Dr. John Haughom explains 5 key Deming processes that can be applied to healthcare process improvement. These include 1) quality improvement as the science of process management, 2) if you cannot measure it, you cannot improve it, 3) managed care means managing the processes of care (not managing physicians and nurses), 4) the importance of the right data in the right format at the right time in the right hands, and 5) engaging the “smart cogs” of healthcare.
Quality & Process Improvement
For healthcare organizations to be successful with their quality and cost improvement initiatives, physicians must be engaged with the proposed changes. But many physicians are not engaged because their morale is suffering. While some strategies to encourage buy-in for improvement initiatives don’t work, there are six strategies that have proven to be effective: (1) discover a common purpose, (2) adopt an engaging style, (3) turn physicians into partners, not customers, (4) segment the engagement plan, (5) use “engaging” improvement methods, and (6) provide them with backup—all the way to the board. Once the organization has their trust, physicians will gain enthusiasm to move forward with improvement efforts that will benefit everyone.
For healthcare organizations looking to achieve outcomes improvement goals, effective governance is the most essential must-have. This leadership culture ensures success by enabling health systems to invest in outcomes improvement and allocate resources appropriately toward these goals.
This executive report is an outcomes improvement governance handbook centered on four guiding principles (and associated helpful steps) health systems can follow to achieve effective governance and start achieving more with less:
With these four principles, organizations can build a foundation of engagement and focus around the work, where they maximize strengths, and discover and address weaknesses. They establish an improvement methodology, define their goals, and sustain and standardize improvement work.
Why Clinicians Are the Missing Link in Healthcare Quality Improvement and Three Principles to Solve the Problem
When it comes to successful quality improvement (QI) in healthcare, clinicians tend to be the missing link. Fortunately, the disconnect between QI initiatives and the day-to-day work of clinicians can be explained and resolved if health systems adopt and embrace three clinician-focused principles:
Principle #1: QI starts at the front line (initiatives should be identified and driven by clinicians).
Principle #2: QI makes it easy for clinicians to do the right thing (removes barriers to good work rather than increasing the amount of work clinicians do).
Principle #3: QI empowers clinicians to adapt care (even if it’s not QI protocol).
Although some clinicians are enthusiastic advocates of their systems’ QI efforts, most are suspicious because they’re frequently cut out of the decision-making process or forced to ignore their best clinical judgement. Health systems that work to close the gap between leaders and clinicians by embracing these three principles will add the missing link—clinicians—back into successful healthcare QI.
For better or worse, hospitals are obligated to collect and report data for regulatory purposes. Or they feel compelled to meet some reputational metric. The problem is, an inordinate amount of time can be spent on what is considered data for accountability or punishment, when the real focus should be on data for learning and improvement. When time, effort, and resources are dedicated to the latter, it leads to real outcomes improvement.
Deming has three views of focusing on a process and this article applies them to healthcare:
Sub-optimization, over-emphasizing a single part at the expense of the whole.
Extreme over-emphasis, also called gaming the system.
The right amount of focus, the only path to improvement.
With data for learning as the primary goal, improving clinical, operational, and financial processes becomes an internal strategy that lifts the entire healthcare system.
The Top Seven Analytics-Driven Approaches for Reducing Diagnostic Error and Improving Patient Safety
From a wrong diagnosis to a delayed one, diagnostic error is a growing concern in the industry. Diagnostic error consequences are severe—they are responsible for 17 percent of preventable deaths (according to a Harvard Medical Practice study) and account for the highest portion of total payments (32.5 percent), according to a 1986-2010 analysis of malpractice claims. Patient safety depends heavily on getting the diagnosis right the first time.
