Solutions for Quality Improvement Directors
Quality improvement skills are necessary for today’s health care professionals to successfully manage their patients and add value to their organizations.
Since medical and nursing training programs do not adequately teach these skills, it falls to medical organizations to provide the necessary training. Creating dramatic improvement in today’s medical organizations requires the “graduates” to have adequate knowledge in sustainable business principles as well as the skills to lead change in complex systems.
Focusing on chronic diseases provides the best opportunity for dramatic improvement in patient care and service while freeing up resources to accelerate further innovation.
Medical organizations such as Intermountain Health Care that provide instruction to health care professionals on quality improvement techniques have taken an important step forward. The Institute for Health Care Delivery Research at Intermountain Health Care offers advanced training programs for health care professionals. They are comprehensive, well established and one of the best programs in the country. I was fortunate to complete their training where I witnessed what can be achieved through the skillful application of statistical process control techniques. Achievements ranged from first time projects by fellow students to impressive projects at Intermountain Health Care stemming from their investment and commitment to quality improvement. I was taught to lead and manage quality improvement projects. In addition to my 30 years of experience caring for patients and leading innovation, the lessons I learned at Intermountain have led me to formulate five recommendations to create dramatic improvement in patient care:
- Focus on the care of chronic diseases
- Shift from “controlling” to “curing” chronic conditions
- Measure multiple results for projects
- Apply an appropriate finance model
- Adopt a long-term strategy toward primary prevention
Chronic disease accounts for up to 80% of our health care costs, results in significant suffering for patients and families and places a burden on most specialties. Focusing on this area provides the best opportunity for dramatic improvement in patient care and service while freeing up resources to accelerate further innovation. It is important for projects to be carried out at the level of the clinical team, where most care of chronic diseases is coordinated and provided. Good initial selections would be arterial disease, obesity or type 2 Diabetes. Consider for example, how these recommendations might apply in the approach to type 2 Diabetes.
From tertiary to secondary prevention
Medical organizations devote resources to the primary prevention (preventing disease), secondary prevention (curing disease) and tertiary prevention (controlling disease) of chronic diseases. They have focused most of their resources on tertiary prevention with the use of drugs and procedures. While understandable, it is not a path to success. Using more drugs and procedures not only adds to the cost of care but also increases the likelihood of complications and errors and at best, slows progression of the disease. During my training, Dr. Larry Staker presented his project on the control of diabetes in his patient population. His project was published in Quality Management in Health Care, 2000, 9(1), 1-13. His work showed improvement by focusing on proper medication (i.e. tertiary prevention) and measurement. Since Dr. Staker’s work in the 1990’s, the science and clinical studies have shown that stabilizing, reversing and curing type 2 Diabetes is indeed possible. My own clinical experience has shown cure (i.e. normal fasting blood sugar and hgbA1C on no hypoglycemic agents) to be doable. What are the implications for quality improvement teams and the organization? The quality improvement teams need to review the scientific literature on secondary prevention for the “causes and effects” step of their project. The goal of the project should be to “cure” not “control” type 2 Diabetes. Since current “quality targets” are often defined based on “control” the team will need to track and report both “cure” and “control” measures. Leaders need to shift the organizational focus from tertiary to secondary prevention both by the projects they sponsor and the goals they set. For instance, a target goal might be to reduce the incidence of type 2 Diabetes in a patient population by 50%… a result that would constitute dramatic improvement.
Innovation in complex or adaptive systems (e.g. clinical teams, health care organizations) should be approached differently than projects involving merely complicated processes such as projects designed to reduce the postoperative infection rate in elective surgery. One key difference is the importance of measuring multiple parameters. There are many examples of innovations that optimize one measure of a complex system only to see decline in other measures or, in the extreme case, the failure of the entire system. For instance a clinic might implement an “open access” model to get patients appointments in a timely fashion. They succeed in getting patients appointments quickly but in the process there is a decline in quality, provider satisfaction and/or finances. Conversely, properly designed and implemented projects in complex systems can see improvement in multiple areas. This is especially true for projects involving the secondary prevention of chronic conditions. The “cure” of type 2 Diabetes often results in the “cure” of other conditions (e.g. hypertension, hyperlipidemia, reflux disease). These parameters are readily identified at the “cause and effect” step during the literature search on secondary prevention for the targeted chronic condition.
The cost of medical care is placing a burden on individuals, families, businesses, the nation and the environment. If quality improvement projects are to contribute to lowering the cost of medical care they need to include measures of financial performance. Leaders, more specifically authorizing sponsors, need to support these projects with the proper financial processes and models. These should be designed to accelerate the diffusion of innovation at the level of the clinical team. The underlying concepts for these models should be included in quality improvement training. At a minimum they should include general financial concepts, budgeting, gain sharing, and investment strategies. Success would be the demonstration of reduced costs for the organization and for patients.
Toward primary prevention
My final recommendation arises from an important design principle in complex systems. To create dramatic breakthroughs especially in decreasing costs you need to focus “upstream” in the design process. An example would be designing a building so efficiently that it didn’t require a heat and air conditioning system. This would mean savings in both construction costs and operating costs, including repairs. This principle provides further support for changing the focus of medical organizations from “tertiary” prevention to “secondary” prevention. Even more success can be found moving farther “upstream” and focusing on “primary” prevention. Few medical organizations have developed programs geared to primary prevention. They trust the job to primary care providers (i.e. physicians, nurse practitioners and physician assistants.) The two biggest problems with pursuing this strategy for primary prevention are the introduction of variability and the lack of knowledge and skills. Both of these problems are addressed by first demonstrating success in the secondary prevention of chronic diseases before developing and implementing programs to deliver on primary prevention. By first focusing on secondary prevention the organization can lay the necessary foundation (e.g. money, provider skills and knowledge, support systems) for developing and implementing systems to demonstrate improvement in primary prevention. An example would be an organizational goal to reduce the average fasting blood sugars in “normal” patients from 90 to 85. If done this would result in fewer “normal” patients becoming prediabetic. It would also result in improvement in other metrics (e.g. weight, blood pressures, cholesterol).
I believe these recommendations will put medical organizations on the path to truly dramatic improvements in quality and service accompanied by reduction in the cost of care. Traveling this path will prove challenging but has the potential to transform medical organizations from providing “disease” care to “health” care. I believe that is a strategy that everyone in a medical organization could support.
I offer a half-day presentation supporting my recommendations. I provide an overview of the science that supports the secondary prevention of arterial disease, type 2 Diabetes and obesity. I introduce the key principles of natural capitalism, which includes leveraging change in complex systems and finance. I propose a path for accelerating improvement using the “freed” up resources from stabilizing, reversing and curing chronic disease. I provide tools (i.e. decision making, prioritizing) to support the work. My experience allows me to offer a unique presentation that “bridges” the gap between front-line health care professionals and health care managers and leaders. My goal is to motivate attendees to begin a challenging but rewarding journey leading to improvement of their personal health and the health of their organizations. Success would include less chronic disease and reduced health care costs.
I offer two 50-minute presentations that serve as an introduction to my half-day session. These are easily integrated into standard quality improvement training courses. They allow leaders of quality improvement training sessions to pilot, preview and evaluate my material. During my visit to give these two presentations I can gather information that would allow me to tailor my half-day session to add value to your existing program.