HMGT 400 DISC 3

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9QUALITY AND SAFETY—EASIER SAID THAN DONE

It is not enough to know, we must also apply; it is not enough to will, we also must do.

—Johann Wolfgang von Goethe

Learning Objectives

• Understand the challenges of managing quality and safety. • Assess the state of the art in process improvement. • Consider the characteristics of a high reliability organization. • Evaluate why healthcare is so “siloed.” • Understand the importance of leadership and governance in quality

management. • Explore the possibility of interprofessional education as a solution.

This chapter will examine the topics of quality and safety in healthcare (see exhibit 9.1). Of course, these two concepts are closely related, to the point that we cannot possibly discuss healthcare quality without considering safety as a foundational component. After all, if patients are not safe, it is difficult to imagine how quality care and quality outcomes can occur.

The Institute of Medicine (IOM 2001) defines quality as “the degree to which health services for individuals and populations increase the likeli- hood of desired health outcomes and are consistent with current profes- sional knowledge.” The IOM defines safety, in a healthcare context, as “the prevention of harm to patients.” Expanding on these concepts, the Agency for Healthcare Research and Quality (AHRQ 2018) defines patient safety as “freedom from accidental or preventable injuries produced by medical care.” To support quality and safety, a system of care delivery must focus on

• preventing errors; • learning from the errors that do occur; and • building on a culture of safety that involves healthcare professionals,

organizations, and patients.

C o p y r i g h t 2 0 2 1 . A U P H A / H A P B o o k .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

EBSCO Publishing : eBook Academic Collection (EBSCOhost) - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS AN: 2452145 ; Stephen L. Wagner.; The United States Healthcare System: Overview, Driving Forces, and Outlook for the Future Account: s4264928.main.eds

The United States Healthcare System288

Cost Equitable

access

Quality

• Nature of our complex system • Historical issues that have influenced the

development of the system •

• Comparison with other developed countries

• Components of our healthcare system • People and providers • • Financing a massive system • • Medical and information technology • The pharmaceutical industry • Complementary and alternative

medicine • Politics/economics • The future of the system

The Aim of the Healthcare System Issues That Require Our Attention

For patients

Provider experience

Beliefs and attitudes about health and healthcare

Patient care—the purpose of the system

Quality—easier said than done

EXHIBIT 9.1 Area of Focus

for This Chapter

Quality and Safety: A Philosophical Background

Although quality in healthcare can be described, measured, and approached in a variety ways, it must start with a personal philosophy of excellence. More than 2,300 years ago, Aristotle (2009, 46) examined the topics of ethics and happiness, writing that “these virtues are formed in a man by his doing the actions.” These ideas were echoed by Goethe (1906) 2,000 years later, with the statement that “It is not enough to know.” Will Durant (1961, 98) sums up Aristotle’s thoughts as follows: “We are what we repeatedly do. Excel- lence, then, is not an act but a habit.” Quality and excellence are things we do automatically, not just because of rules, regulations, processes, or policies, but because quality and excellence are part of who we are. Great thought leaders on quality continue this line of thinking today.

Deming and the Red Bead Experiment W. Edwards Deming, regarded as the father of the quality revolution, famously said, “We are here to make another world” (Deming Institute 2019a). Deming emphasized the importance of understanding the “why”— not simply the “what”—in achieving superior services and performance. He

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 289

believed that people, for the most part, want to do their best, even when their working situation stands in the way, and that quality and high performance could not be achieved by inspection or coercion—a point illustrated by his famous red bead experiment (Deming 1986, 2000).

In the red bead experiment, a production line of unwitting partici- pants is shown a box containing a mix of red and white beads (Hunter 2014a, 2014b). The participants are given a paddle that has 50 slots, which can accommodate 50 beads. An instructor, playing the role of a supervisor, tells the participants to dip the paddle into the box and pull out 50 beads, with the goal of pulling out only white beads. With each paddle of 50 beads drawn by the participants, the inspector counts and records the number of red beads. Of course, retrieving 50 white beads is almost statistically impossible, given the mix of beads in the box, so the participants fail to meet the goal.

Typically, the hapless production workers in the experiment will try in vain to convince the supervisor to alter the process. They might provide ideas for how to improve the process or even attempt to alter the process them- selves, only to be chastised by the supervisor for deviating from the approved process. The supervisor might threaten, “If you don’t improve your produc- tion, if you all don’t work harder and do a better job making white beads, we will have to lay people off.”

The point of the study is that the failure is not the result of the partici- pants’ performance, but rather a bad process. Adhering to an ineffective pro- cess does not produce better results, and when a supervisor refuses to listen to the production workers about how to improve the process, the situation will only get worse. Eventually, the company fails, and all the workers—as well as the supervisor—lose their jobs.

Earlier in my career, I had the good fortune to learn from Deming and experience the foundations of quality management firsthand; I even got to do the red bead experiment with him. The most interesting thing I have observed about the experiment is the incredible frustration it produces on the part of the participants. They want to do a good job, but they continually fail because the process is bad; when they attempt to alter the process, they are corrected and admonished, and their opinions are ignored. Even as part of a game, the situation is frustrating and demoralizing. Readers are encouraged to view some of the videos of the red bead experiment being conducted (see, for instance, Hunter 2014b).

Arguably, the teachings of Deming and the great thinkers before him are more relevant today than ever before, as so many of their ideas are repack- aged into modern quality improvement tools. Often, however, this focus on tools can cause the true meaning and philosophy of quality and excellence to get lost. Tools do not replace wisdom, and a true appreciation for excellence should be guided by principles, not just targets. Applying a tool without an understanding of the “why” and without profound knowledge of what you

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are doing is not going to produce the desired results. If you do not truly understand the why, you might not even be working on the correct issue for improvement. Systems are complex, and the interactions of moving parts can often escape logic.

Applying Real Wisdom Exhibit 9.2 emphasizes the idea that data are only a starting point; from there, we must understand the data and convert them into information, knowledge, and, finally, real wisdom or insight about what we do and why. Too often, we swim in a sea of data but have few insights as to the data’s meaning. The old saying about “not seeing the forest for the trees” holds true. Clearly, a focus on process is important, but we also need an appreciation for the fundamental foundations of quality, as well as for the importance of the team and the value of each team member’s knowledge and perspective.

Often, the established knowledge and principles that we honor as part of our profession can be counterproductive to innovation and problem solv- ing; in other words, we can become hampered by what we know and believe (Isfahani et al. 2015; Robinson 2006). Cynthia Barton Rabe, in her book The Innovation Killer, describes the importance of “zero-gravity thinkers”—those people who might have little expertise about a particular problem or situation but who offer fresh ideas that are not bound by an existing knowledge base (Rabe 2006; Nayar 2012). Such individuals might be able to see solutions that others do not, especially if the solutions involve innovations that violate established teachings or professional discipline. Healthcare, in particular, has a great number of highly educated people who have been taught, for good reason, that deviation from the norm can be dangerous; thus, the field can be highly risk-averse with regard to changes in practices (Echazu and Nocetti 2013; Maggio et al. 2013; O’Brien 2008).

Data

Information

Knowledge

Wisdom

EXHIBIT 9.2 Use of Data to

Gain Insight

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 291

Sir Ken Robinson (2006) tells a story about a young girl who could not sit still in her chair at school. She was constantly moving about, and her behavior soon became a matter of concern. School officials and the girl’s teacher encouraged the child’s mother to take her to a specialist for evaluation of her “condition,” and the mother complied. After examining the child, the specialist turned on the radio and asked the mother to accompany him out of the room. As the music played, he and the mother, observing from behind a two-way mirror, watched as the girl gracefully moved about the room. Finally, the doctor said, “Gillian isn’t sick, she’s a dancer.” The prescription was not to put the child on medication so she could “calm down” but rather to enroll her in dance school. Robinson (2006) continues the story:

She was eventually auditioned for the Royal Ballet School; she became a soloist; she had a wonderful career at the Royal Ballet. She eventually graduated from the Royal Ballet School; founded her own company, the Gillian Lynne Dance Company; and met Andrew Lloyd Webber. She’s been responsible for some of the most successful musical theater produc- tions in history, she’s given pleasure to millions, and she’s a multimillion- aire. Somebody else might have put her on medication and told her to calm down.

These lessons are highly relevant to healthcare administration. Health- care—as much as or more so than any other industry—needs creative people who can bring effective innovation to the delivery and financing of care; it also needs leaders who nurture the people around them and encourage them to bring new ideas to the table. Healthcare leaders must develop the talents of the people on their teams and recognize that the highest quality will be achieved by a variety of talents working in combination. Diversity is an asset, not a liability.

Why, Not Just What Process without purpose is truly pointless. We cannot simply maintain a fastidious fixation on doing a discrete function without understanding the reasons behind it. To achieve our desired results, we need to incorporate a deep knowledge of healthcare delivery and its processes, as well as an appre- ciation for the need for change to provide the care that our patients need and deserve (Deming 1986). Knowing what to do is not enough; we must also know when to do it and why it must be done.

Deming spoke of a system of profound knowledge, which included four interrelated components: knowledge of the system, knowledge of psy- chology, the theory of knowledge, and knowledge of variation (Deming 2000; Deming Institute 2019b; Bedford 2012). Combining fundamental

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knowledge and wisdom of the past with new knowledge and a focus on the future prepares all stakeholders to deal effectively with the many changes in the years to come.

Above all else, we must first do the right thing and then do it correctly—which is not unlike the oft-repeated phrase attributed to Hip- pocrates: “First, do no harm” (Kleisiaris, Sfakianakis, and Papathanasiou 2014; North 2002; Nutton 2012). In the movie Jurassic Park, mathemati- cian Ian Malcolm says to the park’s creator, “Your scientists were so preoc- cupied with whether they could that they didn’t stop to think if they should” (Spielberg 1993). In many ways, the same has happened in the US healthcare system. Too often, we have lost sight of purpose and pursued quick fixes to complex problems. Stakeholders have acted in their own best interests, responding to short-term incentives and fragmented laws, rules, programs, and policies without a clear, unified strategy and guiding principles (Heine- man and Froemke 2012).

How does one balance the aim of emptying the hospital by improving people’s health with the need to keep the beds full so the hospital can survive economically? People will often joke, “The healthcare system doesn’t want you to die, but it really doesn’t want you to be healthy either.” That kind of thinking reflects the healthcare economic annuity: Keep the people coming as a base for more services (Lyu et al. 2017; Makary 2012). My own view is more hopeful, but serious change to our system’s incentives will be neces- sary (Conrad 2015; Enthoven 2011; Friedberg et al. 2015; Ginsburg 2011; Heineman and Froemke 2012; Pracht, Langland-Orban, and Ryan 2018). We are living in a time when the “win–lose” game is delivering diminished returns, not just economically but emotionally and societally as well.

