Bolder-Dash Blog

Despite the focus on bedside safety, I don’t believe a next major improvement in healthcare will happen with another National Patient Safety Goal. As insightful as they are, they are missing the larger picture – and one to which each of us no doubt can relate. Rather, the next big improvement will result from a comprehensive integration and alignment of operations within and across the healthcare organization – proving that alas Structure does indeed lead to Process which influences Outcome. (Thank you Avedis Donabedian). Thankfully, such operational excellence is possible today – no, yesterday.

The challenge in healthcare is the much broader and deeper structural barriers. This explains the multiple attempts to improve processes and outcomes that fail after months of hard work.  Creating and maintaining  sustainable improvement often succumbs within the bureaucracy of the organization.  The organizational structure seems to be designed to inhibit change in favor of the status quo.  Therefore, the greater need for improvement is not with process and outcomes, but with structure.

For example, lasting solutions must include considerations beyond policy revisions and staff education/training. Improvement also requires application to disparate system-wide concerns – such as job descriptions and annual evaluations, supporting documents, job tools, just in time resources, bedside medical record documentation and EMR changes, awareness of patients, physicians, managers, families, public, governing board – and building itself into a culture of high(er) reliability.  In other words, improvement requires a cohesive and supportive structure.

A cure is found in consistently integrating and aligning those standards, policies, education, forms, consents, job descriptions, handbooks, patient education, websites, rules & regs, etc. Making sure staff have access to ONLY the latest and comprehensively aligned version to provide a consistent message to all staff – all the time. A change in a standard triggers the need to review and /or revise the associated tools to keep everything current and compliant.

Maybe then we will be able to make some significant, lasting improvement to process and outcome.

It is possible to do this today? Yes. Would it benefit patients and staff? Yes. Would it help bring some harmony to the mayhem? Yes. Is there any good reason not to do it now? Absolutely not.

After being in the business nearly forty years, I have come to realize I no longer (and perhaps never did) understand the meaning of the word “healthcare.”

The concept of “healthcare” is malleable; it morphs into every size, shape, application, time, and location. Healthcare can be found inside a wrecked a car along a dark desolate road and simultaneously be at home in the most lavish corporate boardroom in America. Its mere 10 letters dominate public news and the Internet while it is bantered and battered in backroom negotiations of employee benefits.

Your Healthcare is the professed focus of commercial pharmacies, the battle cry of attorneys, and the marketing motto and mission of equipment providers, researchers, mental health providers, clinics, and software companies. Every year, it is the salvation of millions and also the death knell to hundreds of thousands.

One can hardly be faulted for being unable to describe something that by its very nature defines paradox. Healthcare is both universal and very personal; it is equal parts sincere compassion and callous power. Its reach encompasses the entirety of human experience; the spectrum of pain and pleasure, miracle and tragedy, altruism and greed.

Healthcare is there in good times and bad as it sweats in gyms, educates the public, comforts babies, responds to disasters, and holds the hand of a dying elder. A single word covers so much, means so much, and does so much.

The term also lends itself to conflicting and confusing jargon. Preventative Healthcare (prevent health – really?). Wellness Health (as opposed to the Badness variety). Alternate Healthcare (what??). These titles just never passed the transparent credibility test for me.

Why have we not, despite our long-standing penchant to complicate things further, made the definition clearer, more concise, and better reflective of what we do? Why can we not label categories of patient healthcare for what it is and should be?

Life Care – to promote physical, mental, and spiritual wellness and the prevention of illness or harm.
Health Maintenance – to manage and constrain chronic illness and harm.
Health Repair – to correct acute medical or surgical episodes of illness and/or injury, recovery, and rehabilitation.

Maybe then I will have a better idea of what the larger concept of Healthcare is really all about.

I just returned from a week-long learning session at the Institute for Healthcare Improvement (IHI).  Being a quality professional, many of the concepts taught were not new to me.  Several of the articles shared I had read before.  Some of the speakers I had seen previously.  Nonetheless, the experience entered the realm of life changing.

IHI is an incredibly magical place where non-stop innovation lives and breathes with a single unifying mission to improve lives of all people.  With just over one hundred employees, much of their work is directed at healthcare. However, they also apply their process improvement expertise to the social factor such as finding housing for the homeless in the United States.  Meanwhile, in Africa, they distribute hope and education among mothers and newborns.  Their reach continues around the world as they provide free online education in patient safety and health improvement for students and faculty.  Their patient safety solutions, assistance, and projects are designed to transcend every challenge of culture, language, resource, time, distance, government, or human condition.

IHI openly shares many of its resources and successes.  Their transparency inspires others and their own internal staff to boldly tackle problems and proclaim, “The impossible is fun!”  However, if their work is bold, it is performed by humble, self-effacing people driven to help others.  Should that all sound too far removed from practical reality, each employee at IHI consistently practices what they preach.  All ideas are encouraged and considered, actions are highly collaborative, communication is across the organization, process improvement methods come from literature, and information is rigorously researched.  There are no egos and there are no big administrative offices with closed doors.  There is a pervasive and enlightened culture of “we” helping others to improve the world.

