Medicare: New Directions in Quality Assurance Proceedings (1991)

Chip Caldwell

This paper addresses a management philosophy and a model referred to as organization-wide continuous quality improvement. It uses examples from one hospital that has implemented this mode to provide real-life examples of the theoretical structure Mortimer (1991) described in the previous chapter.

I would introduce my hospital, West Paces Ferry Hospital, as a radically different place to practice medicine and to receive health care than it was before November 1987. I would introduce it as a place where employees in every position understand the mission of the hospital, the definition of quality, how we measure quality, and most important, their individual roles in improving quality. It is a place where every employee understands the tools necessary to measure and improve quality.

How do I know this is true? Let me offer several brief examples. I spent one hour and forty-five minutes with every employee in an orientation session that emphasizes exercises using quality improvement tools. Every department maintains an active Quality Improvement Team (QIT), and the QITs produce improvements so rapidly that we have difficulty tracking them. Finally, we have a systematic mechanism for measuring quality advances at every level of the organization. Our Patient Quality Trends increased from 77 percent in October 1988 to 88 percent by October 1989.

More specifically, the hospital-wide quality improvement process contains three components, Quality Improvement (QI) Policy, Quality Improvement Teams, and Quality Improvement in Daily Work Life. QI Policy answers those questions I first raised. What is the mission of our organization?

What are our definition of quality, the measures of quality, and the role of each individual and physician in the organization in improving quality? What are the tools necessary to measure and improve quality? The structure to implement QI Policy is through QI Teams and QI in Daily Work Life.

We are excited about what we are doing. Many questions remain about applying the continuous improvement model in health care and about using the techniques taught us through the Deming management method in clinical applications. We have some clinical successes, but as many questions remain to be answered as have been answered.

I was delighted with the ideas discussed by Mortimer (1991). A drawing similar to his Figure 5.1 was produced in early 1988 when a group of quality assurance directors within the Hospital Corporation of America (HCA)¹ met to debate the differences between quality assurance and quality improvement. Quality assurance identifies the 5 percent or so of problems evident in every process and seeks to reduce the bad outcomes. Quality improvement, by contrast, examines the entire spectrum of outputs and attempts to improve the entire process and reduce variation.

The first judgment of the HCA group was that quality assurance was bad. We have come a long way in our understanding since then. Quality assurance is not bad; it is just part of a quality improvement model. It is a subset of quality improvement, an activity we now call "quality alarms." All quality organizations we have studied—Florida Power and Light, Xerox, Baxter, Hewlett-Packard—have quality alarms and processes to attack those "special causes" of problems. Thus, we have begun to think about quality assurance in a very different way. There is reason to look at the 5 percent or so of bad outcomes and systematically reduce them, but what I think we have ignored for the past 30 years in health care is the opportunity to improve the entire system and to reduce variation. That becomes, then, the focus of our quality improvement efforts—to reduce variation. Examine variation in outcomes, and the underlying processes producing these outcomes, rather than just concentrating on quality alarms.

What is the relation of our perspective to the recommendations of the Institute of Medicine (IOM, 1990) report? I am quite excited that the report

addresses continuous improvement as a model worth exploring. That conclusion is, nevertheless, associated with skepticism in many quarters about whether this continuous improvement can be applied to a health care system.

When I first began to see that continuous improvement was a better way to run hospitals, I had the same kind of skepticism about what we are doing now. I would begin with the question, Are this country's current models of quality assurance effectively improving the quality of health care in the United States? Perhaps, but the Japanese and more and more American companies are abandoning old ways for a continuous improvement approach. I embarked upon continuous improvement of quality not because of regulatory pressures, and not because of Joint Commission on Accreditation of Healthcare Organizations standards, but because I personally saw a better way to run hospitals and a better way to work cooperatively with our medical staff to improve quality. I also have many colleagues, both within the HCA and outside, who feel the same way and who are trying to make this work in their organizations. Many of us believe that quality of care can be improved if we can develop a mechanism in which we all learn and share together in the advancement of quality.

With that very brief orientation to a quality improvement program, I have five observations about the committee's work from a continuous improvement perspective. They are

1. a commitment to continuous improvement;

2. the power of locally developed initiatives;

3. widespread education about QI in schools of medicine, administration, and nursing;

4. the development of supportive methods of public review and oversight; and

5. community hospital as focal point of implementation.

First, an organization-wide continuous improvement model needs to be encouraged. I have had conversations with many people in sessions like these where it appears that attendees concluded that quality improvement is merely intensified quality assurance, simply a matter of degree of activity. That is not true. Continuous improvement is a matter of a distinction in fundamentals, not of degree of activity; it is organization-wide, and it calls for organization-wide commitment.

If we characterize HCA West Paces Ferry Hospital in 1988 as Hospital A, it is not in 1990 simply Hospital A plus quality improvement. Quality improvement is not just a management program. We in fact are experiencing a cultural transformation in which we are becoming Hospital B, a totally different organization in which the medical staff, employees, and the entire

management structure function around these measures of quality and the structures of QI in Daily Work Life. The hospital feeds itself on improvements.

Second, it is important to recognize the power of locally developed strategies. I was fearful when I saw that one of the ''new directions'' for this conference included "system-focused" quality improvement, perhaps implying that an effort such as this must be mounted through a "system" such as HCA. HCA is a wonderful resource for us, and HCA leadership has ensured an environment that fosters the QI Culture. Furthermore, many people at this conference, of course, are not with HCA but have become very valuable resources to us as well. My point, though, is that it is the power of a local institution, its employees and physicians, and its local culture of continuous improvement that make QI happen. It is the very nature of our culture that becomes so important, I think, not some regulatory pressure.