Health systems know reducing diagnostic error to improve patient safety is a top priority, but knowing where to start is a challenge. Systems can start by implementing the top seven analytics-driven approaches for reducing diagnostic error:
Use KPA to Target Improvement Areas
Always Consider Delayed Diagnosis
Diagnose Earlier Using Data
Use the Choosing Wisely Initiative as a Guide
Understand Patient Populations Using Data
Collaborate with Improvement Teams
Include Patients and Their Families
Establishing a healthcare improvement initiative is just the first step toward transformation. The real work of improvement lies in sustaining it, which is why qualified change agent are essential to meaningful progress.
Change agents are trained to lead organizations in:
Case for change
Change management concepts
Cost Benefit Analysis
Health Catalyst’s Accelerated Practices Program gives change agents adaptive leadership training to guide systemwide change within their organizations. They are prepared to meet technical adaptive challenges while keeping teams engaged and productive, and, importantly, to use data analysis to improve quality, cost, and patient satisfaction outcomes.
In pursuit of the Triple Aim, healthcare leaders work hard to improve care, reduce costs, and improve the patient experience. But accomplishing these goals requires an engaged staff that makes progress, day in and day out. Adaptive Leadership (AL) principles help leaders understand human behavior to mobilize change and overcome work avoidance, which happens when staff operate above or below the productive zone of tension.
By understanding what adaptive work actually is (and that adaptive problems can’t be solved with technical fixes), and why work avoidance happens (because people are overwhelmed; the heat is too high), leaders can keep their teams engaged by using influence and leadership—not authority—to “lower the heat” on their people:
Validate the difficulty of the situation.
Simplify/clarify the work.
Provide additional resources (time, training, etc.)
Dr. Ulstad has worked with healthcare leaders and teams for the last 20 years to help them understand behaviors triggered by rapid, high-volume change, and apply AL principles to guide the changes critical to their organizations’ success.
Outcomes improvement is complicated, but we’re beginning to understand what successful quality improvement programs have in common:
Adaptive leadership, culture, and governance
Evidence- and consensus-based best practices
Although understanding the top five essentials for quality improvement in healthcare is key, it’s equally important to understand the most useful definitions and key considerations. For example, how different service delivery models (telemedicine, ACO, etc.) impact quality improvement programs and how quality improvement starts with an organization’s underlying systems of care.
This executive report takes an in-depth look at quality improvement with the goal of providing health systems with not only the top five essentials but also a more comprehensive understanding of the topic so they’re in a better position to improve quality and, ultimately, transform healthcare.
Perceptions of standardization and personalization vary widely by healthcare industry role. Advocates of standardized care say it improves efficiency, outcomes, and patient safety. Advocates of personalization, however, don’t want to see a one-size-fits-all approach become the norm. They want to see a healthcare system in which physicians treat patients like unique individuals.
But what if standardization and personalization didn’t have to be mutually exclusive? What if these historically competitive approaches to care improvement could work together to improve care?
Dr. Corbett describes how health systems can prioritize standardization and personalization using data to bridge the gap. Data enables informed decision making, customized treatment plans, and patient engagement. It supports both standardization and personalization approaches in the ultimate quest for care delivery improvement.
Healthcare process improvement leaders not only have to be a jack-of-all-trades, but they need to be a master, as well. This is one of the most important leadership roles in the healthcare system with responsibilities that can ultimately end up saving lives, improving the patient experience, improving caregiver job satisfaction, and reducing costs. Although there are many others, these eight skills are the most critical for the efficient, and ultimately, successful process improvement leader:
Understanding Process Management
Understanding Care Management Personnel
Constructive Accountability and Constructive Conflict
Resiliency and Persistency
Seeing the Big Picture
Along with the right training, education, and sponsorship, it’s easy to see why this role blends many elements of art and science.
The healthcare industry is currently obsessed with outcome measures — and for good reason. But tracking outcome measures alone is insufficient to reach the goals of better quality and reduced costs. Instead, health systems must get more granular with their data by tracking process measures. Process measures make it possible to identify the root cause of a health system’s failures. They’re the checklists of systematically guaranteeing that the right care will be delivered to every patient, every time. By using these checklists, organizations will be able to improve quality and cost by reducing the amount of variation in care delivery.
