Tuesday, May 26, 2009

Planning for Quality

First, a note of sincere thanks to my colleague Dan Dunlop who, in his blog, recently offered far kinder words than I deserve for my sporadic efforts here at hcpropellerheads. To quote Hamlet’s Polonious, “Brevity is the soul of wit,” and Dan’s daily shots of idea-juice show he is a man of concentrated wit (and, possibly, reveal the “witless” nature of my long rambles…) with considerable chops to spark intense, thoughtful discussion. Thank you Dan for introducing your fans to this little project. I hope some of you find it intriguing and helpful.

I spent a lot of last week on airplanes and had the chance to catch up on some reading. One article I found particularly interesting appeared in a supplement to Health Affairs. The entire supplement is dedicated to “Value in Health Care” with some impressive minds providing interesting perspectives on the ubiquitous concept of “value.”

In, “Building Organizational Capacity: A Cornerstone of Health System Reform,” Janet Corrigan and Dwight McNeill from the National Quality Forum posit, “achieving higher levels of performance requires organizational capacity, including information technology and specialized expertise, not present in most settings.” While I could certainly go after this set-up (not today) I’d rather focus on a potentially inflammatory notion they put forth:

“[T]he health sector lacks the ability to bring these innovations [in quality of care systems] to scale; best practices in care delivery may take years, if not decades, to spread throughout an institution, much less the nation. Moreover, what we have not seen is fundamental reform in the delivery system aimed at the development of new organizational models capable of consistently providing effective, safe, and efficient care across each entire patient-focused episode.”

Now, fairly, Corrigan and McNeill can cite studies, like those spotlighted in Modern Healthcare recently, that suggest, despite decades of work, the delivery system struggles to make meaningful gains in quality and efficiency.

Before I proceed, a moment of full disclosure. The Joint Commission is a client of SPM’s and a client with whose work I am intimately involved. And, to quote the old adage, “where you stand depends on where you sit,” I also acknowledge that NQF, the Leapfrog Group, HealthGrades (authors of the two reports cited in the Modern Healthcare article) and The Joint Commission, all have biases and agendas that fuel their respective assertions. I get that. It’s out on the table, admitted. Now, let’s move on.

I have two points to make today. The first is, to say that broad, national progress on key measures of patient safety, quality and efficacy have not been realized and can’t be realized on a broad scale is simply not true. On The Joint Commission’s website you can view the 2008 Report on Quality and Safety. There you’ll see, perhaps self-servingly, that Joint Commission accredited hospitals deliver evidence-based treatment of heart attack 96% of the time – up from 87% in 2002. Further, with many National Patient Safety Goals, such as accurate patient identification, “read-backs” of orders and test results, reducing falls, and implementing the universal protocol, average national performance at Joint Commission accredited hospitals exceeds 95%.

Admittedly, The Joint Commission is an organization that has room for improvement. There is considerable debate about standards and how things like the universal protocol were developed and deployed. True. Fix it. But, to claim that little progress has been made, and that the system is incapable of making leading practice common practice nationwide is pure hyperbole. In my own, biased, opinion I believe The Joint Commission, for all its warts, has been and will continue to be the best catalyst for health system improvements in safety, quality and efficiency.

But, that’s not even my primary point for today. My second concern involves hospital/health system strategic planning and the right role of clinical improvement. Recently I was reviewing a hospital strategic plan for a fairly large (> 500 bed) institution. This particular plan, at first, reinforced a belief of mine that hospital strategic plans typically don’t get much beyond being budget justifications. This plan is much better than most (it included actual decisions on priorities) and, to be fair, acts like a business development plan more than a strategic plan. It outlines programs of excellence, investment, delivery system strategy and criteria for evaluating the future mix of services and programs (all things I love to see in a plan).

However, for all its specificity around target markets, services, programs and capabilities, the discussion around quality was vague. The plan calls for investment in IT and EMR as tools to aiding improvement, the development of new platforms to take a non-siloed approach to quality and patient safety improvement and greater transparency/accountability. Above I said, “at first” because my initial reaction was to be disappointed by the light treatment the issue of clinical practice of medicine received; especially when I read further on that attaining market leadership in patient safety, clinical and service quality are seen as key forces for market differentiation.

What I instinctively wanted to see was a conversation about things like Core Measures, National Patient Safety Goals, demonstrated best practices, evidence based medicine, etc. I later realized that, perhaps, the most important next step for this institution may be organizing better to attack specifics such as this. So, I cut them some slack.

However, that did fuel a question – should we expect/hope to see greater specificity in hospital/health system strategic plans around their pathway to clinical improvement? Just two weeks ago, providers promised the President they could shave $2 trillion over 10 years. “The crux of the plan is to merge more streamlined care and a focus on quality and efficiency with “common sense improvements.” One tenet urges the better coordination of care and adherence to evidence-based best practices. Another calls for better use of health information technology. The groups have wagered that such changes can greatly cut how much is spent each year on healthcare.”