That leads me to a parallel observation about research. We need careful examination of the incentives that are present in our system today. What incentives are there for physicians to work cooperatively for quality improvement? Equally important, what disincentives are present in our system today? How effective have our sanctioning regulations been? Should we not systematically remove those disincentives?

The science practiced in community hospitals like mine is often viewed as bad science. A corollary notion is that if science does not come from a major academic center it is not good science. We have seen in our efforts at West Paces Ferry, however, that there is so much to be learned from the individual practices of local physicians if our research is systematically structured. Physicians embrace research initiatives. One question I am often asked is, why are physicians willing to become involved in clinical process improvement? My answer is, they enjoy it. Physicians by and large enjoy research; that is not the issue. It is the issue of disincentives and incentives, I think, that dampens their enthusiasm.

The power of learning from local physicians about their practices may be the best way of addressing the issues of overuse and perhaps even underuse of health care resources. As we systematically examine variations in practice patterns and locally based initiatives, it is evident where overuse occurs. Locally developed strategies should be cultivated by our regulators.

If the nation is to embark upon a transformation toward the widespread use of quality improvement in health care, many other things that have only been touched on will be fundamental to progress. One of these is the

exploration and publication of the best quality improvement practices. We need to develop mechanisms for learning from industry. For instance, one of our mentors is Florida Power and Light. We have learned tremendous things from them, but their tools are not universally applicable. Thus, in the past six months we have hired a physician to educate our medical staff in the use and modification of the seven statistical tools of the Deming method for their application in medicine. We are please with our success so far, but an accelerator to this progress would be better information and education about the best quality improvement practices that can be developed for use in health care.

More broadly, we need to learn how to teach this in schools of medicine, administration, and nursing. For instance, one early assignment for new department managers and employees at West Paces Ferry Hospital is complete reeducation regarding quality improvement. Why is variation important? What is a process? Within medical staffs, how can individuals work together and what is the role of continuous improvement in health care? It would be a tremendous accelerator and cost savings if physicians, nurses, and administrators came to the workplace in possession of these skills.

My fourth observation is that we should develop supportive methods of public review and oversight. A lot of dialogue is necessary for us in the field to examine how existing and future methods can support and provide incentives for advancing continuous improvement. Often, as positive programs such as the Medicare peer review organization program and those mentioned by the earlier panel are implemented, they unintentionally evolve into punitive bodies. These public review and oversight mechanisms are taken as antagonistic and intimidating by providers, rather than as partners.

As a chief executive officer (CEO) of a large enterprise, it often strikes me that the greatest threat to productivity in our work force is intimidation and fear. In fact, one of Deming's Fourteen Points is "drive out fear." Yet it seems that, every time we establish regulations, they evolve to the point of intimidation. There is not a person in this room, I think, who is motivated best by fear of being singled out as a failure. Rather, motivation works because, as individuals, we like to feel a part of what we are doing and to enjoy our successes. By our very nature we like to advance quality and to be recognized for our achievements. Yet it seems that so often our regulatory practices and other initiatives are antagonistic and intimidating.

The final observation I would make is that there is merit in considering the community hospital as a focal point for QI initiatives. There is no focal

point today, no mechanism to examine the effectiveness of care provided through a doctor's office, a hospital, or an outpatient setting, and to examine those patients three months, six months, or two years later.

I want to be careful that, because I am a CEO in a hospital, this point is not seen as an issue of control or power. Rather more importantly, the community hospital offers a mechanism, a meeting place or in quality policy deployment lingo, the community hospital offers a framework and structure for people to come together, including physicians, nurses, home care providers, and doctor's office personnel. We have a number of QI Teams where these kinds of initiatives are successful. One of these, our cesarean section team, for example, has been able to reduce the Cesarean-section rate at West Paces from about 22 percent to just over 18 percent.

As Dr. Relman (Relman, 1991) says, one thing absent in the IOM committee's recommendations is the focal point for physician office practices. I would like to suggest that the community hospital offers a mechanism through a continuous improvement model that looks at the extended process. There are other examples. We have a QI Team looking at operating room turnover. That team was able, in just a few months, to reduce the length of time in the holding area from 23 minutes to 16 minutes. The team also includes someone from a doctor's office, because as it looked for root causes of variation, it found that one major cause of variation was the absence of laboratory, x-ray, and electrocardiogram work. The team further examined root causes and found that the pre-admission process could facilitate efficiency. This team was expanded to include those people outside the boundaries of the hospital, and it increased the pre-admission rate from 17 percent to more than 80 percent.

West Paces Ferry Hospital, and others, have had numerous successes in implementing quality improvement to which I could point. What would be lost, in concentrating on the specifics of our exhaustive improvement diary would be the broader knowledge of the strength of the QI model, of having everyone in the organization involved in the continuous improvement of quality, of organizing the medical staff to work within that framework, and of the power of a culture in which improvements are commonplace.

Organization-wide continuous improvement has proven to be a necessary tool for America as we struggle to regain world dominance in the manufacture of industrial goods. It has proven effective in selected settings, such as HCA West Paces Ferry Hospital, in stimulating an environment in which quality improvement is a part of daily work life. Should we not capitalize on the creative energies of the thousands of Americans in health care professions dedicated to quality improvement, by giving them a supportive regulatory framework and an organization committed to continuous improvement?

Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990.

Mortimer, J.D. Organization- and System-Focused Quality Improvement: The Committee View. Pp. 31-36 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.

Relman, A.S. A Physician's Response to the Institute of Medicine Report. Pp. 167-173 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N. eds. Washington, D.C.: National Academy Press, 1991.