How healthcare providers in America can teach lessons on quality improvement

As quality improvement fellows funded by the Health Foundation, we are privileged to spend a year studying and learning at the Institute for Healthcare Improvement (IHI) in Cambridge, Massachusetts – a long-standing international leader in the field. 

On entering the US, we were both asked by immigration officers whether the US was really the best place to study healthcare, and many readers may share the officers’ scepticism about the US healthcare system. 

Whatever the answer to that question might be, the timing of our fellowship is deeply significant: briefly side-stepping a cataclysmic reorganisation of the NHS back home, we are witnessing major changes in healthcare in the US, with the gradual implementation of the Patient Protection and Affordable Care Act (assuming that legislation survives).  

One of our wise mentors here, Professor Paul Batalden, reminded us that the challenge of our day is not to cut costs, but to do what we are here to do more efficiently. For us in the NHS, this is the only way to remain true to the NHS’s purpose and values (1).

Our aim as fellows is to learn to improve the experience for individual patients, and the health outcomes for populations, at an affordable per capita overall cost. Achieving these three interrelated aims (the ‘IHI Triple Aim’) (2) is challenging in whichever country you work. Even in the competitive US healthcare ‘industry’, organisations that have trusted in business models that aim primarily to increase market size and market share are having to think again.

In the UK, the challenge is to provide more value with the same resource (3) during the largest-ever NHS reorganisation. Each time we describe it, we see American jaws drop.

Reflecting on these challenges, the definition of leadership by Marshall Ganz, lecturer in public policy at the Harvard’s J.F. Kennedy School of Government, resonates strongly with us: ‘Leadership is taking responsibility for enabling others to achieve shared purpose in the face of uncertainty’.(4)  

This view of leadership requires us to equip people at all levels to lead in order to achieve their common purpose. Mary Parker Follet, an inspirational Bostonian observer of 20^th century business, asked: ‘How can a business be so organised that workers, managers, owners feel a collective responsibility?’(5)

With this in mind we asked ourselves, what have successful healthcare organisations done to create a common purpose, and to be able to deliver that purpose in times of great challenge and uncertainty?

The Commonwealth Fund’s recent detailed comparison of seven healthcare systems ranks the UK second and the US system last (6). Despite this rather dismal overall picture of US healthcare, individual healthcare organisations and their leaders in the US have achieved admirable progress. 

We share our impressions of what we have observed in some of the US healthcare providers that have successfully focused their attention on quality improvements, while keeping a close eye on their bottom line (7) (8) (9) (10) (11) (12) (13). We describe the common themes we have noted and that appear to be helpful in building the necessary will to execute change:

1. A consistent approach to improvement, and capability building for improvement

Enabling people to lead improvements in their own work processes is key. The successful and dynamic US healthcare organisations we have had the privilege of visiting (Virginia Mason, Seattle, WA; Intermountain Healthcare, Salt Lake City, UT; Baylor Health Care Systems, Dallas, TX; Bellin Health, Green Bay, WI; Mayo, Rochester, MN; Kaiser Permanente - to name just a few) have a consistent model and approach for improving quality and performance. 

They offer internal training programs to introduce staff to the organisation’s model and methods for continuous performance improvement. In many cases, however, the learning is “on the job” – you learn how to improve while improving your own work processes under the guidance of improvement coaches or experts. This ensures that a critical mass of staff speak the same language and are able to use effective, simple, and commonly understood methods across the organisation. 

This does not necessarily require a large training machinery; what seems more important is that a consistent approach is practised across the organisation (be it Lean, Six Sigma, Model for Improvement, Production System Design, or any combination thereof), and staff are supported in developing and applying relevant skills. As a consequence, these learning organisations are capable of identifying and reducing waste, and improving their way out of a whole variety of problems. 

2. Population health thinking and solution building

Thinking of and enacting solutions beyond disease and organisational boundaries appears to be a critical strategic precursor to the ‘Triple Aim’ (2): better care for individuals, better health for populations, and lower per capita costs. The Triple Aim is premised upon reducing disease burden over time and not just treating it now.