Change is essential to the future of healthcare, and meaningful change requires courage. Healthcare presents challenges at every turn, with constant temptations to take the easy road. To truly improve the system, however, lead- ers must have the courage to look beyond what is immediate and expedient and do what is necessary for long-term sustainable practice. To quote Deming, “A bad system will beat a good person every time” (Hunter 2015).

Deming (1986) often talked about his 14 points for management, one of which was to reduce or eliminate the use of slogans. Slogans, he believed, provide no clear understanding or direction for accomplishing the task at hand. In healthcare, a slogan might promise “excellent care” or “remarkable care” as part of an effort to differentiate an organization’s services, but what do such slogans really mean? How would you operationalize such a slogan? Excellent or remarkable care to one person might be mediocre care to some- one else. Rather than a simple declaration of intentions, organizations need to have goals and targets that are specific and based on measurement. When such goals are combined with an inculcated philosophy of quality and excel- lence in the organizational culture, improved outcomes will occur.

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 293

The State of the Art in Process Improvement

For many years, the US healthcare system placed a much greater emphasis on issues of access than it did on quality improvement (Kaiser Family Foun- dation 2011). That focus began to shift with the publication of two reports by the IOM—To Err Is Human in 1999 and Crossing the Quality Chasm in 2001—that raised serious concerns about quality and safety (IOM 1999, 2001). The reports estimated that as many as 98,000 people each year die as a result of medical errors in US hospitals and that preventable adverse events alone account for about $8.8 billion in healthcare spending—not to mention the pain, suffering, and disability they cause. The reports called for sweeping, immediate action to address the problem of medical errors and to create a culture of safety and quality in healthcare organizations. Everyone working in the healthcare field should be well versed in the issues addressed in these landmark reports.

Following the release of the IOM reports, efforts to improve qual- ity and safety focused largely on standardization, with the aim of reducing variation. Soon, a variety of quality improvement tools and techniques were applied to healthcare management, including the following:

• Total quality management (TQM) • Lean • Six Sigma • Lean Six Sigma • Data analytics • The Triple Aim

Total Quality Management TQM, an early entrant into the quality improvement arena, is “a manage- ment approach to long-term success through customer satisfaction” in which “all members of an organization participate in improving processes, products, services, and the culture in which they work” (American Society for Quality [ASQ] 2019). TQM originated in the 1980s but still enjoys a following today; many of its features have provided a basis for other quality initiatives. The following elements are central to TQM, and they resemble strategies often seen today in Lean and Six Sigma (ASQ 2019):

• Patient focus (or customer focus). Patients ultimately determine the level of quality. Of course, their assessment may be clouded by information disequilibrium. After all, how can a person who does not fully understand the situation or the complexities of healthcare know what quality looks like? Quality is truly in the eyes of the beholder.

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• Total employee involvement. Everyone throughout the organization participates in working toward common goals.

• Process-centered approach. A focus on process thinking is a fundamental part of TQM. The process is the series of steps that takes inputs from suppliers (internal or external) and transforms them into outputs to be delivered to customers (internal or external). The necessary steps are defined, and performance measures are continuously monitored to detect unexpected variation.

• Integrated system. TQM focuses on the interconnecting processes across the various departments and functional areas of an organization. Patients should interact with the organization’s functions as a single experience, not as a series of functions or separately managed processes. The individual functions add up to the larger patient treatment or procedure, and the aggregate of all patient care reflects the performance of the organization.

• Strategic and systematic approach. Everyone must understand the organization’s vision, mission, and values. Organizational performance must be monitored and communicated continuously. Strategic management involves the formulation of a strategic plan that integrates quality as a core component.

• Continual improvement. The organization should be both analytical and creative in meeting patient needs on an ongoing basis.

• Fact-based decisions. TQM requires that the organization continually collect and analyze data to inform decision making. As a popular quote sometimes attributed to Peter Drucker says, “If you can’t measure it, you can’t manage it.”

• Communication. Effective communication is critical for maintaining morale and motivating employees at every level. Communications must be relevant, frequent, fact based, transparent, and timely.

Implementation of TQM and other quality improvement method- ologies often encounters roadblocks. Exhibit 9.3 presents a list of factors, developed by the AHRQ, that can inhibit the success of Lean implementa- tion; these same observations can be applied to other quality improvement strategies as well (Aij and Teunissen 2017).

Japanese Management Concepts Virtually all of today’s quality models have been shaped by ideas put forth by Deming, Philip B. Crosby, Armand V. Feigenbaum, Joseph Juran, and others from the early years of the quality revolution (Crosby 1979; Deming 1986; Feigenbaum 1951; Juran and De Feo 2016; Juran and Gryna 1993; Neyestani 2017). In addition, Kaoru Ishikawa brought a number of Japanese

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 295

management concepts to Americans, including the famous Ishikawa diagram, or fishbone chart. A valuable tool for root cause analysis, the chart is useful for diagramming the various components of a larger process (Ishikawa 1986).

Another important Japanese concept is nemawashi. The term has no direct English translation, but it refers to an informal process of quietly lay- ing the foundation for a proposed change or project by talking to the people involved and gathering support and feedback. The term reflects the collec- tive mentality commonly emphasized in Japanese culture. English phrases

Note: RCE = rapid cycle event; UTI = urinary tract infection.

Source: Reprinted from Agency for Healthcare Research and Quality (2014b).

EXHIBIT 9.3 Major Factors That Inhibit Lean Success

Factor Lessons Learned

Leadership • Loss of a process owner following an RCE led to poor follow through in implementing and revising process changes.

• Lack of staff accountability by the process owner and leadership for changes made by the RCEs and for completing activities on the action plan can derail RCE success.

• Lack of outward support from all senior executives creates a climate where lack of adherence to process changes by all staff is tolerated.

Scope • Failure to review the medical evidence base may lead to a focus on improving processes that are unrelated to reducing UTI rates.

• Attempting to improve too many processes can overwhelm staff.

• Failure to complete all steps of the improvement process can derail the effort.

Resources • Without resources being allocated for data collection, it is difficult to determine the impact of Lean on efficiency, clinical outcomes, patient experience, and patient safety or to revise processes that are not working.

• Lean events are time consuming for staff. • Staff turnover might make it difficult to make and

sustain process changes and to develop a Lean culture.

Co mmunication about Lean

• There is not always effective communication about events and solutions to the staff who do not participate in the event.

Le an team composition and size

• Using the same staff repeatedly on Lean events might lead to burnout.

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that convey similar meaning might include “consensus building,” “sending up trial balloons,” “getting on board,” and “getting on the same page” (Kopp 2012). I first became familiar with the word through Deming, and I attempted to research the concept while working on my master’s thesis. Of course, literature searches were more difficult then, but my exhaustive search produced just a single reference to the word (in Japanese). If you Google the term today, you will find more than 100,000 hits.

The Baldrige Award One of the most noteworthy initiatives to grow out of the quality movement is the Baldrige Performance Excellence Program, under the auspices of the National Institute of Standards and Technology (NIST). Established by the Malcolm Baldrige National Quality Improvement Act of 1987, the program seeks to recognize and improve the performance of the nation’s businesses, hospitals, schools, nonprofit organizations, and government agencies. To be recognized with the Baldrige Award, organizations must undergo a rigor- ous process to demonstrate their adherence to exceptional levels of quality management (Baldrige Foundation 2019; NIST 2019). Some hospitals and healthcare organizations have begun modeling their systems around the Baldrige guidelines and using the International Organization for Standardi- zation (ISO) 9000 family of standards. The ISO 9000 family provides tools and guidance to support quality improvement and to help organizations meet the requirements of patients and other stakeholders (ISO 2019).

The Leapfrog Group The Leapfrog Group, founded in 2000, is an organization of large employ- ers and other healthcare purchasers brought together by the goal to drive “giant leaps forward” in the quality and safety of US healthcare (Leapfrog Group 2019). Its members include Fortune 100 companies, consumer advo- cacy groups, and approximately 30 regional business coalitions on health. The business coalitions consist of employers who work together to provide high- quality healthcare for their employees at a lower cost. Coalition members leverage their purchasing power to negotiate reduced rates and premiums for benefits programs (Lehigh Valley Business Coalition on Healthcare 2019).

Lean in Healthcare The application of Lean in healthcare is primarily a process improvement approach that focuses on the following (Drotz and Poksinska 2014; Poksin- ska 2010; Toussaint and Berry 2013):

• Defining value from the patient point of view • Mapping value streams • Eliminating waste to create continuous flow

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 297

Lean is often coupled with the plan-do-study-act (PDSA) cycle, also known as the Deming cycle (see exhibit 9.4). The PDSA cycle offers a stepwise framework for incorporating incremental change into a process and measuring the results. As the name implies, the steps of PDSA are done repeatedly in a cycle to bring about continuous quality improvement (Ber- wick 1998; Institute for Healthcare Improvement [IHI] 2019). The steps can be completed any number of times for any specific process.

Another important focus of Lean is the elimination of waste. In healthcare, waste can be defined as anything that does not add value for the patient. Lean strives to eliminate eight types of waste (Skhmot 2017):

1. Defects. Waste associated with defects reflects time spent doing something wrong, finding errors, and correcting errors. In healthcare, defects can lead not only to waste and additional costs but also to pain, suffering, disability, and even death to patients.

2. Overproduction. This type of waste involves doing more than is needed or requested by the patient. Unnecessary diagnostic tests are the most common example.

3. Transportation. Transportation waste occurs whenever unnecessary movement of people or items is required—for instance, when a poor hospital layout requires patients or specimens to be transported over long distances.

StudyAct

DoPlan

Predict what will happen when implemented

Propose idea

Reflect on plan success

Implement idea

Document learning

Analyze data and information

Compare to prediction

Decide whether ideas should be

adopted, changed, or abandoned

Share information

The PDSA Cycle

Collect data

EXHIBIT 9.4 The Plan-Do- Study-Act Cycle

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4. Waiting. Many of the most common complaints in healthcare involve patients waiting unnecessarily for a doctor’s appointment or for some other healthcare event. Waste associated with waiting produces uneven patient flow and causes stress to patients and staff. Even the existence of a waiting room could be regarded as a waste: In an efficient system, a designated space for waiting would serve little if any purpose; thus, the costs, construction, maintenance, and management of a waiting area could be considered wasteful.

5. Inventory. Having excessive inventory leads to unnecessary financial costs associated with storage and maintenance. It also creates the potential for expiration of dated supplies and medications.

6. Motion. This type of waste occurs when employees, because of poor layout or work flow, move more than should be necessary during the course of their work. Waste of motion might occur, for instance, if nursing stations are located long distances from patient care areas.

7. Overprocessing. The waste of overprocessing occurs when work is done that does not produce value for the patient—for instance, when an organization collects information that is never used.

8. Skills, or human potential. This type of waste—one of the greatest wastes of all—occurs when employees are not engaged and listened to, when ideas are not considered, and when career aspirations are not supported and nurtured. Such waste often results in burnout, turnover, and the loss of valuable intellectual capital.