IT teams are the guardians of health system data. Their role in quality initiatives in healthcare is undeniable. Yet maximizing IT contributions to quality initiatives requires a shift in IT’s traditional role.
Traditionally supporters of data governance, security, privacy, and access—all important for achieving quality initiatives—IT teams need to do more. They need to integrate five must-haves:
Data best practices
Engaged frontline staff
The industry is up against expanding regulatory requirements that will place high demands on IT teams, including ONC’s goal to reduce the collection and reporting burden on providers. IT teams that embrace these five must-haves are best positioned to create user-centric tools and processes that reduce this burden.
One of the most important aspects of managing clinical interventions is how you measure an intervention to determine if it is effective. A run chart is a very important tool for measuring improvement, but it doesn’t give you all the information you need to assess the effectiveness of your process change. The next step in maturation of your measurement process is creating a statistical process control (SPC) chart. An SPC chart shows you if your intervention is changing the process in a significant way or whether changes in the data just represent random variation.
Healthcare organizations from Hamburg to Gothenburg to Boston are realizing the future of care delivery through a value-based approach, as portrayed in this video documentary featuring professor Michael Porter of the Harvard Business School. Measured Outcomes: A Future View of Value-Based Healthcare explains how value-based care is a methodology that involves standardizing outcome measurements, tracking them over the long term, and putting clinical teams in place with the longevity needed to build a sustainable program. More importantly, it is healthcare that matters most to patients because they report and track their own quality measurements, giving them a say in their own healthcare experience. Providers are winning, patients are winning, and the results for the organizations showcased in this video are remarkable, such as an 88 percent prostatectomy success rate for the Martini-Klinik in Hamburg, Germany, compared to a 32.8 percent rate for the rest of the country. And with just 10 surgeons on staff, they are doing more volume than any other facility in the world, by far, all attributable to their value-based approach.
Usually, when we think of the phrase “patient engagement,” we think of what providers and healthcare systems are doing to involve patients in their own care. Patient engagement is often defined as providing access to a patient portal or reaching out to patients through social media channels or via an organization’s website. But it’s also about patients proactively becoming involved in their own care, in partnership with their healthcare providers. Call it “DIY” or “personalized” medicine, but it can reduce preventable admissions and shorten lengths of stay. It can also significantly improve an individual’s outcomes and always creates better awareness of one’s symptoms and how they are changing. With proper tracking, patients can create a view of their personal data that enhances what’s conventionally available to their providers. This is one motivated patient’s account through an episode of personalized medicine.
The transition from fee-for-service to value-based reimbursement is driving many healthcare systems to fine-tune processes and work waste out of the system. In the search for quality improvement tools there has been much buzz surrounding lean, touted for its ability to remove waste from processes. Many have tried lean and, failing to achieve any sustainable benefit, are learning that applying lean principles to healthcare can be quite difficult. The lean approach isn’t a magic potion. Sustainable change will never become real without a committed organization dedicated to making it a reality. Lean, or any quality improvement tool, works in healthcare only when it is part of a larger initiative driving real cultural change.
Too often, hospitals and health systems stop at developing broad clinical quality improvement statements that come up short of achieving their desired goals. What’s missing are clearly defined improvement objectives in the form of aim statements that take into account the effects on other areas of the organization: patient safety and satisfaction, physician engagement, and financial contribution. Aim statements help articulate the problems that add value for patients and the organization, but good data, and the analytics tools required to understand the data, are essential to illuminating high-value problem areas. Additionally, aim statements must stick to the SMART guidelines: Specific, Measureable, Achievable, Relevant, and Time-bound.
The prescription for improving healthcare outcomes is pretty straightforward: improve quality by working with good data that’s based on patient perceptions of quality, as well as functional health outcomes. Then make that data accessible and actionable among your physicians and give them the leeway they need to reduce variation and, ultimately, improve outcomes. As simple as this may seem, it’s been complicated by an inefficient data infrastructure with non-standardized components (EHRs) and the inability to distribute analyses and visualizations where they are needed most (at the point of care). Dale Sanders explains these issues in detail and outlines solutions in this article published in the April 2015 edition of BMJ Outcomes.
