High Performance Health Care

By Dan McLaughlin

Many industry and governmental leaders have advocated for the greater use of information technology in the health care delivery system. Many providers are making large capital expenditures to acquire and install these systems today.

However the results of the use of these systems are mixed. I was recently teaching operations management to students in our Mini MBA for Health Care Management and I asked for a show of hands on how many of my students had installed an Electronic Health Record in their organization. About half of the class raised their hands. I then asked how many thought it had improved their productivity. No hands were raised.

However, a recent article in Health Affairs outlines some of the key organizational elements and approaches necessary to effectively use the powerful tools of health information technology.(1)

The Geisinger model
The Geisinger health system is an integrated delivery system located in central and northeastern Pennsylvania with 700 employed physicians. Because Geisinger has used an integrated electronic health record since 1995 they have become skilled in its use as the basis for significant improvements in the care delivered to their patients.

Two key elements are required for this success. First, the care system is integrated across 22 clinical service lines with leadership provided by physician/administrator pairs. Secondly, the electronic health record is accessible throughout the system by Geisinger employees and physicians, affiliated physicians and patients themselves

Innovation and improvement
Geisinger’s approach to improvement and innovation involves four important steps:

1. A highly collaborative team is formed to address a problem which involves clinicians, operational and financial staff, payers and, frequently, patients.

2. Targets for improvement are identified based on specific criteria such as impact, unjustified variance, best practice guidelines availability, clinical interest from patients or outcomes farthest from expected clinical performance.

3. A clinical business case is next determined by examining clinical evidence, workflows, financial incentives, regulatory and safety requirements and the anticipated financial impact.

4. Finally, Lean and Six Sigma tools are applied to define and improve the process. Geisinger puts special emphasis on creating reusable components (human processes, software technology and analytics).

Implications
Geisinger has used this approach very successfully to develop its medical home model of care, optimize chronic disease management and reduce costs while improving quality in acute care services.

Health information technology can be powerful tool when used in combination with disciplined management processes such as those employed by Geisinger. Unfortunately, the first requirement – an integrated system – will be a challenge for much of the health care system in the United States, where more than two-thirds of the physicians work in practices of 10 or fewer. (2) To significantly improve the performance of the American health care system, health reformers will need to find solutions to this key issue.

1. Paulus, Ronald, Davis, Karen, Steele, Glenn. Continuous Innovation in Health Care: Implications of the Geisinger Experience, Health Affairs, September-October 2008, 1235-1245

2. Schoenbaum, Stephen C, Physicians And Prepaid Group Practices, Health Affairs online, February 4, 2004

Click here for directions on obtaining academic article such as these.

Posted by Erica Lyons at 11:09 AM | Permalink | Comments (0)

By Dan McLaughlin

The structure for measuring and improving quality in the American health care system was pioneered by Avis Donabedian in 1966. He was one of the first researchers to view healthcare as a system composed of structure, process and outcomes.(1) This viewpoint of quality persists to this day and many unique organizations have been created to assure quality within this framework (e.g. Joint Commission and NCQA).

However, even as these organizations matured and their standards were adopted by the health care community, the quality movement was growing internationally in other industries. In 1987 the International Standards Organization created the ISO 9000 series of standards, which assures that goods or services purchased from an organization meets internationally accepted standards for quality.

ISO in Health Care
In the interest of improving the quality of health care and reducing or maintaining costs, many automotive manufacturers have begun to require that their health care providers be ISO 9001 certified. Driven by this, ISO developed guidelines for implementing ISO 9001:2000 quality management systems in the health care sector, IWA 1, Quality Management Systems - Guidelines for process improvements in health service organization.

The ISO standards require an organization to prove that they are following their own quality processes uniformly. ISO 9001:2000 focuses strongly on progress and outcomes and very little on structure, which distinguishes it from the traditional health care quality accreditation process in place in the United States today.

Medicare, Quality and ISO
Since the advent of the Medicare program, hospitals needed to be accredited in order to assure the taxpayer that quality care was being delivered. Medicare would either inspect hospitals themselves or let the Joint Commission do so, then provide the hospital with accreditation as “deemed status.”

Recently the Centers for Medicare and Medicaid Services have announced that other organizations can now provide deemed status using the ISO 9001 framework. Interestingly, the first company to do so is a Norwegian (DNV) company that has already surveyed and approved a U.S. hospital.

