Week 12 Assignment 6
PLEASE USE TEXTBOOK AS REFERENCE!
Describe each component of the Triple Aim and its importance to the US healthcare delivery system.
All assignments are to be written in an essay format, with the appropriate heading, an introduction, body and conclusion/summary. References must be included on all assignments. Please use your textbook as your main reference. The essay should be at least two pages in length, typed, double spaced, with 12 font.
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C H A P T E R 1 0
QUALITY MANAGEMENT IN THE PHYSICIAN PRACTICE
Quality and reliability are system properties.
—W. Edwards Deming
➤ Articulate the nature of performance management.
➤ Describe the approaches to performance improvement.
➤ Appreciate the impact of variation on performance.
➤ Discuss the components of the Triple Aim.
➤ Describe process improvement.
IntroductIon One of the most important issues to address in the medical practice is the quality and safety of the care provided to patients. The Institute of Medicine (IOM 2001), a presti- gious branch of the National Institutes of Health, stated in its landmark report Crossing the Quality Chasm: A New Health System for the 21st Century, “In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves.”
C o p y r i g h t 2 0 1 7 . H e a l t h A d m i n i s t r a t i o n P r e s s .
A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .
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Another historic IOM (2000) report, To Err Is Human: Building a Safer Health System, indicated that a shocking number of people—an estimated 44,000 to 98,000 per year—are harmed by the healthcare system. A more recent study found that this number has increased since publication of the 2000 IOM report despite substantial efforts to improve. Medical errors have now become the third leading cause of death in the United States (Makary and Daniel 2016).
The complexity of medical service and the inconsistency with which these services are delivered, not to mention the fragmented nature of the system, have led to a number of quality concerns (Mosadeghrad 2014), including a lack of systematic approaches to care delivery and quality improvement. Efforts to improve quality in the medical profession have a long tradition of focusing on individual performance versus system performance. Exhibit 10.1 illustrates the potential flaw in this thinking. The bell-shaped curve, P-1, represents the overall performance of any given system. Curve P-2 illustrates an improved system of performance where the median performance is moved from M-1 to M-2. If an organization seeks to improve by only focusing on the low performers, it experiences only a small improvement, shown as I-1. By improving the system as a whole, a much larger improvement is seen, as demonstrated by I-2. Although focusing on removing bad behavior and poor performance is necessary, it will not produce the optimum level of improvement being sought in the US healthcare system.
QuaLIty and safety ImProvement Much of the work in quality improvement has focused on healthcare institutions such as hospitals; however, the findings of the IOM research are applicable to the medical practice as well. A common denominator in all healthcare environments is the healthcare provider.
exhIbIt 10.1 Performance
Remove the Bad
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In a landmark study published by RAND Corporation in 2006, quality was found to be lacking in the services offered by medical practices. Overall, adults received about half of the recommended care; furthermore, that finding did not vary significantly across metropolitan areas. In addition, wide variability in the quality of care received was noted across communities for the same disease state. All social and demographic groups were affected. One conclusion of the study is that the lack of care received by patients was caused by the absence of investment in systemwide information technology, performance tracking, and incentives for improving care (RAND 2006).
For the most part, practices still are not reimbursed for services by third-party payers on the basis of the quality of care delivered, but on volume (McKesson 2016). Although no practice wishes to provide care in a way that produces poor quality, the focus on volume and the lack of focus on outcomes create distortions in the way leaders manage their prac- tices. In fact, this reimbursement methodology is a major contributing factor to misaligned incentives (Network for Regional Health Improvement 2008; Miller 2009). These ideas are not new, but progress toward moving to value from a volume-based system has been slow, painstaking, and resisted by stakeholders. As discussed in the “Change Management” section of chapter 8, healthcare is plagued by high resistance to change.
The National Committee for Quality Assurance (NCQA) has also made striking observations about the US healthcare system. A report published in 2007 states, “Research shows that the quality of health care in America is, at best, imperfect, and, at worst, deeply flawed” (NCQA 2007).
