Providers mandate: Earn back consumer trust
Promise quality and deliver it
(Don Berwick, MD, is our featured guest for this month's interview. Don's name and that of his IHI (Institute for Healthcare Improvement) Breakthrough Series are well-known to quality professionals, especially when discussions turn to rapid improvement of health care outcomes.
In 1991, he co-founded IHI, a nonprofit organization that brings together health care institutions committed to changing their care processes in order to improve clinical outcomes and other aspects of health. IHI advocates cooperation rather than competition in the health care industry. A practicing pediatrician at Boston Children's Hospital and pediatrics consultant at Massachusetts General Hospital, Berwick stays firmly grounded in the everyday issues of health care delivery. He is completing a one-year appointment to President Clinton's Advisory Commission on Consumer Protection and Quality in the Health care Industry.
For the Commission's report, visit the Web site http://www.hcqualitycommission.gov.)
Question: Tell us how your Breakthrough Series is different from other quality consortia?
Answer: The series is a little different from approaches I'm familiar with, as well as those I've used in the past. The series focuses on speed using the theory that enough knowledge exists for achieving improvement, and that knowledge is ready for use. We're willing to push rather hard on shortening the time before that knowledge is put into action. It's also more focused on the topic. It's not about quality improvement or quality management or any particular set of tools. It's about the particular topic being examined - for example, cardiac surgery, low back pain, or waiting times.
It's a very strong subject matter focus and linked more closely with processes in which the supply of information is crucial. And it emphasizes testing. The theory we use in the Break-through Series emphasizes the use of prototypes and cycles. Cycles are what we call PDSA: plan, do, study, act. These cycles are the hallmark of action. When people are conducting tests of change, then they're into the improvement process.
Question: What steps are dropped from the traditional change process?
Answer: I don't think there's any one traditional process. We have to be careful not to interpret either the forerunners or the Breakthrough Series in a cookbook way. We're certainly learning as we go. I think we have less emphasis on tools.
We don't require a tremendous amount of quantitative data analysis of existing processes or documentation of problems. We're willing to trust intuition and data from other places. If there's a prevailing problem in the management of asthma, for instance, it's likely that the problem exists in your organization and even a little bit of information might be enough. We're also less concerned about people following a particular series of steps. We want to see people getting to the test as quickly as they can. I don't want to claim that the Breakthrough Series is alone or that we're the final answer to anything. We are in the process of trying to understand how to accelerate improvements in organizations. Every new collaborative is different from, and hopefully better, than the ones that went before.
Question: How important is it that organizations use accelerated change methods?
Answer: It's not important that they use accelerated change methods, but it is important that they accelerate change. It's time that we in the industry use what we know more deliberately.
Question: As an industry, how are we doing with the time it takes to make change today compared to five years ago?
Answer: Some things are definitely better. There's more physician involvement; it's much easier to gain doctors' and other clinicians' readiness to make changes. Often they try to participate in - and sometimes even try to get control of - the improvement processes, which is great. I think we're getting good at project-level improvement. Once someone at a senior level has decided that a specific improvement should occur and has really given it resources, we usually know how to achieve it.
With the Breakthrough Series, we can probably succeed in projects up to three out of four times. There's a better understanding about the positive relationship between efficiency and quality and between cost reduction and improvement of process. The same things that make our patients better often save money.
Gaps that are obvious now are the centering of improvement as a strategy in the organization and taking responsibility for improvement by senior clinical and executive leaders in organizations. I don't think we're going fast enough yet. We have to learn not to sit around, especially when we have a prototype. There's a particular problem we have as an industry in spreading prototypes into general use. System integration remains a problem. We can generate fragmentary improvements, but it's very hard to make it all tell a story. The next phase of our improvement in health care will be to deal with creating systems improvement.
Question: Are there certain clinical or operational areas that are underserved by quality improvement efforts?
Answer: Yes. The opportunities for improvement in health care are everywhere. They're not just in clinical areas. They're in back office processes, operational processes, architecture, the flow of supplies, and resource management. Believe me; the low-hanging fruit is still on the tree!
Question: It's been suggested that, as an industry, we put a lot of effort into identifying our quality problems but very few resources into solutions. If that's so, is it changing?
Answer: That's an insider-outsider issue. The accreditation organizations have increased the heat. And surveillance of the health care industry for problems is growing - even as we speak - under the banner of accountability or public release of performance information. So inside health care, all of us are moving forward quickly to reveal problems in the way we do our work.
The outsiders - the surveillance apparatus - can't possibly make the changes in the system. That's not their job; they can only highlight what we're doing. It's the insiders in the organization that have to make the changes, and that's where the lag is. We know a lot more about what we could improve, but we have not centered those improvements in the strategies of organizational leaders.