High Reliability Organizations The concept of the high reliability organization is extremely important when discussing quality and safety in healthcare. According to Weick and Sutcliffe (2015), high reliability organizations function under difficult and demand- ing conditions yet have fewer problems than one might expect, because they have learned to “manage the unexpected” and use fragments of past experi- ences to optimize outcomes. Some of the key attributes of high reliability organizations are shown in exhibit 9.5. Unsurprisingly, each characteristic centers on the people and management elements of the system. As I have told my students, if you do not wish to become obsolete, you should learn to do what machines cannot—and that is to deal effectively with people.

This emphasis on the human element requires an understanding of when and how people succeed and fail. James Reason (1990), in his book Human Error, notes that the human mind is only capable of about a 90 per- cent rate of accuracy; thus, systems that rely on human performance alone will have high rates of failure. Atul Gawande (2009), in his book The Check- list Manifesto, states that medical errors can be reduced dramatically simply by requiring the people who perform procedures to follow a detailed check- list to ensure that all the proper steps are completed in the correct order.

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 299

Characteristic Description

Pr eoccupation with Failure

Everyone is aware of and thinking about the potential for failure. People understand that new threats emerge regularly from situations that no one imagined could occur, so all personnel actively think about what could go wrong and are alert to small signs of potential problems. The absence of errors or accidents leads not to complacency but to a heightened sense of vigilance for the next possible failure. Near misses are viewed as opportunities to learn about systems issues and potential improvements, rather than as evidence of safety.

Re luctance to Simplify

People resist simplifying their understanding of work processes and how and why things succeed or fail in their environment. People in HROs understand that the work is complex and dynamic. They seek underlying rather than surface explanations. While HROs recognize the value of standardization of workflows to reduce variation, they also appreciate the complexity inherent in the number of teams, processes, and relationships involved in conducting daily operations.

Se nsitivity to Operations

Based on their understanding of operational complexity, people in HROs strive to maintain a high awareness of operational conditions. This sensitivity is often referred to as “big picture understanding” or “situation awareness.” It means that people cultivate an understanding of the context of the current state of their work in relation to the unit or organizational state—i.e., what is going on around them—and how the current state might support or threaten safety.

De ference to Expertise

People in HROs appreciate that the people closest to the work are the most knowledgeable about the work. Thus, people in HROs know that in a crisis or emergency the person with greatest knowledge of the situation might not be the person with the highest status and seniority. Deference to local and situation expertise results in a spirit of inquiry and de-emphasis on hierarchy in favor of learning as much as possible about potential safety threats. In an HRO, everyone is expected to share concerns with others and the organizational climate is such that all staff members are comfortable speaking up about potential safety problems.

Co mmitment to Resilience

Commitment to resilience is rooted in the fundamental understanding of the frequently unpredictable nature of system failures. People in HROs assume the system is at risk for failure, and they practice performing rapid assessments of and responses to challenging situations. Teams cultivate situation assessment and cross monitoring so they may identify potential safety threats quickly and either respond before safety problems cause harm or mitigate the seriousness of the safety event.

EXHIBIT 9.5 Characteristics of High Reliability

Note: HRO = high reliability organization.

Source: Reprinted from AHRQ (2019).

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Consider, for the sake of comparison, pilots preparing to take off in an aircraft. As a matter of routine, they carefully run through a rigorous checklist of all the important actions required before departure, ensuring to a high degree of reliability that the aircraft will perform correctly. Certainly, experi- enced pilots are aware of all these elements, and in most cases they could run the steps purely by memory. However, because of the high stakes of aircraft safety and the ever-present risk of distraction or other human failure, pilots use the checklist every time.

Healthcare was late in accepting this principle. Why should practitio- ners have to spend their time and effort running through a checklist if they have already performed the procedure hundreds of times in the past? The answer is human error. When failures have serious consequences—as in the case of wrong-site surgery, failure to administer a preoperative antibiotic, or even doing the wrong procedure—relying on the human mind as our only safeguard is insufficient (Donaldson 2009). We simply are not capable of absolute perfection.

Importance of a Safety Culture In Crossing the Quality Chasm, the IOM (2001) stressed the importance of a safety culture: ‘‘The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportu- nities to improve the system and prevent harm.’’ Machines and processes do not create culture—people do (Joosten, Bongers, and Janssen 2009).

Continued Quality Concerns

Despite the widespread use of quality improvement methodologies and the billions of dollars spent on quality and safety efforts, the data on medical errors and patient outcomes continue to raise concerns. A 2013 study in the Journal of Patient Safety estimated that between 210,000 and 440,000 pre- ventable hospital deaths occur in the United States each year (James 2013); the Leapfrog Group (2016) estimated that 206,201 avoidable deaths occur in hospitals annually; and Makary and Daniel (2016) estimated that the number of deaths resulting from medical errors was as high as 250,000. The Centers for Disease Control and Prevention (CDC) does not report medical errors as a cause of death, but if medical errors were recorded in this man- ner, they would rank as the country’s third leading cause of death, after heart disease and cancer (Kavanagh et al. 2017; Allen and Pierce 2016; Shanafelt, Sinsky, and Swensen 2017).

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 301

Comparison with Other Countries Schneider and colleagues (2017) at the Commonwealth Fund analyzed 11 healthcare systems in countries with similarities to the United States, using 72 indicators across five areas: (1) care process, (2) access, (3) administrative efficiency, (4) equity, and (5) healthcare outcomes. The United States ranked last in overall performance (see exhibit 9.6) and was last or near last in four of the five areas (all except care process). The United States ranked especially poorly in system performance relative to spending (see exhibit 9.7).

Source: Reprinted with permission from Schneider et al. (2017).

Eleven-country average

Higher performing

UK AUS NETH

NZ NOR SWIZ SWE GER

CAN

FRA

US

Lower performing

EXHIBIT 9.6 Healthcare System Performance Scores

Note: Health care spending as a percent of GDP.

Source: Reprinted with permission from Schneider et al. (2017).

Higher health system

performance

Eleven-country average

Lower health system

performance

Lower health care spending Higher health care spending

US

FRA

CAN

SWE

SWIZ

NETH

NOR GER

NZ

AUS UK

EXHIBIT 9.7 Healthcare System Performance Scores Relative to Spending

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The United States Healthcare System302

Clearly, the United States has much to learn from other countries that produce superior results, and exposure to healthcare systems around the world should be part of the education process for all future healthcare lead- ers, policymakers, and providers. Given its wealth and resources, the United States has the potential to develop the best healthcare system in the world; doing so, however, will require substantial change (Schneider and Squires 2017).

Failed Strategies? Why have the improvement methods developed and implemented thus far failed to produce measurable leaps forward in quality, safety, and perfor- mance? It is certainly not from a lack of trying or good intentions. The answer could be that process-oriented improvements are insufficient for a system in need of more fundamental change; it could also be that financial and business pressures limit the level of change organizations are willing to accept. Florida Power and Light (FPL), for instance, was one of the first users and advocates of TQM, even winning Japan’s Deming Prize for qual- ity management (Gitlow, Loredo, and Dekker 1992; Niven 1993). Ulti- mately, however, it abandoned its program because of worker complaints about excessive “red tape” and its inability to demonstrate the cost benefit (Mathews 1993).

Most of the quality improvement tools being used in healthcare have been borrowed from the manufacturing industry, which, of course, primar- ily deals with inanimate objects. Questions remain about how effectively such tools can be applied to healthcare, given the nature of the field and the unpredictability of the human element. For instance, Virginia Mason Medi- cal Center was one of the first healthcare organizations to embrace Lean as a quality improvement methodology. However, in 2016, it was denied full accreditation from The Joint Commission after failing to meet a number of quality and safety standards; instead, it received only “contingent accredita- tion” (Aleccia 2016). Virginia Mason’s diligent work on improvement has clearly provided benefits to the organization, but many of the benefits have been associated with cost cutting as opposed to quality.

Moraros, Lemstra, and Nwankwo (2016) conducted an extensive review of the use of Lean in healthcare and concluded: “While some may strongly believe that Lean interventions lead to quality improvements in healthcare, the evidence to date simply does not support this claim. More rigorous, higher quality and better conducted scientific research is required to definitively ascertain the impact and effectiveness of Lean in healthcare settings.” Other writers have similarly stressed the need for more and better research on quality improvement strategies such as Lean and Six Sigma in healthcare (AHRQ 2014a; Amaratunga and Dobranowski 2016; DelliFraine, Langabeer, and Nembhard 2010).

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 303

Patient Experience and Satisfaction

Patient experience and patient satisfaction reflect the full range of interactions the patient has with all components of the healthcare system. Although the terms are sometimes used interchangeably, they are not the same. Patient experience relies on an objective evaluation of whether something did or did not occur in the healthcare setting. Patient satisfaction, on the other hand, is subjective, relying on the perspective of the individual patient. Two people, for instance, might experience the exact same treatment but have very differ- ent levels of satisfaction (AHRQ 2017).

Attention to both experience and satisfaction is essential for healthcare quality and a key aspect of patient-centered care. Patients who have positive experiences tend to be more compliant with care instructions, which can have a significant impact on healthcare outcomes (Brown and Bussell 2011; Hodari et al. 2006; Levinson, Lesser, and Epstein 2010; Thom, Hall, and Pawlson 2004).

Surveys and Metrics Several tools have been developed to measure patient experience and satisfac- tion. The Hospital Consumer Assessment of Healthcare Providers and Sys- tems (HCAHPS) survey, for instance, is a government-sponsored tool that is administered to patients within 42 days of discharge from a hospital. The survey contains 19 core questions about important aspects of the patient’s hospital experience, including the following (Centers for Medicare & Med- icaid Services [CMS] 2019b):

• Communication with nurses and doctors • Responsiveness of hospital staff • Cleanliness and quietness of the hospital environment • Pain management • Communication about medicines • Discharge information • Overall rating of the hospital, and whether they would recommend it

HCAHPS also includes additional items intended to direct patients to rel- evant questions, to adjust for the mix of patients across hospitals, and to support congressionally mandated reports. The survey is often used for com- paring hospitals and is increasingly being incorporated into payment models. Hospitals that are paid under the government’s Inpatient Prospective Pay- ment System are required to report HCAHPS data.

Similar surveys have been developed for the ambulatory care envi- ronment. The Consumer Assessment of Healthcare Providers and Systems

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The United States Healthcare System304

Outpatient and Ambulatory Surgery (OAS CAHPS) survey includes ques- tions about the patient’s experiences with the following (CMS 2019a):

• Preparation for a surgery or procedure • Check-in processes • Cleanliness of the facility • Communications with the facility staff • Discharge from the facility • Preparation for recovering at home

The survey also includes questions about whether the patients received infor- mation and instructions concerning possible side effects during recovery. The survey can be administered by mail, by phone, or by mail with a follow-up phone call. The OAS CAHPS survey was implemented on a voluntary basis in 2016, with the first reported results in 2018. It is expected to be used, much as HCAHPS is, for the comparison of facilities and in payment models (CMS 2019a).