In Crossing the Quality Chasm, IOM (2001) recommends that private and public purchasers, healthcare organizations, clinicians, and patients work together to redesign healthcare processes in accordance with the rules that follow:
1. Care should be based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just through face- to-face visits. The health care system should be responsive at all times (24 hours a day, every day), and access to care should be provided over the Internet, by telephone, and by other means in addition to face-to-face visits.
2. Care should be customized based on the patient’s needs and values. The system of care should be designed to meet the most common needs but should have the flexibility to respond to an individual patient’s choices and preferences.
3. The patient should be in control. Patients should be given necessary information and the opportunity to exercise as much control as they choose over health care decisions that affect them. The health system should be able to accommodate differences in patient preferences and should encourage shared decision making.
4. The system should encourage shared knowledge and the free flow of information. Patients should have unfettered access to their own medical
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information and to clinical information. Clinicians and patients should communicate effectively and share information.
5. Decision making should be evidence-based. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.
6. Safety should be a property of the system. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety will require systems that help prevent and mitigate errors.
7. The system should be transparent. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, a hospital, or a clinical practice or when choosing among alternative treatments. Patients should be informed of the system’s performance on safety, evidence-based practice, and patient satisfaction.
8. The system should anticipate patients’ needs. The health system should be proactive in anticipating a patient’s needs, rather than simply reacting to events.
9. The system should constantly strive to decrease waste. The health system should not waste resources or patients’ time.
10. The system should encourage cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate with each other to ensure that patients receive appropriate care.
The prevailing mind-set and attitude about quality and safety should be in alignment with the sentiment from this quote from Antigone, by Sophocles (2005): “All men make mistakes, but a good man yields when he knows his course is wrong, and repairs the evil. The only crime is pride.” Errors of commission, errors of omission, errors of communica- tion, errors of context, and diagnostic errors are all to blame. Furthermore, the human desire to be perfect contributes to the problem, not the solution (James 2013). The illusion of perfection is a point of view that is unrealistically held by the public. In the face of all these issues and variables surrounding patient safety and quality, leaders and managers of medical practices can no longer cling to the status quo.
the trIPLe aIm Medical practices are at the forefront of population health management, as the medical practice is often the first contact patients have with the healthcare system. The Triple Aim is a cornerstone population health concept developed by Donald M. Berwick, MD, founder, president emeritus, and senior fellow of the Institute for Healthcare Improvement (IHI). In a sense, the approach has become national health policy in terms of the way many healthcare providers are beginning to think about healthcare. As shown in exhibit 10.2, the Triple Aim is focused on the following intersecting elements (IHI 2017):
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◆ Per capita cost. This component of the Triple Aim intends to lower the cost of care per person (not cost in aggregate, because as population increases, costs should naturally rise).
◆ Patient experience. The Triple Aim is concerned with patient experience because it has a huge impact on whether patients adhere to the treatment prescribed by providers. Evidence shows that patients who are satisfied with the care they receive and consider the care experience to be “good” are more likely to comply with the recommendations of their providers than are those who perceive their experience as unsatisfactory. Another benefit of consistently positive patient experiences is that it provides for an overall pleasant environment in the practice (Manary et al. 2013).
◆ Better health for the population as well as the individual. Considering the care of individual patients is no longer sufficient; to improve patient care, medical practices must take a broad look at the communities and populations served and develop strategies that improve the overall health of those groups.
Naturally, medical practices are focused on individuals and individual care. They want to achieve the best outcome for each patient. However, attending to the health of the entire population is important because small segments of that population use enormous
exhIbIt 10.2 The IHI Triple Aim
Health for the Population We Serve
Per Capita Healthcare
Source: Adapted from IHI (2017).
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amounts of healthcare resources, and society is asking the medical practice to take a sub- stantial role in addressing this critical issue.
