requires knowledge. It’s not possible to pull a book off the shelf when you need to do a Root Cause Analysis or produce a Pareto chart to decide where to start. The knowledge must be available in the minds of well trained employees.
Above all, however, there must be a goal. We must know what improvement would look like. Where are we going? Then, we can employ the tools to get us there.
For this, my five minutes would distill into one minute and no slides:
“Take this as your goal: Make everything you do cost less next year than it did last year. Every service, every procedure, every product must cost less than before. Go forth and do good work."
Used to be that quality meant statistical analysis of assembly line output. Then Deming pointed his finger at management. Today, we hear about process improvement, LEAN, and TPS. Then, there are dashboards and Six Sigma and myriad other tools. So which is the magic bullet? The key to success.
Rene Dubois, the shepherd of the French anti-smoking efforts talked about the variety of initiatives his group had done over many years to achieve a notable and unlikely success. Someone asked what was the most important factor--the key to success, and he replied, “You have to do it all.” There is no shortcut. Managers must be nimble and skillful in selecting the right tool at the right moment. This requires knowledge. It’s not possible to pull a book off the shelf when you need to do a Root Cause Analysis or produce a Pareto chart to decide where to start. The knowledge must be available in the minds of well trained employees.
Above all, however, there must be a goal. We must know what improvement would look like. Where are we going? Then, we can employ the tools to get us there.
For this, my five minutes would distill into one minute and no slides:
“Take this as your goal: Make everything you do cost less next year than it did last year. Every service, every procedure, every product must cost less than before. Go forth and do good work."
Monday, January 10, 2011
Resolutionists
They fill the health club in January. It's so easy to see how the world ought to be. But attendance drops off as they discover there is work involved. Physical work. And pain. And sacrifice. By March their resolve begins to dissolve, and the health club is mine again.
Will healthcare be different? Will we be able to lose some weight? The continuous expansion of costs in our healthcare system resembles an over 40 waistline, and changing the paradigm that generates these costs will win a spot on the "Biggest Loser." Doing nothing, however, is a threat to our economy and to the healthcare system itself. There is always the chance that Congress will recognize the problem and do something no one will like.
So, let's make some resolutions to reduce costs in healthcare in 2011.
1. Become more efficient. More than that, let's set up a mechanism for becoming more efficient. This means that the effort will continue beyond initial success. Perhaps a team with training in Lean and associated disciplines. These folks will roam the halls, helping various process owners wring the waste out of what they are doing.
2. Integrate and communicate with physician groups. Look for ways to share information and resources. Get surgeons to schedule their own cases via the internet. Why should a patient have to register in the hospital when they are a known patient in the surgeon's office? And we can schedule the post op visits from the hospital recovery room. Look for seamless integration and transparency for the patient. These techniques will save time and money for everyone.
3. Promote and reward wellness among healthcare employees. They should be an example for the community. There are lots of examples from industry. Pick one . . . or two . . . or twenty-two. Make it happen. Don't forget to collect data to demonstrate success.
4. Look at the visitor/family experience in any healthcare institution. These are future customers, and a captive audience. What do they need but don't know it yet? How about a health assessment while you're waiting?
6. Prepare to compete. Select at least one process and make it world class in terms of the patient experience and the profit margin. Next year, do something else.
7. Try to maintain our resolve beyond March.
Will healthcare be different? Will we be able to lose some weight? The continuous expansion of costs in our healthcare system resembles an over 40 waistline, and changing the paradigm that generates these costs will win a spot on the "Biggest Loser." Doing nothing, however, is a threat to our economy and to the healthcare system itself. There is always the chance that Congress will recognize the problem and do something no one will like.
So, let's make some resolutions to reduce costs in healthcare in 2011.
1. Become more efficient. More than that, let's set up a mechanism for becoming more efficient. This means that the effort will continue beyond initial success. Perhaps a team with training in Lean and associated disciplines. These folks will roam the halls, helping various process owners wring the waste out of what they are doing.
2. Integrate and communicate with physician groups. Look for ways to share information and resources. Get surgeons to schedule their own cases via the internet. Why should a patient have to register in the hospital when they are a known patient in the surgeon's office? And we can schedule the post op visits from the hospital recovery room. Look for seamless integration and transparency for the patient. These techniques will save time and money for everyone.
3. Promote and reward wellness among healthcare employees. They should be an example for the community. There are lots of examples from industry. Pick one . . . or two . . . or twenty-two. Make it happen. Don't forget to collect data to demonstrate success.
4. Look at the visitor/family experience in any healthcare institution. These are future customers, and a captive audience. What do they need but don't know it yet? How about a health assessment while you're waiting?
6. Prepare to compete. Select at least one process and make it world class in terms of the patient experience and the profit margin. Next year, do something else.
7. Try to maintain our resolve beyond March.
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.
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.
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.
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