Research findings on the relationship between HCAHPS results, patient experience, patient satisfaction, and healthcare quality have thus far been inconclusive (Bendapudi et al. 2006; Manary et al. 2013; Pérotin et al. 2013; White and Griffith 2019). Some researchers see no relationship between care quality and survey results, whereas others have found an asso- ciation (Kennedy, Tevis, and Kent 2014). At this point, the survey results are best viewed as tools to support the improvement of experience and satisfac- tion, as opposed to measures of actual healthcare outcomes. The growing interest in patient satisfaction and experience has spawned a new industry that works to develop, administer, and analyze appropriate metrics (Modern Healthcare 2017).

Healthcare Is “Siloed” Exhibit 9.8 points to an important problem with patient experience in the United States. The various departments and functions of our healthcare sys- tem are too often presented as a series of separate “silos” with which patients interact. Such an arrangement enables organizations to more easily assign accountability, define scope of responsibility, and measure individual func- tions, but it does not reflect the way patients actually experience healthcare. Patients typically view their interaction with the healthcare delivery system as a single experience; thus, a problem in any part of that experience (i.e., in any silo) can make the overall experience unsatisfactory. As the old saying goes, “the chain is only as strong as its weakest link.”

Surely, many of us have experienced delays and inefficiencies while receiving services from different parts of a healthcare organization—for

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 305

instance, having to reregister because systems are completely independent of one another. Many organizations have sought to address this issue by focus- ing on the Lean principle of “flow”—the smooth transition from one stage of a process to the next, without delay, unnecessary complexity, or other barriers to a seamless process (Andersen, Røvik, and Ingebrigtsen 2014; Moraros, Lemstra, and Nwankwo 2016). Better coordination and collaboration among health professionals can have a significant impact on patient experience, qual- ity, and safety (Cunningham et al. 2012).

A Focus on People

By now, it has probably become evident that quality improvement centers around affecting people and their behavior. Behavior is really the only thing we can see and evaluate; we cannot know what a person is truly thinking or feeling, but we can know that person’s actions. People in every segment of the healthcare workforce need to be trained, educated, motivated, and engaged to generate the desired outcomes (Barnett et al. 2011; Fulford, Peile, and Carroll 2012; Weick and Sutcliffe 2015). Resistance to change and other obstacles to improvement need to be addressed and overcome (AHRQ 2014b; Kaplan et al. 2014; Waring and Bishop 2010).

Behavioral Economics Smoking and obesity are leading causes of illness and disability in the United States, and both issues are largely behavioral in nature. Everyone knows that eating too much fast food is unhealthy, yet the US fast-food industry gener- ated $198 billion in revenue in 2018—and that number is expected to grow

D ep

ar tm

en ts

Fa ci

lit ie

s

Se rv

ic es

Tr ea

tm en

ts

D et

er m

in an

ts o

f h ea

lt h

Patient A

Patient B

Patient C

Patient D

Disease state A

Disease state B

Various Silos

The patient sees care in a longitudinal fashion.

EXHIBIT 9.8 How a Patient Experiences Healthcare

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The United States Healthcare System306

to $223 billion by 2020 (Statista 2019). A study by Moriarty and colleagues (2012) found that the annual incremental mean costs of smoking by age group ranged from $1,274 to $1,401 and that the costs associated with a designated level of morbid obesity ranged from $5,467 to $5,530. Smok- ing and obesity are primary risk factors for diabetes, a disease that affected an estimated 30.3 million people—or 9.4 percent of the US population—in 2015 (CDC 2017). The prevalence of diabetes is expected to increase by 54 percent to more than 54.9 million Americans between 2015 and 2030 (Row- ley et al. 2017). Over the same period, annual deaths attributed to diabetes will climb by 38 percent to 385,800, and total annual medical and societal costs related to diabetes will increase 53 percent to more than $622 billion.

Why do we as a population so often engage in unhealthy behaviors against the advice of healthcare professionals, public service announcements, and general common knowledge? Part of the answer lies in behavioral eco- nomics. The field of behavioral economics applies insights from the study of psychology to analyze human behavior and to explain economic decision making (Heshmat 2017; Thaler 2015). Behavioral economics has contributed many of the techniques by which the fast-food industry and other businesses influence people’s behavior and encourage unhealthy choices. However, the field also holds great promise in the areas of quality and safety (Rabin 2016; Economist 2018). Human beings often act irrationally and make decisions that are not in their own best interest. By gaining a better understanding of the reasons behind such behavior, we can work toward improvements that will have a positive impact on health.

Key Principles Certain principles of behavioral economics are particularly relevant to health behaviors. First, human beings tend to be strongly motivated by meaning, as opposed to simple reward. Therefore, an attempt to influence people’s behavior will be most effective if it includes not just a basic instruction but also a clear explanation of the action and its implications (Pink 2011). Sec- ond, people, by nature, tend to favor immediate reward over future value or benefit. Dan Ariely (2010), in his book Predictably Irrational, uses the example of a box of chocolates. If a person is offered a choice between receiving one box of chocolates immediately and receiving a box and a half of chocolates sometime in the future, people will overwhelmingly choose the immediate reward, even though that option has fewer chocolates.

This latter principle was the focus of the famous “Stanford marshmal- low experiment” conducted by Mischel, Ebbesen, and Zeiss (1972). The researchers would place children in a room with a marshmallow on a plate. Each child could choose to eat the single marshmallow immediately, or they could choose to wait ten minutes and receive an additional marshmallow.

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 307

Follow-up studies of the children who participated in the experiment found that those who were able to delay eating the marshmallow showed greater competence and higher test scores in the years ahead. The findings of the marshmallow study have at times been called into question, but they none- theless suggest that delayed gratification and consideration for one’s “future self” may be important contributors to future success. For example, a person might achieve greater success in the long term by delaying an immediate income to receive an education to secure a higher income in the future.

The marshmallow experiment incorporated various techniques that helped distract the children from the marshmallow and delay their desire to eat it. Often, children who were able to delay their gratification did so by singing, by sitting on their hands, or by looking away and concentrating on something other than the marshmallow (Mischel, Ebbesen, and Zeiss 1972). This aspect of the study has significant implications for healthcare. Attempts to influence people to change their negative health behaviors are more likely to be effective when they incorporate techniques and devices to help people overcome their natural tendencies to favor immediate gratification over future value. Awareness and knowledge are not enough.

Another important psychological element in behavioral economics is choice. Is choice always a good idea? How much choice is too much? Choice relates to the phenomenon of rational optimization, which involves trying to decide which option in a set of options is the best. Sometimes, offering people too many options can make their decision making more difficult or cause them to regret whatever choice they ultimately make. Often, a discrep- ancy exists between people’s stated preference for increased choice and their actual reaction to the provision of choice (Botti and Iyengar 2006).

Iyengar and Lepper (2000) conducted a simple experiment involving two tables with samples of jam—one with 6 samples and another with 24 samples. Surprisingly, people who were confronted with the larger number of samples purchased less jam and were less satisfied with their purchases than the people who were presented with fewer choices. The retailer Costco fully subscribes to the findings of Iyengar and Lepper. The firm has studied the impact of the number of choices on purchasing behavior and concluded that offering limited choice is beneficial (Quintanilla 2012).

Consider all the choices people make with their healthcare. They have insurance choices, provider choices, treatment choices, and lifestyle choices (e.g., diet, exercise). Obviously, we want to make the best choice, but in some instances the variety of options can become too much for the human mind to process. Sometimes, a trade-off exists between making the best choice and limiting the amount of effort involved in making the choice; often, people will use simplifying heuristic strategies to help narrow a choice based on limited information (Payne, Bettman, and Johnson 1993). Difficulty in

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choosing from among options can sometimes cause people to defer to the easiest solution, which is to do nothing.

The concept of “libertarian paternalism,” developed by Thaler and Sunstein (2008), posits that people should be given choices (a feature of libertarianism) but that the decisions should be guided by experts (a feature of paternalism). For instance, patients can be given a set of options, but physicians can “nudge” them toward decisions that are in their best interest.

Further research on the psychological aspects of healthcare decision making will be essential in the years ahead, particularly as the system increas- ingly emphasizes patient engagement, patient-centered care, and end-of-life decision making (Doonan and Katz 2015; Herzlinger and Parsa-Parsi 2004; Steer 2006; Thaler and Sunstein 2008; Drought and Koenig 2002; Zolkefli 2017). Students are encouraged to review Thomas Rice’s (2013) article “The Behavioral Economics of Health and Health Care” for more information on this important concept.

Examples of Behavioral Economic Interventions Behavioral economics offers a variety of tools and strategies that can help improve the health of our communities (Ariely 2010; Rabin 2016; Thaler 2015; Heather and Vuchinich 2003; Loewenstein et al. 2012).

The “Ulysses contract,” for instance, is a kind of contract in which a person agrees to be bound by another person’s decision in the future. The Ulysses contract is named after the hero of Homer’s Odyssey. In the story, Ulysses asks his men to tie him to the mast of the ship so he can experience the Sirens’ song, and he gives them instructions not to release him under any circumstances (Homer 1999). Ulysses contracts have sometimes been used in mental health situations, where a patient empowers a provider to override the patient’s later objection to treatment. The ethics and legality of Ulysses con- tracts in healthcare have been called into question, and such contracts often are not enforced (Davis 2008; Walker 2012). In some instances, people can effectively form Ulysses contracts with themselves by making it impossible for them to engage in certain behaviors. For instance, by putting your smart phone in the trunk of your car before departing, you can make it impossible to use the phone while driving.

Another behavioral economics tool is a simple agreement between the patient and the provider—for instance, the patient might agree to follow a prescribed course of treatment or lifestyle change. Often the agreement will carry no penalties, but the mere act of committing the agreement to writing and having the parties sign it increases the probability that the actions will be completed.

Simple reminders and the power of suggestion can also be excellent behavioral economic tools (Payne et al. 2015). In one study, customers

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 309

were given shopping baskets with a yellow line across the middle, and a sign instructed shoppers to use one side of the basket for fruits and vegetables and the other side for everything else. Average produce sales more than doubled (Moss 2013).

The behavioral economic technique of “opting out” has proved highly effective in organ donation. If a country’s organ donation program is designed in a way that assumes people’s participation and requires them to opt out if they do not wish to donate, it will likely have nearly universal participation; on the other hand, if a program requires people to “opt in” to become a donor, it will likely have a low participation rate. Simply put, people are more likely to not act than act (Johnson and Goldstein 2004).

