High Performance Health Care

As health reform progresses, stakeholders are reaching consensus on needed changes in the system that would clearly improve quality and reduce costs. High on this list is the much wider use of evidence based medicine accompanied by contemporary process improvement tools such as informatics, lean and six sigma. It also includes the expansion in the number of primary care physicians. However, progress on this path may not be as rapid as reformers would like and the reasons are complex and challenging.

For many years, some clinicians resisted evidence based medicine as “cook book” medicine. Thoughtful primary care practitioners have now begun to express other reservations. In a recent Health Affairs blog posting on the medical home Dr. Caroline Poplin predicts:

Reformers hope that the patient-centered medical home will quickly transition to the real goal, the “accountable health care organization,” paid by capitation and run by professional managers. At the bottom of these organizations will be the people who see patients. And the goal will be to see as many as efficiently — which is to say, as fast — as possible. Inside the organization, this is no longer wasteful volume; it is valuable “productivity.” In place of the twentieth-century conveyor belt, we will have EMRs linking the workers at the various stations, including the physicians. Each patient will appear with all the data, well-organized with appropriate prompts, that the physician or other provider needs for rapid diagnosis and treatment, so she can direct the patient quickly to the next station: pharmacy, physical therapy, whatever. At the end will be quality control; frequent reviews of how well the providers meet their performance, productivity, and customer satisfaction targets; and appropriate rewards and punishments. And at the top will be the “experts,” who are accountable to no one.

She predicts this standardized, non-professional environment will create an even larger barrier for medical school students to choose a career in primary care.

This conflict of standard work verses professionalism and innovation has also been an historic argument in the field of operations management. A 2008 Academy of Management meeting was devoted to this subject. Adler and colleagues summarized the debate at the meeting:

For more than a century, operations researchers have recognized that organizations can increase efficiency by adhering strictly to proven process templates, thereby rendering operations more stable and predictable. For several decades, researchers have also recognized that these efficiency gains can impose heavy costs. The capabilities that enable consistent execution can also hinder learning and innovation, leaving organizations rigid and inflexible. Many once-successful organizations collapse when they prove unable to adapt to environmental shifts. By optimizing their processes for maximum efficiency in the short term, organizations become brittle.

This brittleness is due to routinization which enables organizations to exploit their accumulated knowledge, increasing efficiency. However, routinization creates a risk: when organizations are guided by old knowledge, they do not create new knowledge. If the environment has changed, the locations of shortcuts and dead-ends may have shifted and more attractive destinations may have appeared or become accessible. To adapt to environmental changes, organizations must seek out new knowledge. Without new knowledge organizations cannot innovate and adapt to changing conditions.

For those of us who believe that there are immense opportunities for process improvement, quality gains and lower costs in today’s health care systems these cautions are important to note and understand. Moving forward will be challenging, but move we must.

References
Adler Paul S. 2009. "Perspectives on the Productivity Dilemma." Journal of Operations Management 27(2): 99.

Posted by Dan McLaughlin at 10:21 AM | Permalink | Comments (0)

Since 2002, the United States Department of Commerce has awarded a special Malcolm Baldrige award for performance excellence in health care.

Health care organizations applying for this award must demonstrate high performance in the following categories:

1. Leadership
2. Strategic Planning
3. Customer Focus
4. Measurement, Analysis, and Knowledge Management
5. Workforce Focus
6. Process Management
7. Results

In a recent article in the Journal of Healthcare Management, John Griffith at the University of Michigan reviewed the ongoing performance of winners of the award since 2005. This included a varied set of 34 community hospitals in nine states.

The results were stunning. Baldrige award winners showed continuing top performance in quality benchmarks, patient and customer satisfaction, financial stability, worker satisfaction and retention, physician satisfaction, and efficiency and cost control. In many of these categories the hospitals scored in the top 10 percent of performance in the country.