IHI is a microcosm of utopia on so many levels.  The impact this small group of people known as IHI have made on millions of lives is astonishing.  They are dedicated people changing the world and providing amazing proof of the human potential possible in the right culture.

I recently spoke with a family member about the hospital care of his wife. He was disgusted with the “quality of care” she received. The bedside table was broken, the pillow was uncomfortable, the nurses did not bring her medicine on time, the sheets were not changed for 2 days, no one helped her to wash her face – the list went on.

In all fairness, I cannot say I was impressed with the place either. I was present as the evening nursing assessment consisted of the nurse introducing herself, explaining the planned activity for the morning (remove catheter and change her surgical dressing), inquiring about pain level, and checking the patient’s IV bag and rate. There was no checking of the IV or surgical site, no listening to her chest or abdomen, no inquiry about intake or output, no advising to turn, cough, and deep breathe, no checks of circulation or movement of lower extremities – in fact there was no hands on touching of the patient at all. Nonetheless, my family member was very impressed with how nice the nurse was.

I found our differences in the concept of quality to be very interesting. He and his wife knew nothing about any checklist used in the operating room or telephone orders read back. They had no concept of the extensive bar coding system and process for medication administration. They were blind to pathways, guidelines, performance measures, and peer review. Their entire perception of quality was only what was in front of them and how it compared to personal and business experience. It was the purest form of customer service – only.

His wife was moved to a rehabilitation facility the next day. My family member raved about the change in environment. Not only is there a garden there, they offered him a sandwich! Despite the fact that his wife arrived on a Sunday, and there is no therapy provided on that day, he could not stop telling everyone about the wonderful care at the rehab facility.

Perhaps there needs to be a better distinction between what healthcare professions call quality versus what patients call quality because, right now we are not talking about the same thing. While I find it unfair that all of healthcare quality can be judged on the comfort level of a pillow or the smile upon the face of a nurse, I also understand that perspective – and I cannot deny its importance.

Barbara Duffy

I have been reading a bit about Accountable Care Organizations lately – after all how can you miss it?  There are some great ideas and plenty of potential being tossed around. Concepts being discussed in the literature include:

–       Coordination of a wide variety of participants in the patient’s health care into vertically integrated networks,

–       The need for evidence-based guidelines for physician practice,

–       The need for technology to coordinate and provide appropriate options of care,

–       Governance structures that include physicians,

–       Combining competitive forces to enable improved negotiations from vendors,

–       Process management, process management, process management,

–       Alignment, alignment, alignment.  Integration, integration, integration,

–       Looking at the entire continuum, working collaboratively, and giving up control to get control,

–       Monitor and evaluate ongoing clinical performance and work flow,

–       Determine how to obtain out-of-network care information before the claim hits,

–       And of course – payment.

There is much more, but I am hoping we are not missing the entire other side of the equation.  It is perhaps the most important one.  What is going to compel the patient to participate in the ACO?  What incentive do they have to leave long-term, trusting, and comfortable relationships with their four (or more) physicians?  For some elderly patients, health care is as much a social event as a health maintenance necessity.  How do we convince them to make the move to an ACO without implying the care they are currently receiving is not ‘good enough’?

I believe ACO’s have boundless potential to tip the balance back to all that is great, altruistic, and cost-effective about health care.  However, I also believe we are going to need some marketing help to persuade a cautious public that ACO’s are not a money-making creation to ration care.  We need to convince the public that technology and skills have advanced enough to improve the health of populations and the individual.  As a result, ACO’s are a synergy of information and physician expertise that permits health care providers to promote health consistently, appropriately, and effectively to each patient and across the health care system.

BD

April 20, 2011

I just read a wonderful article that brought together something that has been dancing around in my mind lately.  Can evidence-based medicine and clinical quality improvement learn from each other? by Paul Glasziou, Greg Ogrinc, and Steve Goodman offers some intriguing insights.  Additionally, the timing could not be more perfect.

My studies pertaining to evidence-based medicine (EBM) in school right now have experienced many close encounters with my quality / performance / process improvement background.  Certainly providing best practice is part of quality care, but as the authors point out, ‘doing the right thing’ and ‘doing things right’, while complementing one another, are not quite the same.

Thanks to technology, identifying what needs to be done in clinical practice is now the easy part.  Determining how to disseminate that practice among multiple providers, disciplines, and settings is trickier.  Established processes within health care systems may prevent ‘right things’ from being accomplished correctly, consistently – or at all.  The implementation of EBM may require the employment of quality improvement methods to integrate evidence into individual clinical practice and entire systems of care.

However, while EBM and QI look like a team destined for great things, I cannot help but think the potential for incredibly awesomeness is being overlooked.  Adding Patient Safety and Informatics to this team provides a multidimensional balance and comprehensive structure that addresses a multitude of interdependent, overlapping, and mutually beneficial concerns.  This group of professionals would have the ability to predict, prevent, implement, and evaluate barriers to providing the highest quality of care.

Maybe then we will have the best chance of ‘doing the right thing right’– for all patients all of the time.

BD

BMJ Quality and Safety 2011 at http://qualitysafety.bmj.com/content/20/Suppl_1/i13.full