Interprofessional Education Education will be a key element in our effort to improve the outcomes pro- duced by the healthcare system (Birk 2017; Buring et al. 2009; Guraya and Barr 2018). Interprofessional education (IPE) is an educational approach that seeks to prepare students in the health professions to provide patient care in a collaborative team environment (Alston et al. 2012; Asch and Weinstein 2014; Brashers, Owen, and Haizlip 2015; IOM 2015; World Health Organization [WHO] 2010). IPE has three main goals (Parsell and Bligh 1998):

1. To enhance understanding of other professional roles and responsibilities

2. To help to develop skills needed for effective teamwork 3. To increase knowledge of clinical skills or topics

IPE occurs when students from two or more healthcare professional groups (e.g., physicians, nurses, social workers, physical therapists, physician assistants, administrative professionals) learn together and gain an apprecia- tion for what each group does as part of the patient care system (Barr et al. 2005; Patrician et al. 2012; Reeves et al. 2013). IPE seeks to address the siloed nature of US healthcare, which contributes to many of the challenges we face.

The reason IPE has such great promise is that healthcare profes- sionals who learn to work in a collaborative manner produce better patient outcomes, higher quality of care, and better working environments. When professionals know one another better, they are more likely to communicate effectively and develop mutual respect (IOM 2015; Shrader et al. 2018). IPE has also demonstrated the potential to reduce medical errors and lower costs, though further research is needed to fully understand this impact (Hammick et al. 2007).

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Negative communication, poor working relationships, and disruptive behavior in healthcare settings can have tragic consequences (Hickson et al. 1994; Hickson and Entman 2008). Gerald B. Hickson of the Vanderbilt Center for Patient and Professional Advocacy, along with his colleagues, has done extensive research on ways of reducing disruptive behavior and negative interactions, thereby improving patient care and lowering cost (Hickson et al. 1992; Hickson et al. 2007).

Leadership and Governance for Quality

A number of problems with healthcare quality and safety are associated with matters of leadership and governance. Sometimes, when leaders feel secure in their positions, they become less willing to take appropriate risk and commit to innovation and improvement (Hlavacek 2018). In some instances, health- care boards are under too much influence by top leaders in the organization; thus, the leaders take on the position of governing themselves, which may not be in the best interest of the organization or its mission (Wagner 2017).

Effective leadership and governance, including clinical governance, are essential for healthcare quality. Leadership for quality in healthcare settings can come from a variety sources, including managers, boards, and physi- cian leaders (Lee et al. 2013; Weiner 2009; Weiner, Shortell, and Alexander 1997). Strong leadership from the top promotes clinical involvement at all levels.

Veenstra and colleagues (2017) write:

. . . clinical governance is a practice-based, value-driven approach that has the goal of delivering the highest possible quality care and ensuring the safety of patients. Bottom-up approaches and effective teamwork are cru- cial for high quality and safe healthcare. Striving for high quality and safe healthcare is underpinned by continuous learning, shared responsibility and good relationships and collaboration between healthcare professionals, managers and patients.

In a WHO report, Kickbusch and Gleicher (2012) further emphasize collaboration:

Collaboration is the new imperative. . . . Lessons can be learned from the rich literature on collaborative governance, including considering the process and design of collaboration; the virtuous circle of communication, trust, commitment and understanding; the choice of tools and mecha- nisms; and transparency and accountability.

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 311

The IHI has developed an excellent framework for governance of health system quality. The framework involves the following components (Daley Ullem et al. 2018):

• Simplify concepts: Use simple, trustee-friendly language that defines actionable processes and activities for trustees and those who support them to oversee quality.

• Incorporate all six STEEEP dimensions of quality: Understand quality as care that is safe, timely, effective, efficient, equitable, and patient centered (STEEEP), as defined by the Institute of Medicine.

• Include community health and value: Ensure that population health and health care value are critical elements of quality oversight.

• Govern quality in and out of the hospital setting: Advance quality governance throughout the health system, not solely in the hospital setting.

• Advance organizational improvement knowledge: Support trustees in understanding the ways to evaluate, prioritize, and improve performance on dimensions of quality.

• Identify the key attributes of a governance culture of quality: Describe the elements of a board culture and commitment to high-quality, patient- centered, equitable care.

Exhibits 9.9, 9.10, and 9.11 provide insights into governance and leadership for quality improvement. The exhibits show the components of quality from the patient’s perspective, a vision of effective board governance, and the framework by which knowledge areas and processes can be imple- mented to achieve that vision.

When considering quality and safety, healthcare leaders, managers, board members, and others can start by reflecting on some rather straight- forward questions:

• What is quality and safety in the healthcare environment? What does it mean?

• What is a culture of safety and quality? • What are the benefits? • What is the cost of poor quality and safety lapses? • What is harm, and how do we prevent it? • How does the lack of timely attention to quality and safety affect our

finances and our reputation? • What are our vulnerabilities related to quality and safety? • Who is responsible for and who will manage and oversee the elements

of quality and safety in the organization?

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Source: Daley Ullem E, Gandhi TK, Mate K, Whittington J, Renton M, Huebner J. Framework for Effective Board Governance of Health System Quality. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018. (Available on ihi.org.)

Keep Me Safe

Help Me Stay Well

Help Me Navigate My Care

Treat Me with

Respect

Provide Me with the

Right Care

Patient

*Safe

*Timely, Efficient *Equitable,

Patient centered

*Effective

*IOM STEEEP dimensions of quality: Safe, Timely, Effective, Efficient, Equitable, and Patient Centered

EXHIBIT 9.9 Core Components

of Quality from the Patient’s Perspective

Source: Daley Ullem E, Gandhi TK, Mate K, Whittington J, Renton M, Huebner J. Framework for Effective Board Governance of Health System Quality. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018. (Available on ihi.org.)

I understand the process to assess,

prioritize, and improve care.

Our board culture demonstrates a commitment to

delivering quality for all patients.

I understand the domains of and key concepts underlying

quality care.

EXHIBIT 9.10 Vision of

Effective Board Governance of Health System

Quality

• How do we monitor quality and safety in the organization? • How do we ensure that we have the proper training (with regard to

knowledge, skills, and practices) to support a culture of quality and safety?

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Chapter 9: Qual i ty and Safety—Easier Said Than Done 313

The Need for a Balanced Approach

Clearly, improving quality and safety in healthcare will require constant dili- gence and absolute commitment from people at every level of the organization. As we seek to improve, we often have a tendency to direct our focus on one particular idea or strategy, or to shift from one extreme to the other; such an approach, however, is not well suited for the movement toward quality. Many strategies have shown promise and demonstrated beneficial results, yet no single strategy alone seems to be the answer for sustained transformative improve- ment. A balanced approach of proven strategies coupled with newer initiatives is likely a more productive path to lasting change and a healthier America.

Discussion Questions

1. How do you define quality and safety? What role does perspective play in your definitions?

2. Are service, experience, and outcome equally important? 3. Can we manage quality in healthcare in the same way that we manage

quality in other industries?

Source: Daley Ullem E, Gandhi TK, Mate K, Whittington J, Renton M, Huebner J. Framework for Effective Board Governance of Health System Quality. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018. (Available on ihi.org.)

Core Knowledge Areas

Core Board Processes

Core Quality Knowledge

Governance of Quality Assessment

• Key processes to oversee all dimensions of quality

• Assessment of progress over time

Core Improvement System

Knowledge

Board Culture and Commitment

to Quality

Vision of Effective Board Governance

of Quality

I understand the process to assess,

prioritize, and improve care.

Our board culture demonstrates a commitment to

delivering quality for all patients.

I understand the domains of and key concepts underlying

quality care.

EXHIBIT 9.11 Framework for Governance of Health System Quality

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References

Agency for Healthcare Research and Quality (AHRQ). 2019. “High Reliability.” Updated September. https://psnet.ahrq.gov/primer/high-reliability.

———. 2018. “Environmental Scan of Patient Safety Education and Training Pro- grams.” Reviewed April. www.ahrq.gov/research/findings/final-reports/ environmental-scan-programs/envscan-program1.html.

———. 2017. “What Is Patient Experience?” Reviewed March. www.ahrq.gov/ cahps/about-cahps/patient-experience/index.html.

———. 2014a. Improving Care Delivery Through Lean: Implementation Case Studies. AHRQ Publication No. 13(15)-0056. Published November. www.ahrq.gov/ sites/default/files/publications/files/leancasestudies.pdf.

———. 2014b. “Major Factors That Inhibit Lean Success.” Reviewed November. www.ahrq.gov/professionals/systems/system/systemdesign/leancas estudies/lean-exhibit4-19.html.

Aij, K. H., and M. Teunissen. 2017. “Lean Leadership Attributes: A Systematic Review of the Literature.” Journal of Health Organization and Management 31 (7–8): 713–29. https://doi.org/10.1108/JHOM-12-2016-0245.

Aleccia, J. 2016. “Virginia Mason Is Denied Full Accreditation After Lapses.” Seattle Times. Published June 21. www.seattletimes.com/seattle-news/ virginia-mason-is-denied-full-accreditation-after-lapses/.

Allen, M., and O. Pierce. 2016. “Only Heart Disease and Cancer Exceed Medical Errors as Causes of Death.” National Public Radio. Published May 3. www.npr.org/sections/health-shots/2016/05/03/476636183/ death-certificates-undercount-toll-of-medical-errors.

Alston, C., L. Paget, G. Halvorson, B. Novelli, J. Guest, P. McCabe, K. Hoffman, C. Koepke, M. Simon, S. Sutton, S. Okun, P. Wicks, T. Undem, V. Rohrbach, and I. Von Kohorn. 2012. Communicating with Patients on Health Care Evi- dence. Institute of Medicine Discussion Paper. Published September. https:// nam.edu/wp-content/uploads/2015/06/VSRT-Evidence.pdf.

Amaratunga, T., and J. Dobranowski. 2016. “Systematic Review of the Application of Lean and Six Sigma Quality Improvement Methodologies in Radiology.” Journal of the American College of Radiology 13 (9): 1088–1095.e7. https:// doi.org/10.1016/j.jacr.2016.02.033.

American Society for Quality (ASQ). 2019. “What Is Total Quality Manage- ment (TQM)?” Accessed October 13. https://asq.org/quality-resources/ total-quality-management.

Andersen, H., K. A. Røvik, and T. Ingebrigtsen. 2014. “Lean Thinking in Hospitals: Is There a Cure for the Absence of Evidence? A Systematic Review of Reviews.” BMJ Open 4 (1): e003873. https://doi.org/10.1136/bmjopen-2013-003873.

Ariely, D. 2010. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York: Harper Perennial.

EBSCOhost - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

Chapter 9: Qual i ty and Safety—Easier Said Than Done 315

Aristotle. 2009. Selections from Nicomachean Ethics and Politics. London: CRW Publishing.

Asch, D. A., and D. F. Weinstein. 2014. “Innovation in Medical Education.” New England Journal of Medicine 371 (9): 794–95. https://doi.org/10.1056/ NEJMp1407463.

Baldrige Foundation. 2019. “The Foundation for the Malcolm Baldrige National Quality Award.” Accessed October 13. https://baldrigefoundation.org.

