The results of a nationwide survey of quality improvement professionals working in healthcare were released July 30, and underscore concerns among those professionals that the obstacles to dramatic quality improvement in healthcare delivery and operational processes are such that major changes need to be made to the ways in which quality improvement is executed in healthcare settings.
The survey of 323 quality professionals in healthcare was conducted by the Milwaukee-based ASQ, a global association of quality improvement professionals that works to support quality improvement across all industries . ASQ is best known as the sole administrator of the annual Malcolm Baldrige National quality Award; the association encompasses 90,000 members worldwide.
Among the 323 quality professionals in healthcare surveyed, when asked what things were “extremely important” to do right now in healthcare, 42.9 percent cited “reducing hospital readmissions”; 34.52 percent cited “creating efficiencies with existing clinical resources (staff and units) to maximize patient throughput”; 30.45 percent cited “implementing patient care coordination programs”; 30.0 percent, “changing medical malpractice laws”; 23.2 percent cited “improving data and analytics on ROI of medical products/technologies”; 21.29 percent, “improving supply chain management”; and 21.22 percent, “redesigning hospital care spaces to be more efficient.”
When asked to name quality improvement approaches that would “help healthcare organizations to cut costs and reduce waste,” survey respondents cited “increasing the use of quality and process engineers in healthcare settings” (29.68 percent); “focusing on Lean management principles” (29.68 percent); “implementing mandatory process improvement training for healthcare professionals” (29.22 percent); “creating financial incentives to deliver more efficient care” (27.12 percent); “forming or joining purchasing collaboratives and group purchasing organizations to leverage their buying power,” 19.14 percent; and “expanding the use of ‘medical technology’ (refers to procedures, equipment, and processes by which medical care is delivered),” 17.43 percent.
Meanwhile, when asked to name difficult “hurdles that healthcare organizations face in making changes to reduce costs,” 48.44 percent of those surveyed cited “The Affordable Care Act and its impact on how healthcare organizations set prices”; 26.14 percent cited “Medicare and Medicaid funding challenges”; 20.78 percent said, “modifying the model of reimbursement so healthcare and health maintenance is preferred over the sick-care, fee-for-service model that currently exists”; 16.29 percent said “lower reimbursement from health insurance exchanges”; 14.56 percent cited “fragmented, uncoordinated care”; 13.2 percent mentioned “persuading physicians to accept changes to the types of devices or supplies being purchased; while only 5.94 percent cited “not enough organizational bandwidth or resources.”
Shortly after the release of the survey results, Joseph M. Fortuna, M.D., spoke with HCI Editor-in-Chief Mark Hagland about the survey and about broader issues in healthcare quality improvement. Dr. Fortuna, the immediate past chair of the healthcare division of ASQ, is the CEO of PRISM, a Milwaukee-based non-profit consulting group working with hospitals and medical groups, to bring process and quality improvement skills, methodologies, attitudes. Dr. Fortuna practiced for years as an emergency physician, before transitioning into work as a corporate medical director, and then consulting work. Below are excerpts from that interview.
Let’s talk about your perspectives on the intersection between quality and healthcare delivery and operations.
Yes. What healthcare people don’t realize very often is that quality in healthcare has many domains. And certainly, many clinicians see it only in the clinical domain. But to really be a high-performing organization, you’ve got to look at the operational domain as well. Most of the errors occur in the operational realm and in support systems. And the culture in healthcare has not progressed to where Toyota is, except in a few organizations like Virginia Mason, to where everyone is looking to eliminate waste. And we’re mostly not doing that in healthcare. And those who are mostly don’t have the high-level skills needed to do that enterprise-wide and to make it a sustainable part of their culture. We don’t do that, and that’s what our organization, ASQ, is really passionate about.
Joseph Fortuna, M.D.
Among the survey results, it was notable that nearly one-third of ASQ members surveyed urged the hiring of professional quality and process engineers in healthcare settings.
I am very passionate about this issue. Many hospital leaders, including both administrators and clinicians, favor training clinicians in quality courses and then employing them as quality and process change leaders. And if you look at advertisements placed in media for people in healthcare, for quality directors, they’re almost always mandating a clinical background. Frankly, for my money, unless somebody is a process engineer first and then goes into clinical practice, those clinicians generally don’t have anywhere near the level of skill sets that process engineers have. Someone who takes a two-week course in Six Sigma and gets a green belt—that person doesn’t have the skill set needed to really create and sustain change.
So we really need professional-level process engineers working in hospitals and medical groups, then?
Absolutely; in fact, we’re developing a white paper on that subject right now.
Can those people be successful without a clinical background?
Absolutely. Those people are trained to do process improvement in any environment. They’re trained to be successful in any environment.
One of the problems in that regard may be the medieval-like system of professional guilds among clinicians in healthcare, as well as the issue of credibility with clinicians, correct?