QuaLIty ImProvement Processes Over the years, the terminology related to quality improvement has shifted from quality improvement (QI) to total quality management to process improvement, Lean, and Six Sigma, and now to Lean Six Sigma. All these have their basis in the work of W. Edwards Deming and other pioneers in the field. Deming often spoke about the nature of the process and outcomes, teaching about process, the involvement of the individuals doing the work, and how important it was to the outcome. To demonstrate this lesson, he used a tool called the red bead experiment (Deming Institute 2017).
In the red bead experiment, participants work on a mock production line. They are given specific instructions on how to carry out their work. They are not allowed to make any adjustments to the process or to the inputs or in any way influence how the result is produced. They are simply required to follow the exact instructions of their supervisor and “work hard.”
The objective is to make white beads, not red beads. Some participants are given paddles containing small holes to accommodate the beads. They dip the paddle in a con- tainer full of red and white beads, shake off the excess, and take the paddle to an inspector, who counts the number of white beads the producer has made. Importantly, the inspector’s role adds no value to the process. The process is repeated, and frustration mounts as the participants realize achieving the best outcome (producing all white beads) is impossible because the input of red and white beads into the paddle is random.
This simple but extremely effective experiential activity demonstrates the fact that the process is fundamental to the outcome of any activity. For example, over-reliance on incentives to deliver performance is misguided; instead, practices must rely on providers’ internal motivation to do the right thing while having an environment and processes in place that create trust and allow employees to flourish. No one ever comes to work on any given day intending to do a poor job. When medical practices rely only on incentives to motivate members, they may accomplish their metrics, but as research has shown, they do not necessarily see improvement (Heidenreich et al. 2016). Metrics often are set too low to ensure success, and any failures to meet the metrics are easily explained. Practices must help all members of the practice evolve in terms of process improvement to contribute to and produce the outcomes desired by engaging teammates’ greatest asset—their mind. In this section, we discuss a variety of tools for process improvement. All these tools should be used with discretion and judgment and with a skill base that develops over time.
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varIatIon and QI
Another important issue in quality and safety are the standards established for the work performed. Medical practices are now expected to create standard work processes that allow activities to be completed in the best way each time to reduce variation. Consider a practice that sees many patients each day. Several of those patients have similar attributes: the same diagnosis, the same gender, the same age, and so on. Why does one patient leave the practice pleased and praising the experience and another leave upset and threatening to never return? They saw the same provider, may even have been in the same corridor, and were seen in adjacent and presumably similar rooms. How could their experiences be so different? The answer is variation. Variation is the enemy of quality and of standard processes. In the absence of standards, tremendous variation emerges in all activities, pro- ducing a wide range of experiences and outcomes.
To illustrate this point further, conduct the “draw a pig” exercise, related to visual cues and carefully crafted instructions, known as standard work. The complete exercise can be found in the Minnesota Office of Continuous Improvement Toolkit (MNCI 2016). Briefly, participants are asked to perform four sequential stages of this exercise.
Stage 1: Each participant is given a sheet of paper with nine equal squares on it. They are asked to draw a pig. Each participant is given two minutes to complete the activity. The facilitator collects all the papers, and the group views the outcomes. The results vary tremendously in the appearance of the pig (the outcome). Each person has applied his or her creativity in producing the pig, which is limited by each person’s expertise in drawing. Significantly, many participants tend not to finish the exercise in the time allowed.
Stage 2: Each participant is given a sheet of paper with nine equal squares on it, as in the first stage. The difference this time is the facilitator also provides a carefully written set of instructions on how to draw the pig. The participants are again given two minutes to draw the pig. Each person reads and interprets the instructions according to his or her own frame of reference. The facilitator again collects all the papers, and again the group sees a great deal of variation, albeit less than in stage 1. As in the first stage of the exercise, a number of the participants typically are unable to finish the activity in the time allowed.
Stage 3: Each participant is again given a sheet of paper with nine equal squares on it. This time, the facilitator provides the group with instructions for drawing the pig as well as an image of what the final result should look like. The participants are given one minute to complete the task.
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At the end of the time, the facilitator collects the drawings and finds that virtually everyone was able to complete the task, with a striking reduction in the variation of the drawings (see exhibit 10.3).