Barnett, J., K. Vasileiou, F. Djemil, L. Brooks, and T. Young. 2011. “Understanding Inno vators’ Experiences of Barriers and Facilitators in Implementation and Diffu sion of Healthcare Service Innovations: A Qualitative Study.” BMC Health Services Research 11: 342. https://doi.org/10.1186/1472-6963-11-342.

Barr, H., I. Koppel, S. Reeves, M. Hammick, and D. Freeth. 2005. Effective Inter- professional Education: Argument, Assumption and Evidence. Oxford, UK: Blackwell.

Bedford, D. A. D. 2012. “The Role of Knowledge Management in Creating Trans- formational Organizations and Transformational Leaders.” Journal of Knowl- edge Management Practice 13 (4): 32–44.

Bendapudi, N. M., L. L. Berry, K. A. Frey, J. T. Parish, and W. L. Rayburn. 2006. “Patients’ Perspectives on Ideal Physician Behaviors.” Mayo Clinic Proceed- ings 81 (3): 338–44. https://doi.org/10.4065/81.3.338.

Berwick, D. M. 1998. “Developing and Testing Changes in Delivery of Care.” Annals of Internal Medicine 128 (8): 651–56. https://doi.org/10.7326/ 0003-4819-128-8-199804150-00009.

Birk, T. J. 2017. “Principles for Developing an Interprofessional Education Curricu- lum in a Healthcare Program.” Journal of Healthcare Communications 2 (1). https://doi.org/10.4172/2472-1654.100049.

Botti, S., and S. S. Iyengar. 2006. “The Dark Side of Choice: When Choice Impairs Social Welfare.” Journal of Public Policy & Marketing 25 (1): 24–38. https:// doi.org/10.1509/jppm.25.1.24.

Brashers, V., J. Owen, and J. Haizlip. 2015. “Interprofessional Education and Prac- tice Guide No. 2: Developing and Implementing a Center for Interprofes- sional Education.” Journal of Interprofessional Care 29 (2): 95–99. https:// doi.org/10.3109/13561820.2014.962130.

Brown, M. T., and J. K. Bussell. 2011. “Medication Adherence: WHO Cares?” Mayo Clinic Proceedings 86 (4): 304–14. https://doi.org/10.4065/ mcp.2010.0575.

Buring, S. M., A. Bhushan, A. Broeseker, S. Conway, W. Duncan-Hewitt, L. Hansen, and S. Westberg. 2009. “Interprofessional Education: Definitions, Student Competencies, and Guidelines for Implementation.” American Journal of Pharmaceutical Education 73 (4): 59. https://doi.org/10.5688/aj730459.

Centers for Disease Control and Prevention (CDC). 2017. National Diabetes Sta- tistics Report, 2017: Estimates of Diabetes and Its Burden in the United States

EBSCOhost - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

The United States Healthcare System316

Background. Accessed October 13, 2019. www.cdc.gov/diabetes/pdfs/ data/statistics/national-diabetes-statistics-report.pdf.

Centers for Medicare & Medicaid Services (CMS). 2019a. “Consumer Assessment of Healthcare Providers & Systems (CAHPS).” Updated September 16. www.cms. gov/Research-Statistics-Data-and-Systems/Research/CAHPS/index.html.

———. 2019b. “HCAHPS: Patients’ Perspectives of Care Survey.” Updated October 9. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- instruments/hospitalqualityinits/hospitalHCAHPS.html.

Conrad, D. A. 2015. “The Theory of Value-Based Payment Incentives and Their Application to Health Care.” Health Services Research 50: 2057–89. https:// doi.org/10.1111/1475-6773.12408.

Crosby, P. B. 1979. Quality Is Free: The Art of Making Quality Certain. New York: McGraw-Hill.

Cunningham, F. C., G. Ranmuthugala, J. Plumb, A. Georgiou, J. I. Westbrook, and J. Braithwaite. 2012. “Health Professional Networks as a Vector for Improv- ing Healthcare Quality and Safety: A Systematic Review.” BMJ Quality & Safety 21 (3): 239–49. https://doi.org/10.1136/BMJQS-2011-000187.

Daley Ullem, E., T. Ganhdi, K. Mate, J. Whittington, M. Renton, and H. Joellen. 2018. Framework for Effective Board Governance of Health System Quality. Institute for Healthcare Improvement. Accessed October 13, 2019. www. ihi.org/resources/Pages/IHIWhitePapers/Framework-Effective-Board- Governance-Health-System-Quality.aspx.

Davis, J. K. 2008. “How to Justify Enforcing a Ulysses Contract When Ulysses Is Competent to Refuse.” Kennedy Institute of Ethics Journal 18 (1): 87–106. www.ncbi.nlm.nih.gov/pubmed/18561579.

DelliFraine, J. L., J. R. Langabeer, and I. M. Nembhard. 2010. “Assessing the Evidence of Six Sigma and Lean in the Health Care Industry.” Quality Management in Health Care 19 (3): 211–25. https://doi.org/10.1097/ QMH.0b013e3181eb140e.

Deming, E. 2000. The New Economics: For Industry, Government, Education, 2nd ed. Cambridge, MA: MIT Press.

———. 1986. Out of the Crisis. Cambridge, MA: MIT Center for Advanced Engi- neering Study.

Deming Institute. 2019a. “Large List of Quotes by W. Edwards Deming.” Accessed December 19. https://blog.deming.org/w-edwards-deming-quotes/ large-list-of-quotes-by-w-edwards-deming/.

———. 2019b. “The Deming System of Profound Knowledge.” Accessed October 13. https://deming.org/explore/so-p-k.

Donaldson, M. S. 2009. “An Overview of To Err is Human: Re-emphasizing the Message of Patient Safety.” In Patient Safety and Quality: An Evidence-Based Handbook for Nurses, 2nd ed., vol. 1, edited by R. G. Hughes, 37–45. Rock- ville, MD: Agency for Healthcare Research and Quality. www.ncbi.nlm.nih. gov/books/NBK2673/.

EBSCOhost - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

Chapter 9: Qual i ty and Safety—Easier Said Than Done 317

Doonan, M., and G. Katz. 2015. “Choice in the American Healthcare System: Changing Dynamics Under the Affordable Care Act.” Current Sociology 63 (5): 746–62. https://doi.org/10.1177/0011392115590092.

Drotz, E., and B. Poksinska. 2014. “Lean in Healthcare from Employees’ Perspec- tives.” Journal of Health Organization and Management 28 (2): 177–95. https://doi.org/10.1108/JHOM-03-2013-0066.

Drought, T. S., and B. A. Koenig. 2002. “‘Choice’ in End-of-Life Decision-Making: Researching Fact or Fiction?” Gerontologist 42 (Spec. No. 3): 114–28. https://doi.org/10.1093/geront/42.suppl_3.114.

Durant, W. 1961. The Story of Philosophy: The Lives and Opinions of the Great Philoso- phers of the Western World. New York: Simon & Schuster.

Echazu, L., and D. Nocetti. 2013. “Priority Setting in Health Care: Disentangling Risk Aversion from Inequality Aversion.” Health Economics 22 (6): 730–40. https://doi.org/10.1002/hec.2858.

Economist. 2018. “Hospitals Are Learning from Industry How to Cut Medical Errors.” Published June 28. www.economist.com/international/2018/ 06/28/hospitals-are-learning-from-industry-how-to-cut-medical-errors.

Enthoven, A. C. 2011. “Reforming Medicare by Reforming Incentives.” New England Journal of Medicine 364 (21): e44. https://doi.org/10.1056/ NEJMp1104427.

Feigenbaum, A. 1951. Quality Control: Principles, Practice and Administration. New York: McGraw-Hill.

Friedberg, M. W., M. B. Rosenthal, R. M. Werner, K. G. Volpp, and E. C. Schneider. 2015. “Effects of a Medical Home and Shared Savings Intervention on Qual- ity and Utilization of Care.” JAMA Internal Medicine 175 (8): 1362–68. https://doi.org/10.1001/jamainternmed.2015.2047.

Fulford, K. W. M., E. Peile, and H. Carroll. 2012. Essential Values-Based Practice: Clinical Stories Linking Science with People. New York: Cambridge University Press.

Gawande, A. 2009. The Checklist Manifesto: How to Get Things Right. New York: Henry Holt.

Ginsburg, P. B. 2011. “Reforming Provider Payment—The Price Side of the Equa- tion.” New England Journal of Medicine 365 (14): 1268–70. https://doi. org/10.1056/NEJMp1107019.

Gitlow, H., E. Loredo, and M. Dekker. 1992. “Total Quality Management at Florida Power & Light Company: A Case Study.” Quality Engineering 5 (1): 123–58.

Goethe, J. W. von. 1906. The Maxims and Reflections of Goethe. Project Gutenberg. Accessed December 10, 2019. www.gutenberg.org/files/33670/ 33670-h/33670-h.htm.

Guraya, S. Y., and H. Barr. 2018. “The Effectiveness of Interprofessional Educa- tion in Healthcare: A Systematic Review and Meta-Analysis. Kaohsiung Journal of Medical Sciences 34 (3): 160–65. https://doi.org/10.1016/j. kjms.2017.12.009.

EBSCOhost - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

The United States Healthcare System318

Hammick, M., D. Freeth, I. Koppel, S. Reeves, and H. Barr. 2007. “A Best Evi- dence Systematic Review of Interprofessional Education: BEME Guide No. 9.” Medical Teacher 29 (8): 735–51. https://doi.org/10.1080/ 01421590701682576.

Heather, N., and R. Vuchinich. 2003. Choice, Behavioral Economics, and Addiction. New York: Pergamon Press.

Heineman, M., and S. Froemke (dirs.). 2012. Escape Fire: The Fight to Rescue Ameri- can Healthcare. Aisle C Production and Our Time Projects. www.escapefire- movie.com.

Herzlinger, R. E., and R. Parsa-Parsi. 2004. “Consumer-Driven Health Care: Lessons from Switzerland.” JAMA 292 (10): 1213–20. https://doi.org/10.1001/ jama.292.10.1213.

Heshmat, S. 2017. “What Is Behavioral Economics?” Psychology Today. Pub- lished May 3. www.psychologytoday.com/us/blog/science-choice/201705/ what-is-behavioral-economics.

Hickson, G. B., E. W. Clayton, S. S. Entman, C. S. Miller, P. B. Githens, K. Whetten-Goldstein, and F. A. Sloan. 1994. “Obstetricians’ Prior Malpractice Experience and Patients’ Satisfaction with Care.” JAMA 272 (20): 1583–87. https://doi.org/10.1001/jama.1994.03520200039032.

Hickson, G. B., E. W. Clayton, P. B. Githens, and F. A. Sloan. 1992. “Factors That Prompted Families to File Medical Malpractice Claims Following Perinatal Injuries.” JAMA 267 (10): 1359–63. https://doi.org/10.1001/ jama.1992.03480100065032.

