Creating a Business Case for Quality Improvement Research Expert Views: Workshop Summary (2008) / Chapter Skim
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1 The Business Case for Quality Improvement
1 The Business Case for Quality Improvement
Pages 5-23
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From page 5... ...
Illustrate how quality improvement and quality improvement research can impact greater production use of plant and human assets, lead to product differentiation and branding, generate revenue enhancements, improve cost structure, and impact other core operational goals to create competitive advantages. • What are the characteristics of an ideal enterprise culture and effective governance orientation that promote and accelerate improvement in quality and quality improvement research?
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Specifically, support services and a focus on primary care for chronic disease management have resulted in improved care, fewer emergency room visits, and fewer admissions, yielding large financial savings. Costs actually increased 5 percent to 10 percent among HealthSpring's other providers.
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The program worked in a managed care, capitated payment system because the care was focused on primary care services and referrals. Primary care physicians therefore often followed their patients across the entire spectrum of health care services and had access to all of their health information, becoming a patient's "medical home." Patients were happier with the care they received because the care was more patient centered, as best shown in settings offering concierge services, such as HealthSpring's Personal Assistant Liaison program, which provides one-on-one support to help members manage their own care.
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The need to create a business case for quality improvement is only one constraint to providing high-value health care; it is not the goal. The ultimate goal of health care is to improve patient care and safety, while the ultimate goal of patient safety is to prevent inadvertent harm to the patient resulting from the care he or she receives.
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Change in health care is not just about reducing costs; it is more about improving value and delivering good care. This must be understood to enlist the support of care providers.
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It was well known that issues associated with health professionals involved in criminal acts, substance abuse, or intentionally unsafe acts would become public, and punishment would follow. However, by changing the environment and clarifying that only those types of activities were subject to punitive measures, workers reporting unintentional errors to the safety system could feel safe.
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Management must be involved in safety efforts by talking about it and making it a priority and a regular part of all activities; it is a marathon, not a sprint. Identifying causes of errors requires root cause analyses, but solving errors requires development of actions, outcome measures, and a commitment to provide resources necessary for change.
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This evolution in thinking came as a result of better science, which gives hope for advancement. In 1955 a physician managing the care of a patient with breast cancer either provided mostly palliative care or performed radical mastectomies in hopes of a cure.
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The system needs to be managed as a whole, not in pieces; when problems are identified, they must be dealt with in order to achieve a safer health care system. Integrated health care system The journey to high-quality, efficient systems is a long one, said Gary Kaplan, CEO of the Virginia Mason Medical System.
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Traditionally in group practices, compacts tend to mean physicians will be protected, have autonomy, and have a sense of entitlement, leading to a physician-centered health care environment, Kaplan said. However, in an environment focused on evidence-based guidelines and patient safety, the traditional compact is inappropriate, leading Virginia Mason to develop a new compact.
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When an insurer pointed out that Virginia Mason was not as cost-effective as it could be in certain areas, it looked for ways to make its processes more cost-effective. The company engaged in a process with the insurer, providers, and employers to focus on the highest cost diagnoses and applied evidence-based guidelines, with lean and cost accounting to redesign care delivery.
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For back pain, Virginia Mason originally made profits only on MRIs, but after standardizing processes and dramatically reducing numbers of MRIs, the employer agreed to triple payments for physical therapy to allow Virginia Mason to break even. The revised, more efficient processes required fewer staff and saved the employer $17 per hour in indirect costs.
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First, the Virginia Mason Production System has improved quality, access, and patient satisfaction and has decreased costs. This has led to an overall improvement in the value of care, leading Virginia Mason leaders to conclude that about half of health care costs may be avoidable.
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Care delivered in accordance with this model improved care coordination, resulting in fewer readmissions, reduced numbers of hospital days, and increased percentages of patients without rehospitalizations. The net savings of the advanced practice nurse transition care model totaled $5,000 per patient and reduced total costs by 38 percent (McCauley et al., 2006; Naylor et al., 2004)
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Efforts to face challenges brought about by changing culture therefore must address physicians, nurses, and all other health care professionals. Each professional must change his or her own practices and adapt training to meet the demands of a changing health care system and, more importantly, the patient.
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While some would say that Virginia Mason is different because it practices in community settings and an integrated system, the problems are the same: Evidence-based care is not followed consistently, and society is overpaying for medical procedures. Advances made by Virginia Mason have been great, Fritch said, but cannot be widely implemented and sustained in the current health care system.
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For example, one practice waived patient copays and provided the nurse support on its own. When the CDC declared that beta blockers should be used in 90 percent of cardiac patients by 2010, the VA was already up to 99 percent, said Bagian.
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Additionally, consumer reports provide comparisons of different cars for people's different preferences. Learning about patient experiences in health care is not as easy.
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THE BUSINESS CASE FOR QUALITY IMPROVEMENT 23 However, transparency is also critical internally within organizations, for people must feel comfortable acknowledging that they can harm patients, a mind-set that must be supported by organizational leadership. Fritch agreed, adding that consumers must be made aware of improved quality and have consistent access to such information.
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