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Health care quality professionals agree that a growing emphasis on process improvement likely will occur in the years ahead. Not surprisingly, they also see much greater use of technology.
But that’s about as much consensus as you can find among the broad spectrum of experts surveyed by QI/TQM. Not only do they have widely divergent visions of the future, but they don’t always agree when distinguishing what should happen from what will happen.
"I’m beginning to think that dwelling on outcomes more than on process may be a misdirection," says Patricia Drury, MBA, a health care consultant in Minneapolis. "The focus should be on process; get the process right, and the outcome will take care of itself. A system that achieves good outcomes inadvertently with a flawed process and fails to meet patients’ emotional needs is nobody’s idea of quality care." (For more on process improvement and what business can teach health care organizations, see "Health care can no longer avoid business-born tools," in this issue.)
The evidence is that if a system does match an individual patient’s needs and the patient feels he or she is better able to play a role in the decision-making process, the outcome is better, says Drury. However, she concedes, "I don’t think it will happen. It’s too hard because there are too many things that are subjective — like adapting to a patient’s emotional state and needs. But what pushes us in that direction is that measuring process is easier than measuring outcomes. It’s more unambiguous; you don’t have to do case mix adjustment and so forth."
We also will see a lot more standardization of care — but not customization, says Drury. "And we will continue to see the development of processes directly related to patient safety. This is clearly under way, and it will get more intense. It will show up in purchasing decisions, accreditation, and employers through the efforts of the Leapfrog Group, [a consortium of Fortune 500 firms designed to address concerns about medical errors.]" (For more information on the Leapfrog Group, see QI/TQM, October 2000.)
Jyme Arthur, RN, PhD, manager of performance improvement at M.D. Anderson Cancer Center in Houston, also sees a mixed bag of challenge and opportunity. "We’re all about improvement, which is encouraging," she says. "Doing a lot more with fewer resources — that’s the name of the game; it feels like we’re fighting the good fight but losing the battle. Health care costs continue to rise in spite of our efforts, but the positive message is that we do continue to improve."
Future trends are daunting, Arthur admits. "The forecast is that we could reach crisis levels again in 2010 and 2020 when the baby boomers’ start to retire and health care costs increase. Then there’s the nursing shortage. I’ve read that 63% of nurses working today are 40 or older, and they’re not being replaced."
Meeting these challenges will require a tremendous influx of creativity and innovation, she says. "When you back up and look at systems, you have to look at what innovations are out there, what creativity we can apply," notes Arthur. "That brings in technology. E-business is going to really modify our profession in the future. Even today, web-based programs are almost universal." Outsourcing will be another major trend, she predicts.
Mary C. Bostwick, health care specialist with the Malcolm Baldrige National Quality Award, based in Gaithersburg, MD, is a bit more sanguine about the prospects for improvement. In fact, she sees encouraging trends already. "We continue to see interest in the health care community in applying the Baldrige criteria in their organizations," she notes. "The evidence is the number of requests we get for criteria. We may send multiple hard copies to the same company."
[The Baldrige National Quality Program (BNQP) is part of the National Institute of Standards and Technology in the U.S. Department of Commerce. The BNQP is a private/public partnership. To learn more about the award go to: www.quality.nist.gov.]
The other positive indicator, she says, is the scoring process. "The average score in each criteria is increasing among health care organizations, and there is also a closing of the gap between health care and manufacturing," she notes. "In 1995, there was about a 15- to 20-point gap. In 1999, it had narrowed to about a 12-point gap. In 2000, it was down to 10%."
Bostwick draws her predictions by extrapolating from some patterns seen in business winners of the Baldrige Award. The national winners — and there have been no national winners yet from the health care industry — are characterized by visionary leadership, a focus on the customer, high-performance work systems, and a process-driven orientation, she notes. How will this translate into health care?
"Focusing on the customer entails knowing who your customers are and what your market segments are," she explains. "While the customer is primarily the patient, there are other stakeholders — physicians, payers, the community. Our winners look at all of them and balance their needs in an effective way. They also build up customer relations, where they listen and learn and respond to changing needs. That’s what results in high customer satisfaction."
High-performance work systems speak to how the job is organized and how the work is organized in a way that taps into the potential of workers, and empowers them to bring their efforts into alignment with the organization’s efforts. "Staff efforts — both paid employees and independent licensed practitioners — are tied back to processes that are driven by those customers’ requirements. That linkage enhances quality," says Bostwick.
