Health Care Article Missed Some Valuable Points

Maureen Bisognano's article "New Skills Needed in Medical Leadership" (June 2000, p. 32) made some good suggestions about improving health care quality. However, the fact that the article didn't address the following issues means that its recommendations are not likely to bring substantial improvement.

1. Numerous studies demonstrate a substantial "practice makes perfect" relationship between hospital volume and patient outcomes. Taking advantage of these findings would require hospitals and their associated physicians to restrict product offerings when in reality, they are both more inclined to expand into areas of less and less familiarity.

Similarly, studies have also found that hospital intensive care physician specialists (intensivists) significantly improve outcomes. While this approach does not impair hospital revenues, it does threaten many physicians and thus is often strongly opposed as well.

2. Traditional "fee-for-service" medicine rewards poor quality by paying more for extended, repeated and additional services incurred as a result of not doing it right the first time. Thus, significant quality improvement would likely reduce the income of many hospitals and physicians.

3. Physicians often do not follow best practices. For example, despite research findings that the use of beta-blocker drugs following a heart attack increases the probability of survival up to 40%, one recent study found that only 21% of eligible patients received them. One reason for such findings is that medicine is a very broad, complicated and constantly changing field. Unfortunately, many physicians view use of best practice medicine guides as an affront to their autonomy, and if sufficiently pressured by hospital administrators, can retaliate by taking their patients elsewhere and/or forcing a change of management.

4. Theoretically, health maintenance organizations (HMOs) are in a much better position to bring about constructive change. For example, they could help direct patients to appropriate high volume providers and hospitals and force improved best practice compliance through practice audits. Unfortunately, severe federal and state limitations on patients' ability to sue HMOs for malpractice reduce their incentive to do so.

5. There is currently little or no credible, readily available information to help consumers evaluate health care outcomes and thus motivate improvement.

So, how can we significantly improve health care quality? We must start by remembering that, for reasons similar to the preceding, significant quality improvement in areas other than health care did not originate from within. Instead, it was led/forced by knowledgeable and dissatisfied customers. Major employers represent some of health care's strongest customers, have strong motivation and leverage to bring about change, and can act quickly. Employers must:

1. Educate their employees and retirees on the "practice makes perfect" findings of credible academic research and ensure that their employees have appropriate alternatives. Similarly, employers should require hospitals to use intensivists in their critical care areas.

2. Require rigorous, regular medical practice audits at the hospital and HMO level, with the results disclosed to the employers' beneficiaries.

3. Require that hospitals significantly reduce medication errors (a major source of quality problems) by direct physician entry of medication orders and automatic computer analysis of those orders for appropriateness. This approach has been demonstrated to be effective and was also recommended in the article "A Trio for Quality" (Paul M. Schyve, M.D., June 2000, p. 53).

The result would be that health care outcomes would substantially improve, and employers and beneficiaries would benefit from reduced health care costs and improved health status.

Scottsdale, AZ 

Teams Won't Succeed Without Certain Conditions

I have a few comments on the article "Creative Thinking for Surprising Quality" by Paul E. Plsek (May 2000, p. 67). The brainstorming technique was first used in America to accomplish two equally important goals: solve problems and begin the turning on of a work force long ignored and needing a great many behavioral issues addressed. The human concepts inherent in the technique accomplished the following:

1. Brainstorming training provided the opportunity to explain and demonstrate why and how the tool worked. It began the important task of letting workers know that the company cared about them.

2. Once into the sessions, it soon became clear to team members that their collective abilities were truly becoming the synergistic reality they were taught about in the beginning. This realization helped to build the inclusive benefits of brainstorming: a greater sense of teamwork, safety and belonging.

3. Worker motivation was slowly unleashed in the safety and success of these sessions.

4. Participants then began to feel an ownership of their jobs, teams and companies.

5. Participants felt so personally validated that they began to explore further avenues of personal growth, including getting more education and becoming more involved in other activities.

The cumulative effects of these activities produced a complete win-win outcome for the worker and the company. But however magical these early brainstorming activities seemed to be, there were several conditions associated with their success. Without these conditions most efforts at creating teams did not and will not succeed. The conditions were:

1. Team members must volunteer or be randomly selected. It later became clear that work units evolved into the most effective teams. Handpicking the sharpest workers to do anything sends a bad message to the others, affording them little opportunity or motivation for growth.

2. All members must be trained in both the techniques of brainstorming and in underlying group dynamics. There are simple ways to transfer understandable knowledge about how certain things make team members feel and behave.

3. A facilitator with a good understanding of group dynamics must constantly monitor the team's behavior, spot any negative influences and determine what training or other action is needed to improve the condition. The same holds true for positive influences.

4. Every proposal emanating from the team must be recognized by management and implemented when possible. When that's not possible, management must explain why.

Creativity was and is an important product of the human processes inherent in a properly trained and supported brainstorming activity. Experienced quality professionals have long considered brainstorming as an almost essential part of early team development and of worker development in general.

Situational variations of solid quality tools are extremely desirable. However, these variations need not replace the tools, just fall into line with other variations that already exist.

