Archive for May, 2008

Clinical Reengineering

Wednesday, May 7th, 2008

It’s easy to get overwhelmed by the health care problem. At the system level, we struggle to cover all Americans, but we are daunted by the costs of system expansion, concerned about uneven quality and safety, and challenged by a shortage of trained professionals. It’s easy to become depressed. Yet there is cause for hope. Across the country, individuals, organizations and institutions are stepping up to make change happen at the grassroots level – one clinical care process at a time.

Historically, health care has paid inadequate attention to the language and practice of reengineering. In the late 1980s and early 1990s, every major industry in America embarked on a journey (which continues to this day) to improve quality and reduce costs. These industries paid systematic attention to business processes, information technology that rationalizes and streamlines those processes, and process improvement. All of this in the name of serving the customer, and making it happen better, faster, cheaper.

Health care is perhaps 20 years behind most industries on this journey. Admittedly, health care is complex, deals with matters of life and death, and has unusual organizational characteristics (such as the fact that some of the most important decision-makers don’t work for the organization). Yet we can’t excuse ourselves in health care from the need to reengineer.

The good news is that we are recognizing the problem, we have advocates and experts who are gaining momentum, and there are success stories on the ground.

Recognizing the Problem

Clinical care is becoming more complex. Patients get older, fatter and crankier every year. The majority of Medicare patients (some 55 percent) have five or more chronic conditions, leading one group of medical residents in the Carolinas to dub the typical patient as HONDAS (hypertensive, obese, noncompliant, diabetic, alcoholic and/or all systems failing). The growth in numbers of multiple comorbid patients puts additional strain on the system. It increases the complexity of intervention; adds to the challenge of lifting, transporting and assisting patients; and heightens the stress nurses and other caregivers face in dealing with complex care regimens.

At the same time, we have an aging workforce and aging physical plants that were designed for a different era. The physical environment can impair efforts to improve care processes, and an increasing body of evidence from the Center for Health Design and elsewhere points to the fact that improved physical layout can have a positive impact on care processes and outcomes.

The rise of transparency has been a positive force in encouraging clinical improvement. But the downside is that the burden of measurement increasingly falls on caregivers at the bedside. Whether it is pay-for-performance systems, patient safety initiatives, outcomes measurement or patient classification systems tied to mandatory staffing ratios, all of these put an additional data collection burden on front-line caregivers. Unfortunately, most electronic medical record systems, even when they exist, do not spontaneously capture all the required data for these new measures of clinical performance.

Trying to improve clinical care by simply throwing more resources at the problem does not seem to be a sustainable solution. (This is the micro version of the “fallacy of excellence” issue I wrote about in a previous column.)

Gaining Momentum

Path-breaking organizations such as the Institute for Healthcare Improvement (IHI) have long recognized the need to help health care transform at the clinical process level. Most recently through the 100,000 Lives Campaign and its sequel the 5 Million Lives Campaign, IHI has rallied the field to improve in the name of patient safety and quality.

At the same time, we are seeing new evidence of how big the gap is between current practice and what might be possible in a better-designed care system. The ambitious time and motion study led by Ann Hendrich of Ascension Health and Marilyn Chow of Kaiser Permanente used multiple, sophisticated tracking tools to monitor the real behavior of nurses on typical med-surg floors. Their early results, and more yet to be published, found that nurses spend a relatively small part of their time (less than a third) in direct patient care. The rest of their time was spent in documentation tasks and “hunting and gathering” activities where they had to chase down equipment and supplies. These insights provide new evidence for the importance of redesigning clinical care processes to eliminate waste motion and to deliver improved patient care.

Keys to Success

As I travel around the country, I see growing interest in and commitment to clinical reengineering. Here are some observations about what’s working well and why.

Importance of leadership. In almost every case of constructive change I have come across, leaders have placed an enormously high priority on clinical process improvement. Some leaders are leading this charge from a patient safety perspective, some from a quality and outcome perspective, and some more from a value perspective. But in all cases leaders are committed to redesigning care processes so they are safer and more reliable, they deliver higher quality care and they eliminate unnecessary costs.

A willingness to look outside. Jeff Thomson, CEO of Gundersen-Lutheran in Wisconsin, is committed to clinical redesign as a physician CEO of a large and nationally acclaimed health system. Interestingly, he has hired system engineering experts from outside health care to work on the redesign. Similarly, Gary Kaplan, another physician CEO who is at Virginia-Mason in Seattle, is a believer in lean manufacturing. He has made regular site visits and immersion experiences in Japan’s lean manufacturing culture, taking along his senior managers and board members to learn from outside health care.

Celebration of victory. While measurement may place a burden on front-line caregivers, it can also reward through demonstrable results. Most folk working in health care are genuinely committed to improving care, and most of them, particularly physicians, respond well to data-driven feedback. There is nothing more empowering than knowing you are doing a better job for patients every day.