Griffith determined that these hospitals met and exceeded the Baldrige criteria through a:

- strong emphasis on mission, vision and values
- responsive leadership and worker engagement
- disciplined strategic planning and execution
- patient, customer and health care market knowledge management
- measurement, analysis and improvement of performance
- workforce focus for stable and enthusiastic employees

Unfortunately, the implementation of quality improvement in health care has often been delegated to a “quality department.” The Baldrige award winners demonstrate that by having an entire organization committed to quality, outstanding results can be achieved. Hopefully, many more organizations will seek to restructure their operations to meet the Baldrige criteria and thereby achieve high performance health care.

References
Griffith, J. R. 2009. Finding the Frontier of Hospital Management. Journal of Healthcare Management.

Posted by Dan McLaughlin at 01:24 PM | Permalink | Comments (0)

In this post we will revisit some of the basic systems principles that underlie the functioning of the health care system today. To make effective change in any portion of this very complex system, the interactions of its parts must be understood.

There are five basic principles of an effectively operating system:

1. A system is greater than the sum of its parts and requires investigation of the whole situation rather than individual parts of the system.
2. Though each sub-system is a self-contained unit, it is part of a wider entity.
3. Every system is an information system and must be analyzed in terms of how suitable information is transmitted between units.
4. Open systems means high interaction with and between the system and its environment.
5. The purpose of the sub-systems must be aligned with the purpose of the system as a whole.

General Systems Theory
A primary developer of the concepts for general systems thinking is Russell Ackoff. His criteria for working with a system:

1. Systems are democratic organizations in which all voices should be heard and authority is collective.
2. Systems have an internal market economy where there are continued trade-offs among sub-sets of the system.
3. Systems are multidimensional structures designed by the allocation of resources.
4. Systems-based planning has to be interactive. Ends have to be clear before means are discussed.
5. Systems-based planning must have control systems in place to make the process manageable.

The Clinical System
The general systems thinking concept can be extended to health care. To improve health care operations, it is important to understand the systems that influence the delivery of care. Clinical care delivery is embedded in a series of interconnected systems (see figure).

The patient care microsystem is where the health care professional provides hands-on care. Elements of the clinical microsystem include:
• The team of health professionals who provide clinical care to the patient;
• The tools the team has to diagnose and treat the patient (e.g., imaging capabilities, lab tests, drugs); and
• The logic for determining the appropriate treatments and the processes to deliver this care.

Because common conditions (e.g., hypertension) affect a large number of patients, clinical research has determined the most effective way to treat these patients. Therefore, in many cases, the organization and functioning of the microsystem can be optimized.

The organizational infrastructure also influences the effective delivery of care to the patient. Ensuring that providers have the correct tools and skills is an important element of infrastructure. For example, the electronic health record is one of the most important advances in the clinical microsystem for both process improvement and the wider use of Evidence-based Medicine. Another key component of infrastructure is the leadership displayed by senior staff. Without leadership, effective progress or change will not occur.

Finally, the environment strongly influences the delivery of care. Key environmental factors include competition, government regulation, demographics and payer policies. An organization’s strategy is frequently influenced by such factors (e.g., a new regulation from Medicare, a new competitor).

Significant improvements in health care can be achieved when the change leaders base their strategy on both general and health care specific systems thinking.

(Additional information in this post provided by Dan McLaughlin)

References:
1. On Purposeful Systems: An Interdisciplinary Analysis of Individual and Social Behavior as a System of Purposeful Events (Paperback) by Russell Ackoff and Fred Emery, Aldine Transaction (2005).

2. Figure Source: Ransom 2005. Based on Ferlie, E., and S. M. Shortell. 2001. “Improving the Quality of Healthcare in the United Kingdom and the United States: A Framework for Change.” The Milbank Quarterly 79(2): 281–316.

3. McLaughlin and Hays, Healthcare Operations Management, Health Administration Press, 2008

Posted by Jack Militello at 11:03 AM | Permalink | Comments (0)