5 Thoughts on Quality for a Value Based World
By: Mischa Dick
Any discussion about quality, particularly in the context of value based healthcare, may as well begin with the famous Yogi Berra quote of “It's like déjà vu all over again”. Quality has been a much misunderstood concept since its inception of becoming a dedicated discipline in the 1920s, and in many cases, it has been reduced to an initiative, closely associated with technical tools, taught in training classes. It is, or should be, a comprehensive business component. Healthcare is following in the footsteps of many other industries that have gone through major change, and many have endured over a decade of difficult times before emerging with new business models fit to deliver given their new reality. In many ways, healthcare leaders can chose to learn from the mistake of others, and avoid prolonged pain and economic distress. The understanding of quality in a comprehensive way, by leadership, has been proven to be an enabler of value based delivery, and this will undoubtedly hold true in the migration of healthcare to new business models. Below, in 5 key points, we explore some thoughts regarding quality from a leadership perspective:
(Disclaimer for the reader: It is impossible to do the topic of quality justice in a short blog, these are merely some initial thoughts on the subject worthy of much more discussion):
- Quality delivers financial results immediately
We struggle to put financials first, and only do so to address the biggest barrier preventing most organizations from embarking on the journey of redefining quality for themselves. The typical argument is as old as the concept, money is tight, and budgets do not allow for spending additional funds on extra programs such as quality. This thought process is fundamentally flawed, and this been proven time and time again. First, quality should never be viewed as a program, more on that below. Second, in most organizations, particularly in healthcare, processes are often poorly designed and operated, leading to wasted effort by double checking others’ work, correcting errors made in other areas of the process, and plain mistrusting the work of anyone that has gone before us, only to re-do all of it again. Quality processes in contrast are clearly defined, and have the control mechanisms in place to ensure that each process elements is completed exactly once, correctly, every time, or the process is not continued to the next step. By building and operating processes to this philosophy, costs are removed from the system, while improving outcomes immediately. Of course a key question is, just how much money and capacity is typically wasted in a healthcare process considered ‘good’ by today’s measures. In one examples recently, we were facilitating the re-design of a clinical process using principles of high quality processes. Over 40% of the effort (labor) spent by clinicians was ultimately wasted due to process quality issues, and to make matters worse, the existing process created unnecessary risks for patients. Re-designing the process not only increased the capacity, thus availing risk management to more patients, but it improved the patient experience and reduced procedure risks. As an added benefit, risks were better identified, leading to appropriate identification of co-morbidities leading to improved reimbursement. Another examples, in the administrative area can be found in revenue cycle operations. As much as 60% of the labor spend in revenue cycles is directly associated with process quality failures, leading to rework across all functional areas. When mapping out ‘rework’ loops in the operation, the picture below emerges:
Revenue Cycle Process with Rework Loops Prior to Process Re-design
Contrast this visual with a revenue cycle that has taken quality to heart and implemented a quality focused philosophy of doing business, depicted below. The contrast is staggering, and creates the capacity to improve cash flow by 6% year over year.
Revenue Cycle Process after Process Re-design
In summary, quality is a positive cash flow and net income driver.
- No quality, no mission
Concern for patients, and quality outcomes, have always been at the forefront of the individual mindsets of clinicians. Clinicians enter the field to fulfill a broader mission and ultimately want to serve their communities with all their might. The real issues is, that this core desire is often hindered by antiquated structures, processes and organizational constraints, and now IT system barriers making true high quality delivery challenging at best. As Dr. Deming pointed out decades ago, quality is determined at the top, leadership is responsible for creating a system within which individuals are able to deliver quality outcomes. The old argument that extrinsic and monetary incentives are all that it takes to create an environment that delivers quality outcomes has been debunked time and time again, and this is particularly true in the healthcare environment. Monetary compensation methods are only one ingredient. Systems thinking, and bringing the philosophies, methodologies and tools to the healthcare environment to create systems to drive quality outcomes is a top leadership responsibility. The examples of system design issues to deliver to the mission are plentiful in many organizations. A short list would be distrustful relationships between physicians and administration (Clinicians versus “The Suits”), a cast system among clinical personnel (Physician, Mid-Levels, Nurses, Nursing Assistants, and Orderlies), lack of good measurement systems for clinical outcomes, a mercenary mindset among fractions of the staff (“If I don’t get my way here, I will take my patients somewhere else”). Ignoring the barriers to true quality, at the system level, is doing injustice to the mission of providing the best possible care at the lowest possible cost to the community.
- Quality is a far reaching strategy element, not an initiative
Quality, in some organizations, has been relegated to the initiatives list, delegated to the Quality department. In that lackluster definition, quality is merely a set of tools, applied by dedicated personnel, to small projects. Quality, if seen as a strategic enabler, is far reaching, and the moves that must be made to ensure success require the highest organizational pay grade to be fully involved. Step one will invariably be a comprehensive review of organizational structures, measures and scorecards, and compensation methods. Once these areas are addressed, the next step can be taken, which is the creation of the quality execution plan. This plan is not stand alone, but part of the comprehensive business strategy. It is a carefully orchestrated action plan, implemented not only along the lines of business criticality but cultural and technical absorption ability. Once the areas of attack are identified, they are addressed with full participation of the work force, supplemented by quality experts, typically from the outside, with fresh views, in a facilitative role. Tools should be brought to bear, and taught, as part of the change process, not as stand-alone training. It is imperative that those actually doing the work have a hand in designing the quality systems and process, as only this approach creates the best possible process and ownership of the solution. Leadership must support the change mostly by being present throughout the change and by lending support, versus providing content advice, to the effort.
- Quality must be nurtured to be an organizational mind set
Quality is comprehensive, and has many facets, but none are more important than the mindset. Any number of tools or projects will not succeed in the long term, unless value, and quality, are an integral part of the organizational DNA, part of all thought processes. This is arguable the most difficult part of creating a quality based organization, and it is also the reason why top leadership engagement is so critical. Unfortunately in many organizations, quality issues are seen as individual failures, not system and mindset failures. Quality impacts all patient interactions and workflows, to name a few: Is the diagnostic quality sufficient given the situation? Is the procedural process mistake proofed? Is the documentation clear and precise to avoid misinterpretation? Are communication protocols designed to minimize errors? Are errors unacceptable and must lead to process change? A quality mindset has to be built over time, and leadership plays a role in creating the structures that support the creation of a quality mind set. As one example, shift briefing or huddles are used in most clinical operations. The question is, are they optimized to change the thought processes of the participants over time? Are they empowering participants to change system elements to enable the best possible outcomes, or are they merely transactional meetings?
- Tools simply support the organizational mindset of quality, they are not a means onto themselves
Tools associated with quality often get center stage when it comes to quality efforts. Tools are simply the enablers to building quality operations, taken out of the bag as the need arises. Certainly, basic structures must be laid in place to begin the journey of becoming a true quality organization, but after this kick starter, tools should be used by anyone, as appropriate, to address an immediate issue at hand. A quality organization can simply not be created through the distribution of tools, it requires leadership involvement at the system and structural level.
Dr. Deming was one of the key contributors to laying the foundation of Quality Management many decades ago, and he outlined his thoughts in the famous 14 Points on Total Quality Management. His first critical point is, “Create constancy of purpose for improving products and services”. There is no industry in the world that should be more clear and united in its purpose, and there is no industry in the world where quality matters more. It is time to rethink quality comprehensively, as a leadership job.