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The following HTML text is provided to enhance online readability. Many aspects of typography translate only awkwardly to HTML. Please use the page image as the authoritative form to ensure accuracy. Can Purchasers Leverage Engineering Principles to Improve Health Care?Arnold Milstein Pacific Business Group on Health and The Leapfrog Group Most purchasers wish we didn’t have to think about the question in the title of my presentation. Most purchasers would like the health care industry to adopt quality engineering methods as a natural expression of professional responsibility; and we would like our health insurance beneficiaries to select only quality-engineered providers as an expression of informed consumerism. However, the three Institute of Medicine (IOM) reports on quality and rapidly increasing health care costs have persuaded large purchasers to consider how they might use their unique role to accelerate American providers’ journey to engineered care delivery. Waiting for other stakeholders to solve the problem is not a promising option. When I ask consumers, like my mother, why she isn’t a prudent buyer, she replies, “When I am well, I don’t want to think about health care. When I am sick, I want to be able to trust that my treatment will be error-free. When I go to doctors’ offices and hospitals, big white certifications with gold seals are hanging on the wall. I’d prefer to rely on them rather than be skeptical.” When I remind regulators that “Our moms are relying on you,” they reply, “It’s the tax cuts. We don’t have the budget to ensure quality, so we rely on accreditors.” When I ask accreditors about the IOM reports and the hospitals they certify, they reply, “You force us to rely on providers to pay us for our accreditation activities. If we become too demanding, they will find a more tolerant accreditor.” When I ask hospitals and doctors about high average national rates of quality failure and the IOM reports, they reply, “We don’t believe that our personal error rates are as bad as the national average. To achieve perfect care, we’d probably have to hire quality engineers and buy complex clinical information systems. Where is the money for that? Insurers don’t pay us any more for these things.” When we then turn to each other in the purchaser community, we agree that we have to do something about this. But many of us are understandably cautious, reasoning, “If we begin to get aggressive and limit our insurance plan networks to providers that are engineering high quality into their care, we will surely receive many complaints from our insurance beneficiaries that we are restricting their access to the doctors and hospitals they know and love. Then our careers will be at risk. We can only go as far as our beneficiaries/ consumers will let us go.” So we are back to our starting point in the “circle of nonaccountability” with consumers. Apparently, everyone is responsible for improving quality via better engineered care delivery methods, but no one feels accountable for its occurrence. Until every stakeholder has more responsibility for solutions, we aren’t likely to make much progress. How can purchasers leverage engineering principles to advance the interests of all stakeholders? Several options are available. First, purchasers can use various purchaser-mediated rewards to encourage health plans and providers to adopt engineering methods. Differential rewards could be offered to plans and providers who widely apply general engineering methods, such as the 80/20 principle, design for safety, mass customization, continuous flow production, and other methods that have worked well in other complex, high-risk industries. The most practical method of implementation may be to develop a meaningful ISO-type certification in health care and to make comprehensive, publicly released performance measurements available. We are very far from having anything like that today, at least not at a level that inspires confidence. Another approach would be to use systems analysis to identify narrow, high-yield single “ingredients” (e.g., uptake of electronic clinical information systems or implementation of robust disease registries to provide continuous, stratified population risk scores). We could select a menu of tangible, multifaceted “best-operating practices,” based on nationally distinguished care redesign efforts, such as the idealized design of clinical office practice or RWJ’s Pursuing Perfection winners, and reward other providers that adopt them or health plans that encourage their adoption. The Leapfrog Group
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