I imagine proceeding down such a pathway – rightly – will require engaging a hospital’s medical and clinical staff in a way they have not before. It’s one thing to pay lip service to quality improvement in a strategic plan and then leave it to task forces and work groups to muddle through sufficiently to meet accreditation and payer standards. But to see actual, planned quality improvement, the kind places like Geisinger [full disclosure part II, also an SPM client] have been recognized for, is for my skeptical mind, a leap. Don’t get me wrong, I believe business development and strategic clinical quality improvement (and marketing communications strategy and brand development) all can and should walk hand in hand.

Are hospital leaders up to the task?


  1. Dan, Thanks for the thought provoking reflections in the blog. I observed a similarly thought provoking discussion about "the business case for quality" in a recent class at Loyola University. My "take away" from that discussion was that if there was a strong "business case for quality" for the institution, more institutions would focus on quality in their strategic plans -- perhaps in a way that would satisfy your criticism about the fuzziness of quality planning.

    That said, the students brought forth impressive arguments that quality initiatives can reduce expenditures -- current and future. By example, through relatively straightforward actions, we can avoid deep vein thrombosis and many of the complications of diabetes, resulting in great dollar savings. Unfortunately, there are two economic issues that may impede more rapid proliferation of programs to expedite implementation of these kinds of programs across the delivery system. First, those who implement the program are often not the financial beneficiaries of the the cost reductions due to the program. An institution can invest resources to reduce the complications of diabetes, but the savings are realized by the insurer or employer. Second, when incentives are in place to stimulate quality improvement, they are often too insignificant to justify the cost of implementation (plus a percent or two in reimbursement).

    There is a structural solution which is prominent in our health care system, but not in vogue. When the payer and the provider are one (e.g., Kaiser or Marshfield Clinic), the benefit of the cost reducing behavior (e.g., avoidance of complications of diabetes), is realized by the combined payer/provider entity. With incentives aligned, the quality initiative is more quickly implemented -- its the right thing to do and its the economically sound thing to do.

  2. Paul, thanks for the thoughtful post. I wonder, because the conversation is quite popular these days, about the, "business case for quality." I get the conversation, don't get me wrong, but...am I beeing to simplistic to wonder why "improving the quality of our product" isn't often an articulated strategy? I guess you could argue that investments in service line infrastructure, key recruitments, etc. are, in fact this said another way, and implicit in the core business of the provider is constant improvement.

    In the construct of, "what gets measured gets done" however, if it's not explicitly in the plan is it an explicit priority?

    Certainly for years GM and Chrysler implicitly set out to improve the quality of their vehicles, but I can't be certain that beyond sales and new model (and most certainly cost containment/management) did core product performance float to the top of their strategic checklist.

    Agreed on your point regarding the value of the integrated delivery system. Who knew we were on the right path in the 90's?

  3. I agree with the idea that quality should be included in any healthcare organizations strategic plan. Any organization's strategic plan should revolve around having a good quality product. Healthcare is no exception. To Paul's point hospitals in particular have little financial incentive to provide preventative care. Pay for performance addresses this issue somewhat but (again to Paul's point) has very little financial impact. Until performance is tide directly to finances is seems unlikely that many hospitals will have quality as the main focus in their strategic plan even though maybe they should.

    On a bit of a tangent:
    Having read the June 1st post which makes a strong case for the inevitability of universal healthcare and now looking at the comments here from Paul and Dan about integrated delivery systems it sounds like a good argument for a single payor universal healthcare system in which the payor also provides the care. In my mind the only payor that could feasibly also provide care would be the federal government (maybe Kaiser but then there is the problem of monopoly power). Is it believable that private insurers are going away? What would the implications be if they did? They represent a large economy and employee a lot of people.

    Is there a way to align payer and provider and maintain a multi-payer system? If there is a way, can that system provide universal coverage or will competition inevitably lead to exclusion or inequity? It seems to me that any multi-payer system that combine payer and provider would result in inequities in quality of care.

  4. Gordon, I believe there is a way to align payer and provider and maintain multi-payer system. Moreso, I think it's essential. A single-payer model has one tool of influence, a big regulatory hammer chained to payments. If you have children you know, "because I said so" is not the most enduring line of attack to get them enthusiastic about changing behavior.

    While I'd love to see a raging incrementalism approach (look through the archives for older posts if you're interested) it doesn't seem that will happen. So, we'll be fixing this thing in the field...sort of like Microsoft's approach to launching it's operating systems, where it takes a few years to get it to where it should have been out of the gun.

  5. Is there a "business case for quality"? I really struggled with this question. I could argue that ethically, socially and possibly economically there will always be a case for quality. But then the question became: why is there no business case for quality in healthcare?

    There is an abundance of literature citing clinical projects with improved patient outcomes and significant cost savings; simple interventions translating into great patient benefits. Why aren't we pursuing them? To echo other entry - why isn't quality at the forefront of the strategic planning? Why isn't the well-being of our patients the priority in care? Why are we comfortable providing sub-standard care for others but demand the highest quality for ourselves? Granted, there has been progress and we are in a state of constant improvement but what about the organizational culture? There are lots of references with respect to institutions creating a culture of safety, why not the culture of quality?

    As long as there are minimal financial incentives for practicing quality there will be delay in the implementation of any initiative. If the institutions are penalized for their lack of quality, they may have to assess cost/benefit of quality sooner - they may be forced to make a business case for quality healthcare.