Hickson, G. B., and S. S. Entman. 2008. “Physician Practice Behavior and Litigation Risk: Evidence and Opportunity.” Clinical Obstetrics and Gynecology 51 (4): 688–99. https://doi.org/10.1097/GRF.0b013e3181899c2c.

Hickson, G. B., J. W. Pichert, L. E. Webb, and S. G. Gabbe. 2007. “A Comple- mentary Approach to Promoting Professionalism: Identifying, Measuring, and Addressing Unprofessional Behaviors.” Academic Medicine 82 (11): 1040–48. https://doi.org/10.1097/ACM.0b013e31815761ee.

Hlavacek, J. 2018. Fat Cats Don’t Hunt: Implanting the Right Leadership and Cul- ture to Accelerate Innovation and Organic Growth. Asheville, NC: United Business Press.

Hodari, K. T., J. R. Nanton, C. L. Carroll, S. R. Feldman, and R. Balkrishnan. 2006. “Adherence in Dermatology: A Review of the Last 20 Years.” Journal of Dermatological Treatment 17 (3): 136–42. https://doi. org/10.1080/09546630600688515.

Homer. 1999. The Odyssey. Edited by R. Fagles and B. H. Langiana. New York: Penguin Classics.

Hunter, J. 2015. “A Bad System Will Beat a Good Person Every Time.” W. Edwards Deming Institute. Published February 26. https://blog.deming. org/2015/02/a-bad-system-will-beat-a-good-person-every-time/.

EBSCOhost - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

Chapter 9: Qual i ty and Safety—Easier Said Than Done 319

———. 2014a. “Lessons From the Red Bead Experiment with Dr. Deming.” W. Edwards Deming Institute. Published March 10. https://blog.deming. org/2014/03/lessons-from-the-red-bead-experiment-with-dr-deming/.

———. 2014b. “The Red Bead Experiment with Dr. W. Edwards Deming.” W. Edwards Deming Institute. Published February 25. https://blog.deming. org/2014/02/deming-red-bead-experiment/.

Institute for Healthcare Improvement (IHI). 2019. “Triple Aim for Populations.” Accessed October 13. www.ihi.org/Topics/TripleAim/Pages/default.aspx.

Institute of Medicine (IOM). 2015. Measuring the Impact of Interprofessional Edu- cation on Collaborative Practice and Patient Outcomes. Washington, DC: National Academies Press.

———. 2001. Crossing the Quality Chasm: A New Health System for the 21st Cen- tury. Washington, DC: National Academies Press. www.ncbi.nlm.nih.gov/ pubmed/25057539.

———. 1999. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press. www.ncbi.nlm.nih.gov/pubmed/25077248.

International Organization for Standardization (ISO). 2019. “ISO 9001 Quality Management.” Accessed October 13. www.iso.org/iso-9001-quality- management.html.

Isfahani, S. S., M. A. Hosseini, M. F. Khoshknab, H. Peyrovi, and H. R. Khanke. 2015. “Nurses’ Creativity: Advantage or Disadvantage.” Iranian Red Crescent Medical Journal 17 (2): e20895. https://doi.org/10.5812/ircmj.20895.

Ishikawa, K. 1986. Guide to Quality Control, 2nd ed. Tokyo: Asian Productivity Organization.

Iyengar, S. S., and M. R. Lepper. 2000. “When Choice Is Demotivating: Can One Desire Too Much of a Good Thing?” Journal of Personality and Social Psychol- ogy 79 (6): 995–1006. www.ncbi.nlm.nih.gov/pubmed/11138768.

James, J. 2013. “A New, Evidence Based Estimate of Patient Harms Associated with Hospital Care.” Journal of Patient Safety 9 (3): 122–28. https://doi. org/10.1097/PTS.0b013e3182948a69.

Johnson, E. J., and D. G. Goldstein. 2004. “Defaults and Donation Decisions.” Trans- plantation 78 (12): 1713–16. https://10.1097/01.TP.0000149788.10382.B2.

Joosten, T., I. Bongers, and R. Janssen. 2009. “Application of Lean Thinking to Health Care: Issues and Observations.” International Journal for Quality in Health Care 21 (5): 341–47. https://doi.org/10.1093/intqhc/mzp036.

Juran, J. M., and J. A. De Feo (eds.). 2016. Juran’s Quality Handbook: The Complete Guide to Performance Excellence, 7th ed. New York: McGraw-Hill Education.

Juran, J. M., and F. M. Gryna. 1993. Quality Planning and Analysis: From Product Development Through Use, 3rd ed. New York: McGraw-Hill.

Kaiser Family Foundation. 2011. “Timeline: History of Health Reform in the U.S.” Published March 25. www.kff.org/wp-content/uploads/2011/03/5-02- 13-history-of-health-reform.pdf.

EBSCOhost - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

The United States Healthcare System320

Kaplan, G. S., S. H. Patterson, J. M. Ching, and C. C. Blackmore. 2014. “Why Lean Doesn’t Work for Everyone.” BMJ Quality & Safety 23 (12): 970–73. https://doi.org/10.1136/bmjqs-2014-003248.

Kavanagh, K. T., D. M. Saman, R. Bartel, and K. Westerman. 2017. “Estimating Hospital-Related Deaths Due to Medical Error.” Journal of Patient Safety 13 (1): 1–5. https://doi.org/10.1097/PTS.0000000000000364.

Kennedy, G. D., S. E. Tevis, and K. C. Kent. 2014. “Is There a Relation- ship Between Patient Satisfaction and Favorable Outcomes?” Annals of Surgery 260 (4): 592–598, 598–600. https://doi.org/10.1097/SLA. 0000000000000932.

Kickbusch, I., and D. Gleicher. 2012. Governance in Health for the 21st Century. Geneva, Switzerland: World Health Organization. www.euro.who.int/__ data/assets/pdf_file/0019/171334/RC62BD01-Governance-for-Health- Web.pdf.

Kleisiaris, C. F., C. Sfakianakis, and I. V. Papathanasiou. 2014. “Health Care Practices in Ancient Greece: The Hippocratic Ideal.” Journal of Medical Ethics and History of Medicine 7: 6. www.ncbi.nlm.nih.gov/pmc/articles/ PMC4263393/.

Kopp, R. 2012. “Defining Nemawashi.” Japan Intercultural Consulting. Published December 20. www.japanintercultural.com/en/news/default.aspx?news ID=234.

Leapfrog Group. 2019. “Raising the Bar for Safer Health Care.” Accessed October 13. www.leapfroggroup.org/about.

———. 2016. “Selecting the Right Hospital Can Reduce Your Risk of Avoidable Death by 50%, According to Analysis of Newly Updated Hospital Safety Score Grades.” Published April 25. www.hospitalsafetygrade.org/about-us/ newsroom/display/442022.

Lee, S.-Y. D., B. J. Weiner, M. I. Harrison, and C. M. Belden. 2013. “Organiza- tional Transformation.” Medical Care Research and Review 70 (2): 115–42. https://doi.org/10.1177/1077558712458539.

Lehigh Valley Business Coalition on Healthcare. 2019. “About Us.” Accessed December 10. www.lvbch.com/lvbch_4_1_2_0_about.html.

Levinson, W., C. S. Lesser, and R. M. Epstein. 2010. “Developing Physician Com- munication Skills for Patient-Centered Care.” Health Affairs 29 (7): 1310– 18. https://doi.org/10.1377/hlthaff.2009.0450.

Loewenstein, G., D. A. Asch, J. Y. Friedman, L. A. Melichar, and K. G. Volpp. 2012. “Can Behavioural Economics Make Us Healthier?” BMJ 344 (7863): 1–3. https://doi.org/10.1136/bmj.e3482.

Lyu, H., T. Xu, D. Brotman, B. Mayer-Blackwell, M. Cooper, M. Daniel, E. C. Wick, V. Saini, S. Brownlee, and M. A. Makary. 2017. “Overtreatment in the United States.” PLOS ONE 12 (9): e0181970. https://doi.org/10.1371/ journal.pone.0181970.

EBSCOhost - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

Chapter 9: Qual i ty and Safety—Easier Said Than Done 321

Maggio, L., N. Tannery, H. Chen, O. Cate, and B. O’Brien. 2013. “Evidence-Based Medicine Training in Undergraduate Medical Education: A Review and Cri- tique of the Literature Published 2006–2011.” Academic Medicine 88 (7): 1022–28. https://doi.org/10.1097/ACM.0b013e3182951959.

Makary, M. 2012. Unaccountable: What Hospitals Won’t Tell You and How Transpar- ency Can Revolutionize Health Care. New York: Bloomsbury Press.

Makary, M. A., and M. Daniel. 2016. “Medical Error—The Third Leading Cause of Death in the US.” BMJ 353: i2139. https://doi.org/10.1136/BMJ.I2139.

Manary, M. P., W. Boulding, R. Staelin, and S. W. Glickman. 2013. “The Patient Experience and Health Outcomes.” New England Journal of Medicine 368 (3): 201–3. https://doi.org/10.1056/NEJMp1211775.

Mathews, J. 1993. “Totaled Quality Management.” Washington Post. Published June 6. www.washingtonpost.com/archive/business/1993/06/06/totaled- quality-management/c0ca5500-bbed-40f9-9bc8-a6e4704b20cf/?utm_ term=.35f7fb964afe.

Mischel, W., E. B. Ebbesen, and A. R. Zeiss. 1972. “Cognitive and Attentional Mechanisms in Delay of Gratification.” Journal of Personality and Social Psy- chology 21 (2): 204–18. www.ncbi.nlm.nih.gov/pubmed/5010404.

Modern Healthcare. 2017. “2017 Largest Patient Satisfaction Measurement Firms Respondents.” Published October 25. www.modernhealthcare.com/article/ 20171025/INFO/310259999.

Moraros, J., M. Lemstra, and C. Nwankwo. 2016. “Lean Interventions in Health- care: Do They Actually Work? A Systematic Literature Review.” Interna- tional Journal for Quality in Health Care 28 (2): 150–65. https://doi. org/10.1093/intqhc/mzv123.

Moriarty, J., M. Branda, K. Olsen, N. Shah, B. Borah, A. Wagie, J. Egginton, and J. Naessens. 2012. “The Effects of Incremental Costs of Smoking and Obesity on Health Care Costs Among Adults.” Journal of Occupational and Environmental Medicine 54 (3): 286–91. https://doi.org/10.1097/ JOM.0b013e318246f1f4.

Moss, M. 2013. “Nudged to the Produce Aisle by a Look in the Mirror.” New York Times. Published August 27. www.nytimes.com/2013/08/28/dining/ wooing-us-down-the-produce-aisle.html.

National Institute of Standards and Technology (NIST). 2019. “Baldrige Perfor- mance Excellence Program.” Accessed December 12. www.nist.gov/baldrige.