It's similar to running track. We have good people on the sidelines with their stopwatches telling us how fast we're going, but the runners aren't changing. It's a fallacy to believe that correct measuring or surveillance is the key to fixing the problem. It isn't; it's a component of the solution. Only when those who make care change care can the problem get better.
Question: IHI Breakthrough Series collaborative membership is relatively expensive. How do you convince members and would-be members that it is cost-effective, especially when most QI departments are experiencing cutbacks?
Answer: The fee for an organization to join its first collaborative right now is $12,000 and $10,000 to join subsequent ones. We're trying to cut that cost, determining what in the collaborative really adds value and what doesn't. The participation fee to join the collaborative is only part of the cost to organizations. They also have to pay their own expenses to manage their teams and travel to meetings. It can be costly. I think the cutback by organizations in investing in improvement reflects the lack of commitment by senior management. It is the same as saying, "We can't afford to improve because we have to do our work."
In some sense, that may be correct because you're not paid directly to improve. Improvement has to catapult you in a better budgetary position. Partly, there's a burden to understand which kinds of improvement do and do not help financially. We haven't done the financial work we need to do in the industry to understand the link between performance improvements and financial improvements.
However, I still have this very strong belief that the return on investment for the improvements the Breakthrough Series undertakes is extremely high. Organizations that join collaborative efforts such as this and achieve improvements are making a lot of money. I think they're gaining on their investment in several ways. In fact, organizations that join the Breakthrough Series report back to us that they save much more than it ever cost to get involved. We have many organizations that are joining additional collaboratives.
So in part, the issue of the apparent expense is an accounting problem. It's difficult to trace all of the benefits unless you have a formal way to examine that.
Question: The Joint Commission on Accreditation of Healthcare Organizations is moving to realign its accreditation standards toward a higher emphasis on quality outcomes as opposed to process measurements. It's setting up its ORYX-Plus system to become a national outcomes benchmark database. Is it in our best interest that ORYX or something similar comes into existence?
Answer: I'm no expert on ORYX so I'd prefer not to comment directly about it. I think it would help to have some common data because there's a bit of a problem nationally. It would decrease the costs because a deliverer of care today may be accountable to a number of parties who are asking for outcomes information, and the deliverer has to put it into a different form for each requester.
Also, if we had standardized outcome data, we might be better able to find organizations that are excelling and use them as national prototypes. I wouldn't like to encourage a vast expansion of the surveillance apparatus in the country because we're really invested in performance measurement right now where we need to invest in improving performance - which isn't the same thing. Or else we're just going to keep measuring the same old stuff.
Question: The Columbia/HCA scandals and the Medicare/Medicaid frauds are putting consumers and providers on edge. Additionally, they're generating tighter controls among the regulatory agencies. How is the industry going to ride out these problems?
Answer: There is a problem here, and it's not just these scandals and frauds and reactions to them. The deeper problem is that most doctors and most executives in health care are honest and are trying to do a good job. They feel beleaguered and insulted and misunderstood when they're the objects of suspicion all the time, so there's an erosion of spirit and trust and goodwill that I think is costly to everyone. Clearly the industry is trying to ride out the problems, but actually it has to solve the problems.
The first thing is to be honest and not tolerate the thieves among us. There's a clean-our-own-house problem here that has got to remain a high priority. In fact, self-policing activities and intolerance of dishonesty, or even craftiness, is something we've got to get better at. But the real answer to trust is to make promises and keep them.
As an industry, if we made more promises to reduce errors and did so, to have a stronger correspondence between the evidence from science and health care; if we were to be more dignified and answered questions faster, reduced wait times, and respected the individual needs of our patients, and then deliver on those promises, I think we'd have less of a problem. People build trust by being trustworthy. The problem in healthcare is not to look better - it's to be better.
Another level to the problem is that society needs to clarify what ethical standards ought to apply to the health care industry. We have an impending crisis as to what ethics unify us all whether we're HMO executives, payers, doctors, nurses, or managers. We tend to have discipline-specific views of ethics. That isn't going to work. Instead, we need a systemic view of ethics. I think that will help us all understand what the boundaries are that we should not cross because it's wrong to cross them.
Question: If you were a CEO in a community hospital, how would you position your facility against these trust issues within your service area?
Answer: Identify aims for improvement. Promise improvement and then achieve it. Get better at meeting needs. In the long run - if not in the short run - if I could identify improvements that patients, families, and the community need and could promise and deliver those improvements, then I would not just survive, I'd be much better off in the future. I would center my strategy on improving my organization and meeting the needs of the people who come to me for help.
[Don Berwick, MD, is president and CEO of the Boston-based Institute for Healthcare Improvement. If you would like more information about IHI or the Breakthrough Series, call (617) 754-4800. Or write to Institute for Healthcare Improvement, 135 Francis St., Boston, MA 02215.]
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