Investing in clinical reengineers. Enlightened organizations are investing in specialized resources dedicated to improving care processes. For example, the Mayo Clinic has specialized staff designing new clinical processes in conjunction with front-line staff and creating working simulations of these process redesigns in specialized experimental space. But we need to take this idea much further and create armies of nurses, physicians, respiratory therapists, laboratory technologists and other professionals who are cross-trained in systems disciplines. It is only when the front-line people are given the knowledge and skill to transform their work that we will have clinical processes that are effective and efficient for patients and caregivers alike.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN OnLine. This article 1st appeared on May 4, 2008 in HHN Magazine online site.

The New American Compromise

Saturday, May 3rd, 2008

In the 1980s and 1990s, an American compromise called managed competition was the dominant force behind health reform. Born from the ideas of Alain Enthoven at Stanford University, the theory laid out a path where consumers picked plans when they were well and lived with the consequences of their decision when they were sick. Integrated delivery systems organized in an HMO model competed for business on the basis of cost and quality, and cost-conscious consumers had real incentives to select low-cost plans; otherwise, they paid hundreds of dollars a month for more expensive (and usually broader choice) alternatives.

Managed competition was the basis for health reform initiatives in California in the 1980s and was really the intellectual foundation for all health reform efforts in the 1990s, including the ill-fated Clinton health plan. Managed competition worked best in a framework of universal coverage. Everyone was to be in a plan, and plan sponsors (such as employers or government) as well as individual consumers would have a marketplace of choices at the plan level or the integrated delivery system level. Kaiser-like entities would then compete on a value basis within a framework of universal coverage. I always kind of liked the idea because it reconciled issues of cost, quality and access, and I felt it was a genuinely American compromise between top-down control and consumer choice.

Shared Sacrifice

There is a “new American compromise” being forged. Emerging from the Romney and Schwarzenegger political aberrations (popular Republican governors in strongly Democratic states), the new American compromise makes universal coverage the primary goal. It is to be achieved through shared sacrifice in payment by business, government, individual households and even, in some cases, payment by special groups like smokers, doctors and hospitals.

The new compromise is forged from a belief that health care is both a right and an obligation: You have a right to expect access to health care but you have an obligation to pay your share of the tab. The compromise is a form of what I have called strategic incrementalism (incrementalism is going from one bad idea to another bad idea; strategic incrementalism takes steady steps toward a broader vision). The new compromise builds on existing public and private health insurance programs, it lets you keep what you have if you like it, it requires you to pay something for coverage if you have none, and it limits the behavior of health insurers in the marketplace.

The Massachusetts plan, Schwarzenegger’s California proposal and the plans of all the Democratic presidential candidates are close variants of this new compromise. Republican candidates as of this writing (in the early stages of 2008) have shown little interest in embracing universal coverage through shared sacrifice, preferring instead a combination of tax credits and deregulation of insurance markets to stimulate competition. Still, while none of them has embraced the new compromise (or said much about health care in his campaigning), whoever emerges as the candidate on the Republican side will be forced to talk about health care as the general election heats up. Why? Because, after the economy, health care is the dominant domestic issue for Democrats and Independents, which is in sharp contrast to the Republican ranking of health care as an issue (behind the economy, immigration and taxes).

A Real Debate

You could argue that the stars seem aligned for a victory for health reform, based on the new compromise, that leads to universal coverage, first in some landmark states like Massachusetts and California and then perhaps emulated through national policy. (I have always argued that Americans will not buy a car they haven’t driven. So they will want to see the new compromise working before they sign off on it.) But it is plausible to expect a real debate about health reform that may actually lead to political change and in turn to legislation.

However, there are a few things to watch for:

God is in the details. While the new compromise has been embraced by politicians on either side, there can be large and important differences in the details such as which groups of newly covered are added at what rate and to what maximum level. Is universal coverage the goal or is it simply significant coverage expansion (“universal coverage for some” was how an old colleague put it)? Similarly, while there is unanimity among Democrats about rolling back tax cuts for the rich to pay for health reform (and other things), unsurprisingly this view is not held by Republicans. Perhaps the most meaningful detail over which there is disagreement is in the degree of regulation or deregulation of the health insurance industry. Democrats are much more likely to tighten the rules on issuance, underwriting, and availability and funding of public versus private choices.

Political victory does not always mean legislation. It is one thing to speechify, to campaign and to win an election with health care reform as a plank in your platform. It is quite another to get laws passed and enacted that make massive change in one-sixth of the U.S. economy. Every lobbyist and their dog is itching to get into the middle of this next round of change making.

Affordability. Here is my big concern. We may succeed in getting everyone an insurance card, but to reach that laudable goal we may be ignoring the need to transform a delivery system to make it better, faster and cheaper than the system we have now. Giving people a card doesn’t solve the fundamental cost problem, and there seems little in the candidates’ proposals that will do much about the cost problem. We will have more people covered and we will pay significantly more to achieve it. Without adequate cost controls we may be digging our children an even bigger fiscal black hole than the one they are already facing.

Health reform should happen – it could happen. But if it addresses only coverage expansion and ignores the issues of affordability, quality and sustainability, we will have missed an opportunity to transform health care to deliver much higher performance for decades to come.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN OnLine. This article 1st appeared on March 4, 2008 in HHN Magazine online site.