Nayar, V. 2012. “‘Zero Gravity Thinkers’ Are the Key to Innovation.” Business Insider. Published July 31. www.businessinsider.com/this-one-thing-could- single-handedly-transform-your-business-into-an-innovative-sustainable- enterprise-2012-7.

Neyestani, B. 2017. Principles and Contributions of Total Quality Mangement (TQM) Gurus on Business Quality Improvement. De La Salle University. Published February. https://doi.org/10.5281/zenodo.345428.

EBSCOhost - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

The United States Healthcare System322

Niven, D. 1993. “When Times Get Tough, What Happens to TQM?” Harvard Business Review 71 (3): 2–11. https://hbr.org/1993/05/when-times- get-tough-what-happens-to-tqm.

North, M. (trans.) 2002. “The Hippocratic Oath.” National Library of Medicine. Accessed October 13, 2019. www.nlm.nih.gov/hmd/greek/greek_oath.html.

Nutton, V. 2012. Ancient Medicine. New York: Routledge. O’Brien, M. 2008. “Leading Innovation in a Risk-Averse Healthcare Environment.”

Healthcare Financial Management 62 (8): 112–14. Retrieved from www. ncbi.nlm.nih.gov/pubmed/18709873.

Parsell, G., and J. Bligh. 1998. “Interprofessional Learning.” Postgraduate Medical Journal 74: 89–95. www.ncbi.nlm.nih.gov/pmc/articles/PMC2360816/ pdf/postmedj00086-0027.pdf.

Patrician, P. A., M. Dolansky, C. Estrada, C. Brennan, R. Miltner, J. Newsom, D. Olds, M. Splaine, and S. Moore. 2012. “Interprofessional Education in Action.” Nursing Clinics of North America 47 (3): 347–54. https://doi. org/10.1016/j.cnur.2012.05.006.

Payne, C., M. Niculescu, D. Just, and M. Kelly. 2015. “Shopper Marketing Nutri- tion Interventions: Social Norms on Grocery Carts Increase Produce Spend- ing Without Increasing Shopper Budgets.” Preventive Medicine Reports 2: 287–91. https://doi.org/10.1016/j.pmedr.2015.04.007.

Payne, J. W., J. R. Bettman, and E. J. Johnson. 1993. The Adaptive Decision Maker. New York: Cambridge University Press.

Pérotin, V., B. Zamora, R. Reeves, W. Bartlett, and P. Allen. 2013. “Does Hospital Ownership Affect Patient Experience? An Investigation into Public-Private Sector Differences in England.” Journal of Health Economics 32 (3): 633–46. https://doi.org/10.1016/j.jhealeco.2013.03.003.

Pink, D. H. 2011. Drive: The Surprising Truth About What Motivates Us. New York: Riverhead Books.

Poksinska, B. 2010. “The Current State of Lean Implementation in Health Care: Literature Review.” Quality Management in Healthcare 19 (4): 319–29. https://doi.org/10.1097/QMH.0b013e3181fa07bb.

Pracht, E. E., B. Langland-Orban, and J. L. Ryan. 2018. “The Probabil- ity of Hospitalizations for Mild-to-Moderate Injuries by Trauma Center Ownership Type.” Health Services Research 53 (1): 35–48. https://doi. org/10.1111/1475-6773.12646.

Quintanilla, C. 2012. “The Costco Craze: Inside the Warehouse Giant.” CNBC. Pub- lished April 9. www.cnbc.com/the-costco-craze-inside-the-warehouse-giant/.

Rabe, C. B. 2006. The Innovation Killer: How What We Know Limits What We Can Imagine—And What Smart Companies Are Doing About It. New York: Amacom.

Rabin, M. 2016. “Psychology and Economic Theory.” Harvard University. Accessed October 13, 2019. https://scholar.harvard.edu/files/rabin/files/ 2035syllabus2016.pdf.

EBSCOhost - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

Chapter 9: Qual i ty and Safety—Easier Said Than Done 323

Reason, J. 1990. Human Error. New York: Cambridge University Press. Reeves, S., L. Perrier, J. Goldman, D. Freeth, and M. Zwarenstein. 2013. “Inter-

professional Education: Effects on Professional Practice and Healthcare Outcomes.” Cochrane Database of Systematic Reviews, no. 3: CD002213. https://doi.org/10.1002/14651858.CD002213.pub3.

Rice, T. 2013. “The Behavioral Economics of Health and Health Care.” Annual Review of Public Health 34 (1): 431–47. https://doi.org/10.1146/ annurev-publhealth-031912-114353.

Robinson, K. 2006. “Do Schools Kill Creativity?” TED Talk. Published February. www.ted.com/talks/ken_robinson_says_schools_kill_creativity?language=en.

Rowley, W. R., C. Bezold, Y. Arikan, E. Byrne, and S. Krohe. 2017. “Diabetes 2030: Insights from Yesterday, Today, and Future Trends.” Population Health Man- agement 20 (1): 6–12. https://doi.org/10.1089/pop.2015.0181.

Schneider, E. C., D. O. Sarnak, D. Squires, A. Shah, and M. M. Doty. 2017. “Mir- ror, Mirror 2017: International Comparison Reflects Flaws and Opportuni- ties for Better U.S. Health Care.” Commonwealth Fund. Published July 14. www.commonwealthfund.org/publications/fund-reports/2017/jul/ mirror-mirror-2017-international-comparison-reflects-flaws-and.

Schneider, E. C., and D. Squires. 2017. “From Last to First—Could the U.S. Health Care System Become the Best in the World?” New England Journal of Medi- cine 377 (10): 901–3. https://doi.org/10.1056/NEJMp1708704.

Shanafelt, T., C. A. Sinsky, and S. Swensen. 2017. “Medical Errors and Preventable Deaths in U.S. Hospitals.” NEJM Catalyst. Published January 23. https:// catalyst.nejm.org/medical-errors-preventable-deaths/.

Shrader, S., S. Jernigan, N. Nazir, and J. Zaudke. 2018. “Determining the Impact of an Interprofessional Learning in Practice Model on Learners and Patients.” Journal of Interprofessional Care. Published September 13. https://doi.org/ 10.1080/13561820.2018.1513465.

Skhmot, N. 2017. “The 8 Wastes of Lean.” The Lean Way. Published August 5. https://theleanway.net/The-8-Wastes-of-Lean.

Spielberg, S. (dir.). 1993. Jurassic Park. Universal Studios. Statista. 2019. “Quick Service Restaurants: Revenue US 2002–2018.” Accessed

October 13. www.statista.com/statistics/196614/revenue-of-the-us-fast- food-restaurant-industry-since-2002/.

Steer, P. J. 2006. “So What’s So New About Patient Choice?” BMJ 332 (7547): 981.1. https://doi.org/10.1136/bmj.332.7547.981.

Thaler, R. H. 2015. Misbehaving: The Making of Behavioral Economics. New York: W. W. Norton.

Thaler, R. H., and C. R. Sunstein. 2008. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press.

Thom, D. H., M. A. Hall, and L. G. Pawlson. 2004. “Measuring Patients’ Trust in Physicians When Assessing Quality of Care.” Health Affairs 23 (4): 124–32. https://doi.org/10.1377/hlthaff.23.4.124.

EBSCOhost - printed on 10/25/2022 12:12 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS. All use subject to https://www.ebsco.com/terms-of-use

The United States Healthcare System324

Toussaint, J. S., and L. L. Berry. 2013. “The Promise of Lean in Health Care.” Mayo Clinic Proceedings 88 (1): 74–82. https://doi.org/10.1016/j.mayocp. 2012.07.025.

Veenstra, G. L., K. Ahaus, G. A. Welker, E. Heineman, M. J. van der Laan, and F. L. H. Muntinghe. 2017. “Rethinking Clinical Governance: Healthcare Professionals’ Views: A Delphi Study.” BMJ Open 7 (1): e012591. https:// doi.org/10.1136/bmjopen-2016-012591.

Wagner, S. L. 2017. Fundamentals of Medical Practice Management. Chicago: Health Administration Press.

Walker, T. 2012. “Ulysses Contracts in Medicine.” Law and Philosophy 31 (1): 77–98. https://doi.org/10.1007/s10982-011-9116-z.

Waring, J. J., and S. Bishop. 2010. “Lean Healthcare: Rhetoric, Ritual and Resis- tance.” Social Science & Medicine 71 (7): 1332–40. https://doi.org/ 10.1016/j.socscimed.2010.06.028.

Weick, K. E., and K. M. Sutcliffe. 2015. Managing the Unexpected: Sustained Perfor- mance in a Complex World. New York: John Wiley & Sons.

Weiner, B. J. 2009. “A Theory of Organizational Readiness for Change.” Implemen- tation Science 4 (1): 67–76. https://doi.org/10.1186/1748-5908-4-67.

Weiner, B. J., S. M. Shortell, and A. Alexander. 1997. “Promoting Clinical Involve- ment in Hospital Quality Improvement Efforts: The Effects of Top Manage- ment, Board, and Physician Leadership.” Health Services Research 32 (4): 491–510. www.ncbi.nlm.nih.gov/pmc/articles/PMC1070207/pdf/hsre- search00036-0116.pdf.

White, K. R., and J. R. Griffith. 2019. The Well-Managed Healthcare Organization, 9th ed. Chicago: Health Administration Press.

World Health Organization (WHO). 2010. Framework for Action on Interprofessional Education and Collaborative. Accessed October 13, 2019. www.who.int/ hrh/resources/framework_action/en/.

Zolkefli, Y. 2017. “Evaluating the Concept of Choice in Healthcare.” Malaysian Journal of Medical Sciences 24 (6): 92–96. https://doi.org/10.21315/ mjms2017.24.6.11.

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CHAPTER

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10THE IMPACT OF TECHNOLOGY ON US HEALTHCARE

Healthcare is the only civil system where new technology makes prices go up instead of down.

—Jaan Tallinn

Learning Objectives

• Analyze the relationship between healthcare costs and the constant development of new medical technologies.

• Gain familiarity with a variety of emerging medical technologies. • Evaluate the impact of e-therapy, telemedicine, e-health, and telehealth

on the US healthcare system. • Recognize the pros and cons of electronic health records and electronic

medical records. • Understand how information technology and value-based care are

interdependent. • Apply key principles of cybersecurity to the workings of a healthcare

organization.

Medical and Information Technology

This chapter will focus on the impact of technology on the US healthcare system (see exhibit 10.1). Deciding where to start a discussion of this topic is difficult, because we will be studying emerging technologies and their impact on healthcare in perpetuity! Technological advances and innovations occur at a rapid pace, almost beyond our system’s ability to manage the change. Evolving technologies can help expand the capabilities of our healthcare system, improve quality, and increase access, although—as stated in Tallinn’s quote at the start of the chapter—they can also be a major driver of costs.

Technology in healthcare largely falls into one of three categories: (1) medical technology, (2) information technology, and (3) data analytics and knowledge management. The additional area of pharmaceutical technology will be addressed in chapter 11.

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