Hemet, CA 

Author's Response

I fully agree with the excellent points raised by Billie Marcum. Brainstorming is a great tool for group involvement. Properly done, brainstorming creates a positive space where everyone is encouraged to participate and criticism is ruled out.

However, I was trying to make a different point. I explained that brainstorming by itself is a weak tool for creative thinking. While the rules of brainstorming create good conditions for individuals to express ideas, the rules do not tell you how to come up with a truly novel idea in the first place.

The tools I described in my article help direct thinking in ways that increase the chances that an individual will get a creative thought. Combine these creative thinking tools with the group process rules of brainstorming, and now you've got something powerful! But if no member of the group has a novel thought to begin with, creating conditions for maximal participation will not get you very far. Zero squared is still zero.

Roswell, GA 

Auditors Aim To Uncover, Drive Improvements

Dennis Arter makes a number of excellent points in his article "Beyond Compliance" (June 2000, p. 57). Many businesses familiar with the traditional compliance type of quality audit are ready to move beyond compliance. They want to use their audits to uncover and drive significant improvements. Success at this requires a shift in attitude by all parties participating in the audit. In particular, the frequent characterization of an auditor as a policeman is detrimental to the atmosphere of trust that's needed if businesses are to progress beyond compliance.

Virtually all audit participants want to see their organizations transformed into vibrant market leaders. Quality professionals can use this common motivation to initiate a change in relationship with general management. In some cases this means actively taking down barriers to trust that we help create, albeit unintentionally.

I disagree with Arter's comments on innovation: "There are times when downplaying innovation is good. For instance, would you really want the operators of a nerve gas incinerator to innovate?" To answer his question: Yes. I'd want the innovation. Innovation does not mean violating procedures or safety rules. It does not require endangering the customer, employee or community. It means using the imagination and creativity of your employees for the good of the enterprise.

Carl Jung said: "The creation of something new is not accomplished by the intellect but by the play instinct acting from inner necessity. The creative mind plays with the objects it loves." Creativity and innovation are going to happen, whether the quality system makes allowances for them or not.

Innovation is particularly important in the regulated industries where the regulations themselves frequently express society's dissatisfaction with the current state of the art. Whether it's the automotive, aviation or medical device industry, the quality professional's challenge is to create systems that make sense, rules that fit and paths that allow for change to be implemented safely and effectively. It is a job for everyone, but quality management can and should lead.

Brevard, NC 

Author's Response

Those are excellent points. Creativity and innovation by the enterprise are desirable and even necessary for survival. This is clearly described by Arie de Geus in his book The Living Company. However, innovation by the operator--alone and without the checks and balances of a management system--can be disastrous in a high-risk environment. Very smart minds have developed the process methods and they must be obeyed to the letter. To do otherwise would be wrong and might even cause harm.

Kennewick, WA 

Some Clarifying Comments On June's 'One Good Idea'

I want to commend Timothy J. Clark for his article "Getting the Most From Cause and Effect Diagrams" in the June 2000 issue of Quality Progress (p. 152). He clarifies the use of a much misunderstood, but powerful, root cause analysis team brainstorming aid. In addition, he illustrates the use of matrices to increase the effectiveness of root cause analyses.

However, an author cannot cover everything in a one-page article, and I think two clarifying comments are in order.

First, Clark's responsibility matrix lists categories as causes. All causes of quality issues are either specific behaviors or specific conditions. Categories don't cause anything and, in addition, are not amenable to solutions. On the other hand, behaviors and conditions can be changed or compensated for. All root cause analyses should get to the specific behaviors and conditions before categorizing them.

Second, a high level principle of root cause analysis is the statement: "Surgery before diagnosis is malpractice." Unfortunately, the unwary could misinterpret Clark's action planning matrix as such. It is not clear that the root cause analysis team has really gone down the "why staircase" far enough to know what the fundamental underlying causes are and what might be done about them.

Windsor, CT 

Author's Response

The intent and scope of my article were not to discuss root cause analysis, but to illustrate how information generated from such analysis could be organized to help optimize improvement efforts.

The causes listed on the responsibility matrix were identified as causes (without the description) on the cause and effect diagram provided in Figure 1. The relationship of the cause and effect diagram combined with the responsibility matrix does make the distinction between categories and specific conditions or behaviors (see cause plus description on the responsibility matrix).

When working with groups in brainstorming potential causes, I prefer to record as many ideas as quickly as possible, and one word is easier to capture. The next step in the process is to transition to the responsibility matrix where more detailed descriptions of the causes are developed by asking "why" several times.

The "wow" phase of the process occurs when the process owner is identified, and the degree of control is determined. This helps participants better understand the systems aspect of improvement and raises the awareness that there are actions that can help make a difference.

Regarding the comment on the action planning matrix, identifying a theory as to the root cause in many situations is in the eyes of the beholder and infers a prediction that is either proved or disproved through action. The purpose of the planning matrix is to facilitate action and learning. Both the responsibility and action planning matrices provide a template that makes it easier to document the story and communicate any resulting best practices of lessons learned.

Indianapolis, IN

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