Quality Improvement in Healthcare: Where Is the Best Place to Start?

My Folder

One of the biggest challenges providers face in their quality improvement efforts is knowing where to get started. Generally speaking, providers know there are opportunities all over their healthcare systems to improve processes and eliminate waste. And that’s the problem. The system itself is so big and there are so many processes, it’s difficult for them to determine the best place to start. What they need is a tool to pinpoint where their efforts will have the biggest bang-for-their-buck.

Here is an analogy to illustrate my point:

Quality Improvement in Healthcare

My brother and I successfully catching bluefish on a commercial fishing expedition in Long Island Sound. No doubt aided by a fish finder!

Fishing is a favorite hobby of mine. When you are fishing just as a hobbyist, most people rely on, and relish, intuition. Finding the right weed bed, fishing near structures, and going to the same spot you caught the ‘big one’ the last time (as long as your buddy doesn’t come with you). The lists of tips on fishing websites are innumerable. Finding the best spot is part of the sport. Then, there are the times when your ability to read the water is wrong, and there are no fish in your chosen spots. That is also part of the sport of fishing. Sometimes you walk away with nothing despite your best efforts. Commercial fishing charter expeditions have the same goal: catching fish. But now people are paying to catch fish. The charter skippers have to know how to navigate through all that water and pinpoint the fish. After all, everyone is expecting to catch fish. That’s where they implement an indispensable tool, the fish finder. They find the best spots based on data and can greatly increase the odds of their paying customers being successful.

So, what’s the fish finder for providers? How do they know where to start looking for fish (if we’re following my analogy)?

In my experience, one of the best ways to overcome that “where do we begin?” factor is by using data from an enterprise data warehouse to look for high-cost areas where there are large variations in how health care is delivered. With this type of analysis (Health Catalyst has a Key Process Analysis [KPA] application that can do it very quickly and clearly, by the way), you can easily see where the biggest opportunities for improvement and the elimination of waste lie, allowing you to deliver the type of clinical results and enhanced ROI that can help your improvement effort get off to a fast start and gather momentum among the staff and the executive suite.

Why Variations Are Such Great Indicators

Variation found through the KPA is an indicator of opportunity. The more avoidable variation that is reflected in a particular care process, the more opportunity there is to reduce that variation and standardize the process.

As a general rule, standardization is an indicator of efficiency. When data from a metric like cost is plotted on a chart grouped by physician or facility, tightly clustered data indicates that everyone is following similar processes. Conversely, a chart that shows a great deal of variation generally indicates there are many different processes and procedures being followed.

Efficiency depends upon economies of scale and repeatability. That’s why it’s cheaper to build complex products such as cars and appliances on an assembly line rather than one at a time, start-to-finish. It’s also why process improvement in manufacturing has been so effective in elevating the quality level of those products.

While medicine is much more complex than an automobile assembly line, the more you have everyone following the same, evidence-based procedures and processes the more control you have – which translates into higher-quality outcomes.

Practical Example

Here’s an example of how a KPA works in practice. The chart below shows a fictional analysis of the cost per case of vascular procedures. As you can see, the bulk of the bubbles in the chart fall right around the $20,000 range. That is the established norm in this hospital.

Quality Improvement in Healthcare

One of the physicians shown, however, is well to the right. Dr. J’s cost per case is $60,000, or $40,000 more than the norm. Since he performs 15 procedures per year, if the hospital can bring his costs in line with others who practice there, the savings opportunity is $600,000 – certainly enough to capture the attention of those wondering about the benefits of an improvement initiative. The more of those bubbles there are that stray from the norm, the greater the opportunity.

While it is not the only variation measure, cost is one of the most important. Wide variations in cost are usually associated with wide variations in health care quality; if you can reduce variations in the cost of procedures, you are almost assured of a corresponding increase in quality.

In an actual KPA engagement, you will want to look at the data from many different areas, such as heart failure, diabetes, obstetrics, and orthopedic surgery, to determine in which direction the first steps should be taken. Stacking them up side-by-side will show you where the greatest opportunities lie. You can then dig deeper with more sophisticated analysis tools dedicated to that particular disease or specialty to gain a better understanding of what is happening – and whether an improvement initiative is worth pursuing.

Adjusting for Severity

While a KPA provides a valuable top-line view, you’ll want to avoid the temptation to use it as an excuse to punish individual providers. After all, there may be a good reason why those outliers are showing up where they are.

Take Dr. J again. In our example we saw that his cost per procedure is 3X the norm. That may seem bad, and it in fact may be bad. But it’s also possible that Dr. J’s cases also have 3X the level of complexity. He may draw all the toughest cases from all over the world because he is so good at what he does and enjoys a national reputation that also brings prestige to the hospital.

In that case, it isn’t fair to measure his cost per case against more average surgeons who only draw from the local area – and who may refer their own difficult patients to Dr. J. For this reason, our KPA stratifies the bubble chart based on severity. So when we are comparing costs and measuring variation, we are measuring variation at a particular severity level.

Determining Where to Start

Suppose after performing a KPA you discover three areas of opportunity. How do you determine which one to pursue, especially if it’s your first journey into process improvement?

The most obvious answer would seem to be the one with the largest potential ROI. That may not always be the best course to pursue, however.

You will also want to take into consideration the readiness/openness to change in each of those areas. For example, bowel surgeries may show up as #3 on the list, but in looking at the personnel you realize that they have a good team that is already inclined to exchange information and is very open to using evidence-based medicine. You also see that they have successfully navigated this type of change before, whereas it is uncharted ground for the other two areas.

In this case, where you need a quick win and a showcase project, you will likely get your best overall return on your efforts by working with the bowel surgery team. They can then set the example, and perhaps even provide guidance to the other teams when it’s time to tackle opportunities #1 and #2.

Variation analysis is the voice of the data, but it must always be balanced with the voice of the institution.

Let Variation Be Your Map

You wouldn’t think of starting a commercial fishing company without a fish finder. The same thinking should apply to a process improvement initiative.

A KPA designed to uncover significant variations can help you identify your greatest opportunities for improvement and serve as the map to help you get started. It may not lead to your ultimate destination. But it will help you start down the right path.

And catch those fish.

For more on how reducing variations can help eliminate waste and improve the value of health care delivery, check out this article from Dr. David A. Burton, Chairman of the Board at Health Catalyst.

Now it’s your turn. Have you used a KPA to look for variations in order to deliver clinical quality improvements? If so, how did it work out?

If not, what other methods are you using to help spot opportunities to improve value? 


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