Bringing Value: No Compromising on Quality of Care

For the greater good of their organizations, physician leaders must be proactive in every improvement initiative. Here are considerations for anyone helping to lead a charge for change.

Every health care institution today has a program related to quality assurance and improvement. Performance metrics are routinely collected, many of which are required by federal and state regulators. But thoughtful physician leaders might wonder if their organizations are doing everything necessary to improve quality, and whether measuring performance and meeting benchmarks means uncompromising quality. The answer is complicated.

Focus on the two most important words in the preceding paragraph: uncompromising and quality. Try to understand the meaning of each in the context of today’s health care environment.

Conceptually, quality always has been thought of as how the customer perceives a product or service. Since health care has many different customers — patients, families, regulators, payers, etc. — the perception of quality will differ depending on the stakeholder perspective. Patients might see it from the perspectives of access and timeliness, while payers might view quality from the perspective of accuracy of documentation. Furthermore, expectations surrounding quality evolve as health care does.

The challenge in creating uncompromising quality is — much like how French essayist Marcel Proust once described the voyage of discovery — a matter of seeing it with new eyes. So let’s put quality into a functional and workable framework with new eyes.

There are four reasons to pursue quality as a primary corporate strategy:

• To improve the experience of the patient.

• To improve the health of the population.

• To reduce per capita costs of health care and become an efficient organization.

• To ensure sustainability of the enterprise.

Every physician understands and probably agrees with the first three reasons. However, the fourth might be difficult to understand. Until recently, health care organizations have been shielded from the competitive landscape common to most other industries. Now it’s imperative for all physician leaders to be able to explain to others in their organizations what’s happening — and also help the organization strategically plan to gain a competitive advantage with quality as the cornerstone.

Quality’s Varying Definitions

The Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine once suggested the following definition of health care quality: “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

This definition is patient-centric and doesn’t provide the broader industry view of quality that would be required of a physician leader, who must bridge the gap between the perception of quality relative to patient care, and the perception of quality relative to the business of medicine.

That’s reflected in this definition: “A business case for an improvement activity exists if the organization that invests in the activity realizes a financial return on its investment in a reasonable time frame, using a reasonable rate of discounting (effects of inflation). This may be realized as ‘bankable dollars’ (profit), a reduction in losses for a given program or population, or avoided costs. In addition, a business case may exist if the organization believes that a positive indirect impact on organizational function and sustainability will accrue (goodwill) within a reasonable time frame.”1

In addition to this definition, one can define quality from an operational perspective, which would include outcomes, features, timeliness, reliability, durability, uniformity, consistency, serviceability, aesthetics, personal interface, flexibility, safety, image and usability.2

Indeed, quality has different faces that need to be incorporated into an organization’s strategic vision and plans.

Quality’s Varying Types

There are three general types of quality that affect every organization, whether it’s a manufacturing company or a service company.

• Perceptive quality: That which is viewed by the customer looking in from the outside. It can be shaped by individual values, attitudes and beliefs, preferences, previous experiences and societal perception.

• Appreciative quality: That which the customer experiences with a service or product. For customer satisfaction, it’s important to segment your customers based on their individual needs and requirements.

• Measurable quality: That which physicians tend to focus on, thanks to defined metrics. Examples include mortality, functional status, infection rates, antibiotic timing, appropriate care, access and more.

There also are three rules that guide those general types of quality.

• Quality always involves meeting or exceeding customer expectations. But most experts say simply meeting customer expectations is a bare minimum.

• Quality is dynamic. What’s considered good today might not be good enough tomorrow. Just think of what was considered good quality in the automobile industry 40 years ago.

• Quality can be improved. The ultimate business truism applies to health care: In order to survive in the marketplace, you have to change or improve faster and more efficiently than your competitors.

When it comes to patient care quality, there are two primary considerations: the service a patient receives and the quality of the care. The first is shaped by the patient’s perception of institutional quality, environmental quality, and quality of provider interaction. The second is shaped by the patient’s perception of the appropriateness of the service and how skillfully it was delivered.

Quality’s Varying Barriers

There might be some obstacles to quality improvement in your organization,3 including lack of time to implement change amid other pressing priorities; resistance to change; inability to see change as improvement; satisfying numerous stakeholders; securing the necessary resources; and gaining leadership commitment.

Management, in particular, might not see a need for change — especially senior leaders who don’t think about systems. Managers might also have unclear goals, which would hinder any improvement process. There also might be a culture unsupportive of change, a weak customer focus, or ineffective workforce training.

The fact that health care largely functions in organizational silos makes quality initiatives more difficult for physician leaders. This often creates a clash of cultures that hinders organizational progress. Consider traditional health care vs. future thinking.

In traditional health care, providers are thought to know what is best for patients and families and care, and institutions and regulators focus on people rather than processes for the cause of harm and bad outcomes. Moreover, many institutions set arbitrary goals that hinder them from achieving better performance.4

Future approaches will require a radical departure.4 Organizations must create cultures in which everyone is expected to exceed the customer’s expectations, focus on improving the processes of care, reward excellence, work smarter using data to drive decisions, and relentlessly pursue zero errors through defined goals.

