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.

There's No Tomorrow

Actually, no today either.  In case you missed it, the world ended last week.  But, if it doesn’t happen as promised, there’s another chance.  This time it’s not the Christian Bible thumpers but the Mayans.  The Mayan calendar will end on 21 Dec 2012. In truth, however, only the Christians have such an apocalyptical view of the world.  The Mayans simply start a new calendar, so perhaps there will be tomorrows.

That ‘s good news, because the ASQ has published their view of what tomorrow will look like.  Others have commented, and, of course, they’re all wrong.  Let’s look at their predictions:
1. Global Responsibility.  ASQ thinks “governments, organizations, and individuals” will act with “a growing awareness of the local imac of local decisions.”  Waste will become socially unacceptable.  Well, they certainly forgot to ask the Tea Party about this, or the Republican party in general.  There are those in Congress who want to remove funding from the EPA, and any thought of a carbon tax brings laughter and derision.  ASQ also talks of waste in the form of “undeveloped minds.”  To turn that around, we would need to strengthen the WIC program and Pre-K enrichment programs for poor kids.  Oh, but we just cancelled those things.  Sorry, despite our fondest hopes in 2008, the U.S. at least, seems headed in the opposite direction. 

2. Consumer Awareness.  They allude to the Internet and social media as providing information to consumers to make purchasing decisions.  Well, yes, some, but that’s here now.  Is there some reason this practice will expand?  Internet shopping is a here and now practice, not a dream for the future.  Even the concept of mass customization is so, well, yesterday.  What about tomorrow?
Globalization.  As they say, globalization of customers and work forces is a factor in most businesses, tho more critical to larger than smaller businesses.  It’s not clear from the discussion what they predict for tomorrow, so hard to argue that they’re wrong unless one could say globalization will become irrelevant.  So OK, I’ll say that.  Globalization will cease to be the boogey-man it once was.  Cheap labor is cheap for a reason, and low wages will no longer be the driving force for location of factories.  Taking healthcare as an example, there will always be a place for medical tourism, but it will never challenge or supplant traditional sources, like your Community Memorial hospital or the Cleveland Clinic.

3. The increasing rate of change.  Change has certainly been dramatic in our lifetimes.  Wow!  I remember dial telephones.  And the first TV in our neighborhood--a 6 inch black and white.  So it’s easy to predict that this will continue.  Easy, at least unless you’re reading the tea leaves.  On a talk show the other nite, someone espoused the radical idea that technology hadn’t really done much in the last ten years or so.  New gadgets, to be sure, but no dramatic improvement in our lives that could be ascribed to technology.  Today’s Washington post carries a column about “life without gadgets.”  So maybe not much will change in the next 5 to 10 years.  Society will take that time to digest what went on in the last.  And we do have a few wars to contend with.  Wars aren’t over when they end.

4. The workforce of the future.  I hope they’re mostly correct here, when they state that unemployment “will become a thing of the past,”  but I suspect this is wishful thinking.  The pressures of high wages have driven productivity ever higher.  We just don’t need that many workers making widgets anymore.  But without paid workers to buy widgets, we don’t need to make so many widgets, so we’ll lay off a few more workers. That’s where we are now.  It’s called recession.  Getting out is hard to do.  Government spending helps, but that only works if you simultaneously raise taxes.  Not gonna happen in the present environment, so unemployment will be with us for the long haul, and may actually get worse. 

5. Aging Population.  ASQ starts this discussion with a prediction that working longer may become an option “if not a requirement,” and I’ve got to agree with this one, with one asterisk.  The requirement part implies extending the retirement age for Social Security.  This makes a lot of sense, and there is talk of indexing the SS retirement age to life expectancy and thus return the duration of retirement to about 10 years.  Current U.S. life expectancy is about 78.   One of the big problems with this is that if the job demands physical effort, it’s hard to keep up when your 70.  Manual laborers will lose out.   ASQ talks about the high cost of healthcare for all these geriatric patients.  Maybe we should revisit Soylent Green.   Healthcare expenses do go up with age, but not as much as you might expect. Furthermore, the increasing number of elderly is not a key factor in the costs of Medicare.  The reason Medicare is such a budget buster is the high and rising costs of individual healthcare services.  Not only are our healthcare costs higher than any country in the world, we provide more of those services per patient than any country in the world.  So, yes, Medicare is a serious problem for the U.S., but no, the aging population is not making it worse--not by much anyway.

6. 21st Century Quality.   For this discussion, ASQ defines quality as what the customer wants.  They present an interesting concept that quality has moved from production lines to process improvement to enterprise assessment.  Whither goest quality as a concept in the future?  Some say nowhere.  In healthcare, at least, attempts to institute “quality” have not produced any system wide gains in efficiency or in quality of care.  In fact, the results of data from NCQA and AHRQ show little if any improvement over the past several years.  Anyone who is surprised at this should remember that any system produces the results it was designed to produce.  Is “quality” an obsolete term?  Has the concept outlived its usefulness?  What is the meaning of quality in a service economy?  Is there any place for it in the future?

7. Innovation.  ASQ initially expresses some confusion over the difference between innovation and improvement, then makes no prediction for the future importance of either.  Just a term they thought they should mention.  Hard to argue with that. 