Understanding the whole population context of health, disease, need, and demand must be a shared knowledge base, and improving population health must be a shared aim. No specialist area or organisation alone is able to address the challenges of an ageing population during tough economic times - with or without reorganisation. 

For services to be sustainable and affordable they need to be planned across the continuum of patients’ health and care needs, not in a well defended bunker. Clinical leadership is essential for this, but not sufficient. The system must allow and equip clinical leaders to act in the interest of population health. This is where a historically strong public health function and coherent healthcare system could put the NHS in a much better position than the fragmented US healthcare system where organisations understandably struggle with both the concept and the execution of a population health approach. 

Nevertheless, the US healthcare providers that have developed and integrated care pathways between primary and secondary (or even tertiary) care (such as Intermountain Health, Mayo Clinic and Virginia Mason) are among the best prepared for the new realities of increasing integration and a move towards more capitation-based payment systems. 

US healthcare systems are beginning to discover the strength of employers (as payers) and their interest in keeping the population healthy, and organisations such as Kaiser Permanente are actively playing an important role in promoting and improving the health of not only their members, but also the wider community. 

3. Leading with intelligence

Any improvement (not just of clinical quality) is dependent upon comprehensive knowledge about processes, as well as the needs of patients and families. In the case of healthcare, this includes intelligence about patient outcomes, the consistent application of best practice, and efficiency of existing processes, as well as the ability to identify and interpret variations in process and outcome measures. Leading healthcare organisations tell us that they would not have achieved the necessary service coordination and integration without electronic health records (in many cases across the service continuum).

The best example known to us is Intermountain Healthcare in Utah, which has a long history of developing clinical information systems. Teams have developed and agreed detailed care processes for the majority of conditions encountered, and regularly review them in the light of not just new evidence, but also local intelligence about the quality and outcomes of care delivered. The comprehensive information system tracks the use of and adherence to agreed care processes, and allows learning from reasoned deviations. 

Uniquely, the organisational structure is aligned with these care processes. Intermountain Healthcare states that: “Data is our vision - we must learn from it.” The data should be patient outcome data, not just activity data, and working towards intelligent IT systems is critical as an organisation improve the electronic healthcare record.

We have seen primary and secondary care providers working on a common dashboard of targets, relentlessly pursuing their “big dots” (i.e., a small number of strategic goals) together. Information systems need to serve the continuous improvement effort, and learning organisations need information systems that support learning rather than merely judgement of performance. Performance management using poorly defined or crude measures has the potential to distort incentives and achieve little or – worse – unintended consequences (14). 

4.  Leadership for quality from the very top, and for the long haul

Successful organisations demonstrate clear and sustained leadership for quality from top to bottom. This is explicitly driven from the executive team and board. “Walking the talk” is a physical not an electronic activity and must be consistent over time, often in excess of 10 years. The chief executive of a tertiary facility told us: “Safety trumps cost every time.” This means that quality is not just someone’s job, it is everybody’s job.  This priority must be reinforced at every level by behaviour, action, and communication.  

An ongoing dialogue with clinicians to define the respective responsibilities of the organisation and clinicians clearly has been a critical process for clinician engagement in several locations. The development and use of this so-called “compact” supports openness and frankness about shared values and commitments, and allows a culture of mutual responsibility and respect to develop.  Good examples here are Virginia Mason, Thedacare, and Cincinnati Children’s Hospital.

5. The patient and their family are the focus of attention at all times

The inclusion of patients and families can have a significant impact on decisions made, not just about individual care, but about how care is provided generally. The patient’s perspective is a vital component in solution building, as patients and families know the complexity of their care only too well. Engaging patients in designing the care so as to reduce wasteful steps and improve handovers can improve outcomes and efficiency simultaneously. This can happen with a surgical procedure (knee replacement in Pittsburgh) or a chronic disease (diabetes care in Minnesota).