Institutions whose cultural profiles score higher on group-oriented and developmentally oriented measures emphasizing collaboration, empowerment and risk-taking are more advanced in implementing their quality improvement activities than institutions whose cultures emphasize hierarchy and bureaucracy.5

Where Physician Leaders Fit in

Culture is the collective beliefs, norms and values, spoken or unspoken, that form the basis for patterns of behavior within an organization.6 Establishing this culture requires embedding specific core values in the organization — a responsibility of the physician leaders in an organization. These core values are behavioral traits that every member of the workforce, including the senior leaders, must display on a continuous basis. These core values include the following: respect for people, communication, timeliness of care, patient-centered care, professional competence, effectiveness of care, employee empowerment, accessibility, leadership at the top, employee satisfaction, continuity of care, appropriateness of care, resource use and continuous learning.

Establishing an understanding of quality requires an in-depth knowledge of the science of performance improvement, an important attribute for any physician leader. So how should a physician leader frame quality into its relevant buckets? The answer is found in six supporting ideas.

• First, understand the operational laws and principles of the health care industry. Like clinical medicine, the practice of business has specific operating principles and laws that govern how the enterprise functions from moment to moment.

• Second, understand and appreciate that a complex organization is made up of a series of systems/processes that are linked and have interdependencies. Changes that affect one system will have a reactionary effect on other systems/processes in the organization.

• Third, reduce variation of care. Methods such as Six Sigma or statistical process control are important areas of knowledge for any physician leader to acquire.

• Fourth, become facile with basic data analysis and interpretation. This requires a strong working knowledge of statistics and data presentation.

• Fifth, understand knowledge management. Organizations that categorize and store information for future use are more capable of advancing improvement because there will be less time spent reinventing the wheel.

• Sixth, and probably most important, understand human psychology. The fact of the matter is that health care, like other industries, depends on the ability of its workforce to appropriately interact with customers and among themselves. Emotions and perceptions influence how humans respond to change.

Defining ‘Uncompromising’

So how does a physician leader create uncompromising quality? Leadership drives the vision for an organization, which, in turn, creates consistency of purpose throughout it. When workers understand this, a culture of quality will be the norm. Uncompromising patient care is driven by a relentless focus on the customer, systems thinking, the use of statistical process control, teamwork, intense communication and timely employee feedback.7 A consistent customer-oriented approach will establish a disciplined workforce, using disciplined thought and responding with disciplined action.

The goals of any quality program should include the following: No unnecessary complexity, no waste, minimal inspection, no rework, continuously improving processes, and an emphasis on zero defects. So what steps can a physician leader do? Here are 10 guiding ideas:7

1. Create a strategic focus for your organization. Develop a mission, vision and values statement that emphasizes quality and defines organizational objectives supported by performance improvement initiatives.

2. Develop a relentless focus on the customer, emphasizing both customer satisfaction and health outcomes as performance measures.

3. Understand your organization as a composite of systems and processes in which leadership analyzes the whole system providing a service, not just a single element (such as a department or nursing floor).

4. Create an environment in which the organization, systems and processes are continually analyzed, using data in order to evaluate performance.

5. Ensure senior leaders involve everyone. This builds alignment — a common understanding of the organization’s delivery processes and the expectations of senior leaders toward customer service and care.

6. Recognize that most problems are due to multiple causation. Uncompromising quality requires identifying all causes of system or process issues. Root cause analysis or failure mode effect analysis can help.

7. Establish a solution identification process that enhances overall system performance through simultaneous improvements in a number of normally independent functions.

8. Seek every opportunity to review and improve care and administrative processes through process optimization, which emphasizes the needs of all internal and external stakeholders.

9. Embed a culture of continuous improvement. Organizations that achieve uncompromising quality are ones that look inward to eliminate poorly functioning processes and outward for evidence-based techniques.

10. Learn from others and from your own mistakes.8 Top organizations emphasize learning to enhance the capacity to generate process improvement and foster personal growth.

Eugene Fibuch, MD, CPE, CHCQM, FACPE, FABQAURP, is professor emeritus at the School of Medicine and co-director of the physician leadership program at the Henry W. Bloch School of Management at the University of Missouri in Kansas City.

Arif Ahmed, BDS, PhD, MSPH, is an associate professor of health administration in the Henry W. Bloch School of Management and co-director of the physician leadership program at the University of Missouri in Kansas City.

REFERENCES

1. Leatherman S, et al, 2003. “The business case for quality.” Health Affairs, 22(2); 17-30.

2. Langley G., et al, 2009. The Improvement Guide. 2nd ed. Jossey-Bass. San Francisco, Calif.

3. Gaucher EJ, J. “Innovative Management.” GOAL/QPC pp 73-88, Fall 2001.

4. Leider HL. “Evolution of Quality.” ACPE Fall Institute. 2007.

5. Shortell S. “Evaluating New Ways of Managing Quality.” J Quality Improvement 1994;2:90-96.

6. Helmreich RL, Merritt AC. Culture at Work in Aviation and Medicine.

7. Sollecito WA, Johnson JK. 2013. Continuous Quality Improvement in Health Care. 4th Ed. Jones and Bartlett.

8. Senge PM. The Fifth Discipline: The art and practice of the learning organization. 1994. Currency and Doubleday, New York, N.Y.