On predicting the future:  I went backpacking with the Boy Scouts, and one of our assignments was to predict the weather.  For six days, there was a morning haze followed by sunny skies.  We, of course, predicted more of the same for the seventh day.  It rained.  Poured down rain.  This illustrates the difficulties of predicting the future by extrapolating from the past.  That’s what ASQ has done:  they picked some trends and extended the line to the next point.  This doesn’t allow for unexpected events (like earthquakes) or disruptive innovation that may make your business obsolete.  The C&O canal in Washington, DC was supposed to be the transportation mode of the future.  Until railroads, that is.

This report by ASQ is almost totally devoid of documentation or data to support the few predictions they make.  For the most part, that’s OK in this venue.  However, when you make an outrageous statement like unemployment will go away, you better have charts and graphs. 

Let me offer my own take on the next ten years.  Mark your calendar and call me back.  I’ll buy drinks if I’m wrong on more than two and ASQ was right.
1. Global responsibility:  There are no incentives for either governments or corporations to be socially responsible.  They will not. A few isolated examples, but generally no.
2. Consumer awareness.  Has reached its peak.  Certainly in healthcare, further attempts to better inform consumers will fail, partly because most patients are incapable of understanding and partly because they don’t care.
3. Globalization.   No one will talk about this in ten years.  No book titles.  No speeches.
4. Rate of change.  Will slow to a snail’s pace.  We may see expansion of wireless networks to broad geographic areas, but it will be the same Internet.  Lots of refinements of gadgets--better iPads--but nothing innovative.
5. Workforce.  Wages will fall, mostly by a drop in benefits, particularly health insurance and retirement.  Healthcare and technology will be the biggest employers, but unemployment will not be much different from today.  The Very Rich will emerge as a distinct class of World Citizens without allegiance to any country.  The gap between the Very Rich and the rest of us will widen.
6. Aging.  The 70 to 90 year old group will become the new middle class. They have money to spend and time to spend it, in modest amounts.  The health in this group will improve, and the time between sick and dying will shorten.  Suicide will become a more common cause of death.
7. Quality will decline in relevance as a buzzword.  In healthcare, quality will come to mean compliance to standards set by government committees or think tanks.

Maybe the world did end yesterday, and I just missed it.  Catch you in 2012.

Leadership in Healthcare

On reviewing Paul Borawski's writing about ideas for education, I looked for common themes--some high level principle that could apply to healthcare also.  I came away with leadership.  Every organization needs a strong leader--someone to point the way and inspire the troops to follow.  This is true for education, and it is also true for healthcare. 
Why?  What do leaders do, and how is that different from managers or supervisors? There is even a Journal of Leadership in Health Services.  Leaders should be visionary and determine the best direction for the organization.  Take charge and accept responsibility.  General George Patton is quoted as saying, "Tell the troops what you want done, but don't tell them how to do it.  They will amaze you with their ingenuity." 

Managers, by contrast, make it happen.  They marshal resources, assign tasks, monitor progress, etc.  Also needed, but a different focus.  supervisors make sure everyone comes to work and has the tools to perform their assigned tasks. 

So, what about healthcare? Taking the hospital as the prototypical example, healthcare organizations use a matrix organizational structure.  This works best in project oriented environments where a given employee may work on different projects sequentially and there is some advantage to sharing lessons learned with others in the same discipline or carry knowledge from one part of the organization to another.  The disadvantage with matrix structures is the confusion that comes with having multiple bosses and the fact that no one is ever in charge of anything.  I remember the chief of the surgery clinic at the University of MI saying one day, "I'm supposed to be in charge of this clinic, but no one here works for me." 

When no one is in charge, no one takes responsibility for what happens.  My wife and I were waitting in a pre-op area, when she noticed a nurse putting paper into a red-bag trash can.  She had heard me talk about the relative costs of red and white trash, so she knew this was wrong.  "Why is she doing that?"  The simple answer was that no one cared.  No one was responsible for that area.  No one's annual bonus depended on the efficient operation of day surgery.  So they put non-hazardous trash into the red bag and paid dollars per pound instead of putting it into the white bag that cost dollars per ton.

This is a major problem with healthcare today.  No one is in charge.  Institutions and sections within institutions are allowed to operate inefficiently, because there is no leader to stress efficiency and cost saving as a goal.  To some extent, the above examples could be explained by the lack of a profit motive in most large hospitals.  A moment's thought, however, will dispel that thought.  What's your favorite airline?  Least favorite?  Why?  Where do the employees of the best airline get their attitude?  Out their thumbs?  Are they born that way?  I was strolling up and down the corridors at Dulles airport recently, waiting for my flight, when I heard cheering and applause at a gate ahead of me.  I thought it must be some group charter, but as I got closer I could see that it was just a routine Southwest Airlines flight.  No one cheered at the Lufthansa gate.  Someone up the food chain set the tone for those employees.  That's leadership.

We recently returned from a cruise where a daily activity was getting people off the ship and on to buses on shore.  One group of employees assigned bus numbers for various tours.  The security group checked passengers off the ship.  Another group drove the tenders to the dock.  I'll let you imagine the chaos that ensued when these groups didn't talk to each other.  Leadership.  Someone needed to be in charge.  Responsible.

This is not to say that chaining the organizational structure of healthcare institutions and assigning leaders would solve all the problems.  Leaders don't always make wise decisions.  However, if we determined a new direction that would solve problems, we would have a mechanism for instituting those changes--a single, responsible individual in charge. 

Leadership in education, and leadership in healthcare.