The Quality Improvement Challenge. Richard J. Banchs
litigation, have eroded patients’ trust in the healthcare system.
The current crisis isn’t new. It has evolved over the last 30 years to the current level of intensity that we now face and can no longer ignore. Reports including the Institute of Medicine’s “To Err Is Human” (Kohn 2000), “Crossing the Quality Chasm” (IOM 2001), and “Transforming Healthcare: A Safety Imperative” (Leape 2009) have highlighted the inability of the healthcare system to reliably provide safe, high quality, cost‐effective patient care. The crisis has deepened by rising expectations of patients who are accustomed to a retail setting, where services are customer‐driven, efficient, and accessible 24/7 through mobile connectivity, and are demanding the same from healthcare. A true “patient‐to‐consumer revolution” (Wyman 2014) is demanding increased access, service, personalization, and speed from a healthcare system that is slow, inconvenient, confusing and difficult to navigate. Competition among healthcare organizations is no longer based solely on reputation, but on service, value, and price.
In this environment, healthcare organizations face a significant pressure to provide high‐quality, state‐of‐the‐art patient care while lowering costs and improving patients’ care experiences. These demands exist in the context of heightened accreditation requirements, uncertain governmental mandates, decreasing reimbursement, and overwhelmed clinicians and administrators. The negative results are experienced by both patients and healthcare professionals.
HOW DID WE GET HERE?
Many factors have contributed to the current state of affairs and the inability of healthcare to reliably deliver safe, high‐quality, cost‐effective patient care. Worth mentioning is an out‐of‐date business model, healthcare’s organizations’ inefficient organizational structure, the traditional quality paradigm, and an ineffective physician compensation model.
The business model. Healthcare organizations have been anchored in a business model that may have been successful in the past but has outlasted the circumstances that created the need for it. Despite the needs of the current marketplace, healthcare organizations have continued to focus on providing a full spectrum of healthcare services, that is, all services to all patients. Clayton Christensen in his book The Innovator’s Prescription (Christensen 2009) describes two types of business models that any organization can follow: a solution shop, where a healthcare organization focuses on diagnostic activities, and a value‐adding process where the focus is on the efficient delivery of care and specific treatments. Christensen argues that these two models are different, and they require different resources, processes, organizational structures, and profit models. With the current technological and scientific progress, healthcare challenges, and diversity of needs, trying to provide all services to all patients is the wrong value proposition. The combination of these two models under one roof creates a system that requires an enormous amount of resources, and results in inefficiencies, waste, and duplication of efforts. It creates a system that functions, as Michael Porter describes, as a “confederation of stand‐alone units that replicate services” (Porter 2016). For every dollar spent, a reported 30 cents are wasted in steps that do not add value, the result of excessive bureaucracy, defensive medicine, and duplication of services.
Organizational structure. Healthcare organizations have customarily been organized according to clinical specialties. While this originally arose from the need to maintain the competency of clinicians to deliver high‐quality care, this structure has created clinical silos that have resulted in fragmented care and dysfuntional workflow across the healthcare organization. Rather than organizing care around specialty departments and special services, care should be organized around medical conditions with multiple subspecialties and teams converging on the specific patient condition. In the current system, effective synchronization, collaboration, and communication are often not present and are more often than not the cause of rework, mistakes, complications, and wasteful spending.
The quality paradigm. In the traditional quality paradigm, quality was defined by the provider and by the effectiveness of care. In this view, quality is achieved when the right treatment is administered in response to a specific recognizable pattern, and results in the elimination of the disease condition. This long‐held view of quality ignored additional dimensions of quality care, such as the need for efficiency, timeliness, and patient‐centeredness (IOM 2001). Focusing only on effective care resulted in a healthcare experience that fell short of patients’ expectations. The traditional quality paradigm, a lack of oversight, and the inability of physicians to regulate their own profession has had a significant impact on the quality of care. As a result, we have seen unethical practices, high rates of patient injuries, and injustices in the ability to access care (Berwick 2016).
The physician compensation model. Incentives for payment have been completely misaligned with the goals of improving the quality of care. Providers and healthcare organizations have been paid for number of procedures performed (volume‐driven payment) rather than for the outcome and quality of care (value‐driven payment). This has resulted in excessive and unnecessary procedures, overly used diagnostic services, increased insurance premiums, and procedure‐related complications.
THE CHALLENGES TO IMPROVE HEALTHCARE
Efforts to improve the quality of care have focused on performance metrics, complex incentive formulas, and increased scrutiny from regulatory agencies. These and other measures have not addressed the real problem and, for the most part, have not significantly improved the quality of care. Patients continue to be disappointed with the healthcare experience, and staff and providers are getting increasingly burned out from the overwhelming day‐to‐day administrative burden. There is a generalized frustration among providers working in a system that is inefficient, overcomplicated, and seemingly at odds with the mission of providing high‐quality care. Despite significant efforts to improve, we have not achieved our goals. Accountability based on metrics developed by outsiders has failed to engage physicians, and too much of the efforts of healthcare organizations is spent on submitting reports, preparing for accreditation surveys, and ensuring adherence to regulatory mandates. Meeting the objectives of specific organizational metrics has become an all‐consuming activity, rather than developing a strategic and comprehensive improvement agenda. There is no question that the work involved to ensure survey readiness and regulation compliance is important, but too much effort is directed at achieving core measure targets and not enough on system redesign. By prioritizing improvement initiatives that address the underlying processes related to the regulatory compliance and core measure targets, we could address both regulatory mandates and improve the healthcare experience.
Quotable quote: “We are faced with a series of great opportunities brilliantly disguised as insoluble problems.” John W Gardner
Healthcare organizations continue to invest resources to improve the delivery of care but face unique challenges that impact the effectiveness of the improvement efforts they pursue. Process improvement is not easy, and it requires a clear understanding of the barriers:
The culture. The primary role of a healthcare organization is to provide care to patients, a high‐stakes undertaking that may exacerbate patients’ clinical conditions if errors occur. As a result, healthcare professionals are risk averse, conservative, and hesitant to try new things compared to other industries. When quality improvement (QI) teams and organizations try to implement changes, they often encounter a resistant culture that labors to maintain the status quo. Incongruously, providers and staff often resist the adoption of standards and other evidence‐based guidelines that support improved patient outcomes in favor of time‐honored, and sometimes outdated, traditional approaches to patient care.
Silos. Improvement initiatives are difficult in healthcare organizations unaccustomed to leveraging teamwork across silos to accomplish their goals. Silos not only exist within the clinical specialties but also exist between the clinical and the operational areas in healthcare organizations. These silos often cut from the top of the organization down to the front line staff members. They impact the effectiveness of any improvement initiative, ultimately leading to a fragmented