Monthly Archives: June 2013

Quality, Evidence and Avedis Donabedian

Quality is the holy grail of health care.  In the United States an entire industry of health care quality has been created.  Unquestionably, some of these health care quality initiatives have resulted in better patient care.  However, one has to question the overall return on investment of the health care quality initiatives over the last decade.  We invest an enormous amount of resources in improving healthcare quality but if the return on investment is poor the opportunity cost is enormous.  The resources could be better utilized elsewhere.  If the current health care quality initiatives have not resulted in great improvement why not?  Sometimes a dangerous discussion to have.  Often those who have the audacity to challenge a health care quality initiative are perceived as uncaring dinosaurs and dullards who just want to maintain the status quo when in reality most of the time just the opposite is true.  The current establishment of health care quality and patient safety does not encourage challenges.  If the assumption that the current health care quality industry is significantly under performing then what are the possible explanations?

First, there is an incredible drive in the health care quality industry to do something rather than something meaningful.  A 2007 publication entitled “The Tension between Needing to Improve Care and Knowing How to Do It” appeared in the New England Journal of Medicine.  The author’s main message was that in the field of health care quality and patient safety the focus is often on haste and action rather than evidence.  They outline and review the dangers of this approach.  Health care quality and patient safety is such an important field so why shouldn’t initiatives be held to the same evidence based standards as therapeutic interventions.  They mention that medical errors are the eight leading cause of death in this country but we don’t apply evidence based criteria to qualit yand patient safety as we do for treating the first seven leading causes of death.  Haste over data.

A second, and possibly more important, reason that the health care quality industry is underperforming is the complete absence of discussion of the human factor.  Avedis Donabedian was a physician and is considered the originator of modern health care quality research.  In 1966 he published a paper entitled “Evaluating the Quality of Medical Care.”  Donabedian is credited with deriving the “structure-process-outcomes” model of health care quality research.  He had a long and distinguished career and essentially established the foundations of health care quality.  Donabedian was also a true scholar and thinker.  Toward the end of his career he said:

“Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession.  If you have love, you can then work backward to monitor and improve the system.”

Donabedian, after a career of research on systems and operations realized that an organization’s success is mostly about the people and the culture in which they work.  There is no structure or process that can prevent bad things from happening when the people factor is bad.  Alternatively, good people with a love for their work can overcome bad structure and process.

How can physicians love their patients and their profession in the current environment when everyone is an adversary?  How can physicians enjoy their work when there are legions of people, who themselves have never practiced Medicine, telling them how to do things better?  These same people add nothing to the quality of the care.  They just encourage everyone to generate more utilization at a lower cost.  That is the only training they have and that is what they are hired to do.

The successful health care system of the future will create the environment and culture where providers can love their patient and their profession.  The first step will be restoring the practice of Medicine to a profession and establishing a culture of caring.  All else will then fall into place.

Heart, Brains and Courage

The health care system in the U.S. is in the process of change.  While it took the economic reality to drive change the system can also be described as dysfunctional in many dimensions.  Hopefully we can finally get this right.  Any meaningful improvement in health care will require the involved stakeholders (patients, providers and payers) to completely disconnect from the current disastrous steady state.  The changes need to be as deep as they are wide.  The Institute of Medicine recently published “Best Care at Lower Cost. The Path to Continuously Learning Health Care in America.”  The authors note that professionals in health care are “overwhelmed” by initiatives to improve care and that any initiative that focuses on incremental improvement and adds to a clinician’s daily work load are unlikely to succeed.  The expert authors suggest transformational change.  We need to transform health care beginning with a foundation that focuses first and foremost on the relationship between a patient in need of health care services and the professional who provides those services.  It needs to be a ground up, not top down, restructuring.

At a recent meeting of an organization that is in the process of assembling an integrated delivery system a leader mentioned that he was receiving calls from around the country to see how he is going to do it.    Those in leadership positions at other organizations are aware that change is inevitable and want to learn from the brave in the front of the line.  If the plan is simply to improve operating margins by 5% via aggressive pursuit of efficiencies the calls will stop and the callers will look elsewhere.  They are looking for innovations.

When something has been so bad and dysfunctional for so long you could argue that it is even beyond a transformation.  It may be best to just CTRL-ALT-DEL health care and start over fresh with a new vision.  Thus, it may be advantageous to be building something new.

Health care now needs leaders who have:  (1) the heart to acknowledge that this is a service that a civilized society can and should provide to all citizens at some basic level, (2) the brains to devise a new system, and (3) the courage to implement the new changes in the face of multiple special interest groups that have only self-serving interests.

The Culture Argument

No one is making the culture argument.

Fundamental, sustainable and meaningful change in the health care system isn’t going to be achieved by new policy or operational initiatives.  No, the more important changes that need to occur involve a transformation of how all involved think about their role in the system.  All stakeholders (patients, providers and insurers) need to reassess and redefine their values and norms.  This is the culture argument and it has been absent in most, if not all, discussion regarding health care reform.

The absence of cultural transformation in the health care debate is understandable in that it is a concept that is difficult to define and/or measure and even more difficult to create and/or change.  But the importance of culture to the success of an organization, or in this case an entire industry, has been well documented.  Peter Drucker, a legendary management consultant, is credited with the saying: “Culture eats strategy for lunch”.

Why is culture so important?  It provides clarity and focus.  It allows for efforts to be aligned and directed to a common goal.  In addition, the values and norms of a group’s culture lead to the actions and behaviors of the group.  People are empowered to act in accordance with the culture.  There is less policy driven micromanagement.  It allows an organization to be less “top-heavy”.

A management professional once said: “You can get a sense of an organization’s culture based on what people are talking about”.   If this is true then there is a lot of work to do in health care.  While there has been a significant amount of discussion about quality and value in health care from outside the industry the talk inside is still for the most part focused on the same old nonsense.  The discussions are still focused on generating as much output as possible at the greatest level of efficiency.  This culture of utilization at the greatest possible efficiency (i.e. the corporate model of medicine) has been one of the main reasons that we now have a crisis.

For those interested in creating the successful health care organization of the future developing a culture of quality and value is imperative.  While this may seem a less tangible goal then optimizing a balance sheet it is absolutely crucial to success.  Everyone in the organization must understand that quality and value take precedent over all other issues and everyone in the organization must be empowered to act and innovate toward quality and value.

Once all energies are focused on a culture of quality and value then the next challenge is to have the culture generate strategies and operations that result in a functional health care system.   For the few who do currently talk quality and value this has also been a challenge.  Admittedly it is easy to talk about a culture of quality and value but to create the working model is more difficult but an absolute necessity.