Implications for Health Care Quality in the United States
The traditional quality assurance organizations in this country have always felt that health care was “different” and needed different systems, but the world is starting to prove this assumption false. Just as medical tourism will impact many U.S. providers, the way we measure and reward quality will clearly be held to international standards in the future.

Dr. James Levett, a surgeon from Cedar Rapids, Iowa, was a participant in our Mini MBA for Health Care Management in 2002. At that time he said he was in the process of getting his clinic ISO certified. He did and has published a very useful article about his experiences.(2) At the time, I thought this pursuit to be a bit odd, but Dr. Levett was clearly ahead of the curve. Now his clinic is one of the leaders in Iowa – and the world.

References:
1. Donabedian, Avis, 1966. "Evaluating the Quality of Medical Care." Milbank
Memorial Fund Quarterly 44 (3): 166-206.

2. Levett, James M. “Implementing an ISO 9001 Quality Management System in a
Multispecialty clinic, Physician Executive, November-December 2005: 46-51.

Click here for directions on obtaining academic article such as these.

Posted by Erica Lyons at 09:40 AM | Permalink | Comments (1)

Checklists save lives. With the all the technology available today in the health care system it seems amazing that this simple tool is only now beginning to be deployed after it has been clearly demonstrated that it can have an incredible impact on patient safety and quality of care.

Central Line Infections
In December 2007, Dr. Atul Gawande published an inspirational article in the New Yorker; “The Checklist - If something so simple can transform intensive care, what else can it do?”He told the story of a critical-care physician at Johns Hopkins Hospital named Peter Pronovost who decided to try to eliminate deaths related to the use of central line catheters.

Often referred to as central venous catheters, central line catheters are tubes placed into a large vein in a patient's neck, chest or groin to administer medication or fluids or to collect blood samples. Each year, an estimated 250,000 cases of central line-associated bloodstream infections occur in hospitals in the United States, and an estimated 30,000 to 62,000 patients who get the infections die as a result, according to the Centers for Disease Control and Prevention.

When inserting central line catheters, doctors are supposed to
1. wash their hands with soap,
2. clean the patient's skin with chlorhexidine antiseptic,
3. put sterile drapes over the entire patient,
4. wear a sterile mask, hat, gown, and gloves,
5. and put a sterile dressing over the catheter site once the line is in.

These steps are accepted practice and have been known and taught for years. However, when Dr. Pronovost initially measured their use by ICU doctors he observed that they skipped one or more steps in more than a third of their patients.

Installing the checklist
After instituting the use of a checklist for these five steps, Pronovost and his colleagues monitored what happened for a year afterward. The results were dramatic: the 10-day line-infection rate went from 11 percent to zero. They followed their patients for 15 more months and only two line infections occurred during the entire period. In this one hospital, the checklist had prevented 43 infections and 8 deaths and saved $2 million in costs.

New Federal Support
Recently, the Agency for Healthcare Research and Quality (AHRQ) has recognized this pioneering work and allocated nearly $3 million for a project to help reduce central line-associated bloodstream infections in hospital intensive care units (ICUs.)

The project will continue the work started by the Johns Hopkins University in Baltimore and the Michigan Health & Hospital Association to implement comprehensive unit-based patient safety program to help prevent infections related to the use of central line catheters. The Health Research & Educational Trust, an affiliate of the American Hospital Association, has been selected to coordinate the new three-year project, which is part of an AHRQ initiative to reduce health care-associated infections. They will implement this procedure in 100 hospitals throughout the nation.

Six Sigma and High Performance Health Care
The science of operations management contains many highly validated tools to improve quality, reduce waste and, most importantly, improve safety. The checklist is one of the seven primary tools of the Six Sigma quality methodology that was developed by Shewert, Deming and Juran in the 1930s and 1940s. Six Sigma was adopted by Motorola and GE and spread rapidly to many other organizations. It is now part of the performance improvement programs within progressive health care organizations. (The other tools are fishbone diagrams, flowcharts, Pareto charts, histograms, scatter plots and run charts – learn about them in our Six Sigma Green Belt programs.)

We teach these tools in the degree and professional development programs within the Opus College of Business. The projects our students conduct in their own health care delivery organizations yield remarkable results. However, our educational boat is small and the ocean of other health system challenges large. The ability to spread this knowledge of tools like the checklist, and to apply them broadly, is the real challenge for progress in the American health care system of tomorrow.

Posted by Dan McLaughlin at 04:33 PM | Permalink | Comments (1)