Stage 4: The participants review the group’s drawings from each stage, further illustrating the points of the exercise.
The overall lesson from this exercise may be obvious, but it is a dramatic dem- onstration in an experiential learning framework that allows the participants to see the nature of variation as well as how important standard work is in reducing that variation. It also emphasizes the importance of experience in the work performed. The more learning opportunities of this nature that practice members experience, the more able they are to understand why similar patients may have very different experiences and perceive a differ- ence in service in a practice.
The red bead experiment and the “draw a pig” exercise might be seen as contra- dictory. The red bead experiment implies that work should not be standardized and that workers should be involved in how the work is done, whereas the “draw a pig” exercise seems to support the notion that standardization improves quality by reducing variation. Both implications are true. Practices must standardize effective processes and continually
exhIbIt 10.3 The Standard Pig
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improve them through worker involvement. In that way, they provide the best methods of performing the work at any given time to all their patients.
Direct contact with the patient requires that professional judgment and variation be applied, but these direct contact processes, including front- and back-office operations and how patients flow through the practice, can all benefit from standardization.
Regardless of a practice’s size or the services it provides, a fundamental knowledge of the quality improvement process is essential. We can always do better, and we should always consider that opportunity in everything we do. The minute a practice stops improving or looking for opportunities to improve, it begins to stagnate. Staying the same in a medical practice is not an option.
Lean is a quality improvement process created by the Toyota Motor Company that focuses on the elimination of waste (Liker 2004). Waste is defined from the perspective of the customer—for medical practices, the patient—as unnecessary steps in a process or procedure that create no value for the customer.
The eight commonly identified types of waste in Lean are as follows:
◆ Overproduction, or doing more than is required or doing it earlier than needed.
◆ Waiting, for people, supplies, or activities, at any step in a process. Waiting to see the clinician, standing in line to register, or being on hold during a phone call are examples.
◆ Transportation, or getting people or things to their required locations. Moving mobile equipment from place to place is an example.
◆ Inventory, such as records, supplies, and unfinished work. Having unfinished charts or keeping more supplies at the work station than needed are examples.
◆ Motion, or extra steps taken because of inefficient layouts of the workplace. Having a work station far away from the examining rooms is an example.
◆ Defects, or rework that must be done because of an error. A lost lab test or record is an example; another is repeat phone calls to the practice due to slow follow-up.
◆ Underutilization of people, or having people work beneath their skill level and not listening to their ideas.
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The time a patient waits to see a provider in a medical practice provides no value to the patient and, in fact, provides no value to the practice. In the author’s experience, the number one complaint for many medical practices is waiting time: Of the more than 5,000 complaints reviewed, roughly 4,000 were related to complaints about wait times or delays in receiving test results. A typical Lean project in a medical practice undertaken to address patient wait times is demonstrated by the following story. The CEO of a well-known healthcare organization was showing a Lean master from Japan around the organization. With much pride, the CEO guided the master from place to place and gave a careful explanation of the services and aspects of each location. When they entered a waiting room, the Lean master asked, “What space is this?” The CEO replied, “It’s a waiting room.” The Lean master responded, “What waits here?” And the CEO, now startled, replied, “Patients, of course!” The Lean master said, “Didn’t you know they were coming?” The CEO said, “Of course. Some of them have had appointments for almost a year.” At that, the Lean master looked the CEO in the eye and said, “Aren’t you ashamed?” He meant, shouldn’t the practice be ashamed that it was not better prepared to receive patients even though it had ample time to do so? The CEO gained a new perspective following this visit (Virginia Mason Medical Center, personal communication, 2013).
The Lean master only asked questions up until the final statement. He was helping the CEO understand the nature of the situation, not simply telling him what it was. In addition, the story helps us see that we are often too interested in explaining why something is wrong or why it cannot be changed, rather than thinking deeply about how we might improve the situation. This excuse making may be particularly evident in healthcare because of the industry’s reluctance to admit its shortcomings.