Well, but that’s basically the chicken-or-egg problem. Just this May, the President’s Council of Advisors on Science and Technology, or PCAST, issued a report that included recommendations for the hiring of professional process engineers in healthcare, and it was the third or fourth paper in several years to do so. And it said, we need to reengineer healthcare. And you’re right, per the medieval-guild aspects of clinician training and development in healthcare. The existing medical residency programs are nothing more than apprenticeships that focus entirely on patient care, but without systems education. So there needs to be education in the healthcare professional schools, as well as the healthcare management schools, around all of this. In fact, a friend of mine, the dean of the Central Michigan University Medical School, has made Lean training mandatory for medical students. And other medical and nursing schools are starting to do this. When a doctor is trained, they come out with some knowledge about MRI functions, even though they don’t run MRIs. Doctors and nurses should get basic training in [quality improvement and process engineering]. We don’t ask doctors and nurses to learn how to build EMRs [electronic medical records]; why should we ask them to fix EMRs? It’s a cultural bias in healthcare, that we didn’t do it that way. And in terms of EMRs, they’re a completely different way of doing the same thing they’re doing now.
Process improvement isn’t necessarily seen as a different way of doing things. I don’t know if you’re aware, but the incidence of claims denials in Medicare is god-awful, it costs us many billions of dollars a year, and we’ve done some work with hospitals, and the reason for many of those denials is because of the lack of a valid signature on a claim; that’s a process issue, and it costs money.
When it comes to adopting Lean management and other principles in patient care organizations and really embedding them into patient care organizations’ culture, are we talking about a CEO-level issue?
Yes, it’s a CEO issue, and it’s a board issue. It’s a fiduciary issue. They’re losing tons and tons of money. And very little of it is clinical waste. I recently talked with a hospital medical director; his organization had done a lot of Lean projects. But it wasn’t accepted and built into the culture. So then they visited Virginia Mason Medical Center in Seattle [Virginia Mason Medical Center has strongly adopted the Toyota Production System as part of its core operating strategy: see this HCI article for more]. And then they saw what churches and street gangs had done successfully forever, and that is to drum into their adherents exactly what to do, over and over. And we don’t have that kind of mandatory culture except in a few places in healthcare, such as Virginia Mason.
So it does have to come from the top, and does it have to be mandatory?
Yes, absolutely, and it also has to be something where the people at the practice level are involved. One of the biggest “aha” moments I had at General Motors, when I worked there, was the revelation that you can’t get anything done without the participation of the people putting the bolts on the cars. I was recently a patient in the hospital; I was pretty sick, actually, and there were a whole bunch of different specialties involved. And the nurses, who were wonderful, told me, these people—the specialist physicians—don’t communicate with each other. And here’s another example: I was lying in bed in the hospital at 2 AM one morning, and a nurse came in and said, I’m here to draw blood. And I said, I’m sure that’s wrong. And another nurse came in and got it clarified; the first nurse was supposed to draw blood from the patient next door! Think about airlines—they have what’s called a 5S process.
So in that regard, we’re talking about the extensive use of checklists, as advocated by Dr. Atul Gawande, correct?
Yes, and Peter Provonost before him, who actually got checklists going. It’s a pure industrial technique. And one of the problems is that people have gone in and started using Japanese names like Kaizen and stuff; well, that’ll turn people off! I’ve taken dozens of process engineers into healthcare. They have to spend a little time learning the vocabulary and cultural issues before they jump right in. But then they absolutely can do it.
In order for patient care organizations to really change, it will take a cultural revolution around the adoption of continuous quality work, correct?
Yes, but at the same time, you’re now starting to see some incentive changes, particularly coming out of healthcare reform, at the federal level, and also coming from private payers. And because of that shift, you’re starting to see some incentive changes. This whole pay-for-performance thing has woken people up.
In the context of all of this, what do hospital and health system leaders need to do right now?
At all levels from the top down, they need to become aware that there is an entire science of process improvement, of quality improvement, and realize that that is at the cutting edge of getting better. And they need to incorporate those tools. And more importantly, get those professionals who know how to do it right, involved, and not at a low level where they’re subject to the whims of the medical and nursing directors, or anyone else; put them into positions of authority. Hospitals are beginning to hire chief quality officers. And in my view, they should not be doctors or nurses with a little training. It’s not about the old quality assurance, what used to happen in the auto industry, with final inspections when the cars are completed. Real quality improvement starts much farther upstream. It’s the Deming approach of, do it right the first time. And you don’t have to go back and do inspections. Most of our quality efforts in healthcare are still of the “inspection” variety, done retrospectively, after the injury or error has occurred. And we have to prevent errors and waste to begin with, not retrospectively. So we need to train doctors and nurses and everybody else in healthcare.
What should CIOs and CMIOs do, in their roles, to promote quality improvement?
Healthcare IT leaders have got to not only choose an EMR, but need to “Lean out” the environment and make sure there’s as little waste as possible before you implement, because after you implement, it’s too late.
Do you have anything else you’d like to add?
I am particularly saddened by the bias and prejudice against professional process engineers, and we’ve got to do something about that.