Introducing the Accelerated Practices (AP) Program: An Innovative Way to Help Health Systems Accelerate and Sustain Outcomes Improvement
We are excited to announce the launch of Health Catalyst University’s Accelerated Practices (AP) Program. This program is a highly immersive, project-based learning experience that healthcare industry experts have spent a lot of time developing. The goal of the program is for participants to leave with the tools and knowledge they need to achieve significant improvements in a short amount of time for their organizations. They will also learn how to communicate the need for change in this new value-based care environment by using data and proven leadership principles.
As the healthcare industry shifts from a fee-for-service to pay-for-performance and accountable care organizations are under greater pressure to make improvements to their clinical, financial and operational outcomes. As clinical quality improvement efforts grow systematically improving and sustaining care across the organization becomes more challenging. In order to ensure sustainable, long-term change a cross-functional, team-based approach that accelerates the implementation of change throughout the organization is necessary. This is the adoption system. Without an adoption system, improvement initiatives become a series of one off projects that may have a temporary positive impact, but soon return to the baseline level.
When deciding to prioritize your clinical improvement or cost reduction efforts, it’s helpful to use clinical program costs as a key input. The idea is to start with the first three or four in the first year, then work down the list. Most health systems prioritize using inpatient costs because they do not have access to outpatient data. However as accountable care and population health efforts increase, looking at costs in silos will not be sufficient. Under the leadership of Dr. Burton, our Health Catalyst team has been collecting, analyzing, and compiling a macro, industry-level view of inpatient and outpatient costs to serve as a guide for healthcare organizations who lack access to either of those views. The following ranking is the first of its kind, combining months of detailed analysis of several California health systems to show a combined total of both outpatient and inpatient costs. The results are surprising. Adding outpatient costs significantly changes the cost rankings of many of the traditional top health system care processes.
The Clinical Integration Hierarchy: A Primer on the Backbone of Data-driven Quality and Cost Improvement
Healthcare delivery is typically siloed into departments and care settings. But accountable care and value-based payment models require organizations to coordinate care across the continuum. To accomplish this, the Clinical Integration Hierarchy groups healthcare into work process that reflect how care is actually delivered. At the most granular level are care processes such as AMI and Cardiac Rehab (some of which are further divided into sub-care processes such as when AMI is divided into PCI and CABG). Next, care process families form the link between care processes through common pathologic conditions. Finally, the care process families comprise clinical programs such as Cardiovascular and Behavioral Health. The Clinical Integration Hierarchy forms the foundation for systematically tackling quality and cost improvement.
There are a number of reasons why hospitals are looking for improvement opportunities to reduce sepsis rates: sepsis costs lives, sepsis adds significant expense to care, and high sepsis rates lead to financial penalties. The three key solutions include an enterprise data warehouse, sophisticated healthcare analytics applications and dashboards, and permanent cross-functional teams for sustainable sepsis improvements.
Streamlining the Risk Management Process in Healthcare to Improve Workflow and Increase Patient Safety
Managing risk in a healthcare system is a tough job. And in this era of quality measures and reimbursement reform, the job of not just managing risk, but also proactively improving patient safety is critical. That’s because improving patient safety improves overall patient outcomes, a goal that’s being driven by declining reimbursements and a potential loss of reputation if organizations aren’t able to demonstrate compliance with the Affordable Care Act‘s mandates — two situations that could put a health system out of business. To reduce the current inefficiencies in the risk management process, two solutions are necessary: an EDW and a simple data entry application tool. These solutions will give risk managers — and everyone else involved in the process — an easy-to-use tool to review the risk event in near real time and in one location. This approach eliminates the current tedious process of using emails and meetings to collaborate on each event.