The Mayo Clinic, one of the most iconic of US healthcare organisations, exemplifies the success of truly patient-centered care, rooted in its statement, ’Quality is not just a simple measure. Quality is a comprehensive look at all aspects of a patient’s experience’ (15). More recent success stories of systems using customer-focused production system design approaches (e.g. Bellin Health) further underscore this point.

6. Alignment of financial measures and quality measures

The challenge when increasing efficiency is to retain value. To this end quality measures should have at least as high a priority as financial measures. We have seen a sharing of the responsibility for delivering cross-system measures so as to support healthy lifestyles and reduce the impact of chronic diseases. This is theoretically much easier for UK local healthcare economies to undertake. The initiation of ‘whole system’ alignment is starting to be seen as a way forward even in the US system where organisational independence and market forces are strong. Further research on how people work in a network to better achieve an agreed outcome may become an additional tool in helping cross-organisational co-operation (16).

Finally, the US healthcare environment provides a natural laboratory in which innovation and improvement develop (and failures happen) in many different ways (17). In the UK, the NHS Institute for Innovation and Improvement, the Health Foundation, and others, have done much to help organisations translate and implement current knowledge to achieve improvements in quality and safety.  

All organisations face a similar leadership challenge: how to maximise confidence and commitment among those involved in order to manage the future challenges of demographics, cost containment, and continuous improvements in safety and quality. Considering each of the areas we described may help organisational leaders deliver sustained quality improvement for their patients and communities.

References

1. http://www.nhsemployers.org/EmploymentPolicyAndPractice/staff-engagement/NHS_Values/Pages/NHSValues.aspx. [Online]
2. The Triple Aim; care, health and cost.Berwick, DM., Nolan, TW., Whittington, J., 3, May/June 2008, Health Affairs, Vol. 27, pp. 759-769.
3. http:www.kingsfund.org.uk/current_projects/quality_in_a_cold_climate/improving_nhs.html. [Online] 2010.
4. Ganz, Marshall.Organizing in the 21st Century: Leadership, Organizing, and Action. Workshop Guide 2010. 2010.
5. http://www.follettfoundation.org/mpf.htm. [Online]
6. Measuring the US Health Care System: A Cross-National Comparison. Issues in International Health Policy. http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2010/Jun/1412_Anderson_measuring_US_hlt_c.Anderson, G., Squires, D.. 2010 June.
7. http://www.leapfroggroup.org/news/leapfrog_news/4784721. [Online]
8. http://www.innovations.ahrq.gov/content.aspx?id=2407. [Online]
9. The Mayo Clinic Approach.Swenson, S., Dilling, J. et al. 2009, The American Jounral of Medical Quality, Vol. 24, pp. 428-440.
10. Cost Cutting in Healthcare without Compromsiing Quality.Clark DD, Savitz LA, Pingree SB. (2), 2010, Health Service Management, Vol. 27, pp. 19-30.
11. http://www.qualityforum.org/News_And_Resources/Press_Releases/2008/National_Quality_Forum_presents_Baylor_Healthcare_Systems_with_2008_National_Quality_Healthcare_Award.aspx. [Online]
12. http://www.wisconsinhealthreports.org/data. [Online]
13. http://www.baylorhealth.com/About/AwardsAccreditations/Pages/BHCSAwards.aspx. [Online]
14. Lewis, R., Alvarez Rosete, A., Mays, Nicholas.,How to Regulate Health Care. s.l.: Kings Fund, 2006.
15. http://www.mayoclinic.org/patient-visitor-guide/. [Online]
16. A Relational Model of How High performacen Systems Work.Hoffer Gittel, J., Seidner, R., Wimbush, J., March/April 2010, Organisation Science, Vol. 1, pp. 490-506.
17. Bate Paul, Mendell Peter, Robert Glenn.Organising for Quality The Improvement Journeys of leading hospitals in Europe and United States vement journey of hospitals. s.l. : Radcliffe Publishers Nuffield Trust, 2008.