Process-driven organizations, Bostwick concludes, design processes that are responsive to customers’ requirements; they manage them effectively; and they are constantly evaluating and improving them and sharing what they have learned with the rest of the organization. "They also must balance all stakeholders’ needs: For example, you can’t satisfy doctors at the expense of patient satisfaction," Bostwick says.
For Louis H. Diamond, MB, ChB, FACP, vice president and medical director of MEDSTAT Group Inc., based in Ann Arbor, MI, the future will be clearly marked by emerging megatrends. "There will be an increasing use of the Internet to facilitate not only communication between patients and members of the health care team, but also to collect information and to share recommendations, to help patients understand more so they can better manage their own care," he predicts.
"It will also enhance the ability of health care professionals to communicate with each other. In hospitals with private practice physicians, there’s no reason not to communicate with them in their offices via the Internet, so they don’t always have to come back to the hospital. When referring patients to specialists, there’s no reason this shouldn’t be communicated and the information transferred through the Internet. And why not communicate with the patient by some use of information technology?" Diamond asks.
The availability and repackaging of information to facilitate decision making will become more a part of day-to-day activities, says Diamond. "The massive explosion of scientific information is not accessible; within the next five to 10 years, it will become more accessible. We will have evidence-based medicine to inform treatment options."
There are groups trying to capture the literature and scientific information and put it into usable form, he says. "Through refined search tools and literature management databases, we will find ways to summarize the information so it will be more usable to the patient," he observes.
As a result of these first two mega trends, the level of participation by the patient will increase. "This will also come about because of a desire from a health care system model point of view to include them in self-care and decision making. A lot of that is already occurring today," says Diamond. Diamond sees these additional trends emerging as well:
— The measurement of performance of systems and individuals is going to be much more of an integral part of the delivery system than it currently is. Use of measures will continue to increase.
— The way we educate medical students, residents, and postgraduates will continue to fundamentally change in the direction of much more active, ongoing learning and problem-solving using the Internet and other technologies as compared to intermittent, theatre-style lectures. "Part of this education will hopefully include patients," Diamond says.
— The "silo effect" mentality will effectively break down to a concept of teams and a multi-disciplined approach, with the patient seen as part of the team.
— As part of the fundamental QI movement, there is going to have to be a standardization and simplification of activities in a way that balances the need for improvement and safety while not squashing out innovation, patients’ wishes, and clinical judgment.
A successful future for health care quality will depend on more complete fulfillment of the potential that exists, says Katharine Luther, RN, MPM, CPHQ, director, quality improvement at M.D. Anderson. "I believe we have plenty of resources, but we’re not using them well," she says. "We put up barriers everywhere. We set things up in health care to pit people against each other — doctors and nurses, health care organizations, and insurance companies. We hire people to watch each other, and the patient is lost in the process. We may have four or five people for every patient; those patients should be getting good care. Patients and their families could be valuable resources, but we’re not using them."
Luther recommends a number of strategies for the future. "Have all the stakeholders at the table," she advises. "Before we start treating cancer patients, we ought to know what they want the outcome to be, what level of care they want, and how they want to get it. Will they travel for care? Do they want their families as part of that care?"
Luther also says the "command/control" model of organization has got to go. "I visit leading health care institutions on a regular basis; you could drop me in any one of them and I could find my way around," she says. "They’re not intuitive to the patient." The challenge, she says, is to make the pursuit of quality real to allow the patient to drive care and to help the frontline staff be able to do that. "We need to begin to take the tools we know and in dynamic change environments begin to help people make changes."
A "dynamic change environment," Luther explains, allows anyone to intervene on behalf of the patient — a housekeeper, a nurse, or a clerk. "In the current environment, most people wouldn’t even try that; they’d get yelled at," notes Luther. "Or if they succeeded, they’d be seen as operating outside the model. We are really not comfortable outside of the box." The key, she says, is to let middle managers be the facilitators of change. "The front line should be saying, We need to make this change,’ and the top should be saying good idea,’" Luther concludes.
What emerges, then, is an industry in tension; knowing that changes are necessary, and in many cases, what those changes should be. Yet the jury is still out on how many of those changes will actually be made in the decade ahead. Will things dramatically improve? "Only if that improvement is measured, and customers know about it," says Drury. n