QI Revolutions Lower Barriers to Improvement

Over the past year, 2directions has met with leading physicians to learn from their successful QI projects. We were most impressed by projects which achieved demonstrable benefits to their patients and to their medical care organization. One such project was Dr. Bela Patel’s success at Memorial Hermann Hospital, in which she essentially eliminated ventilator associated pneumonias (VAP) from her ICU for five years and counting. Review of her achievements highlights patients who experience fewer adverse outcomes and arrive home sooner.

To accountants, those patient-centered results equate to cost savings and increased turnover. Previously, 2directions presented an analysis of how bed turnover is one of the primary drivers of hospital efficiency. Better turnover increases capacity and widens bottlenecks that otherwise limit patient flow. It’s much easier to justify those benefits through a low cost, low risk quality improvement project, than through heavy capital expenditure and disruptive construction of new beds. We estimate her work releases $1.7 million from the annual operating budget and avoids $3 million of capital expenditures.

Her work provides meaningful patient stories and a compelling business case. But even as Bela Patel’s Medical Intensive Care Unit has gone without a VAP for five years, in most hospitals, VAPs remain a monthly occurrence. This observation led 2directions to ask what barriers prevent rapid adoption of such tremendous accomplishment to other healthcare institutions.

Several of us at 2directions have experience outside healthcare. Software, industrial manufacturing, and retail provide reference of successful scale: the explosive growth of social networks, the economics of precision in mass production, and fashion trends. The answer to why scale is not possible in quality improvement is the same reason my former employer, IBM Consulting, has been tremendously successful, even in economic downturn -- QI is a highly customized service. Solutions aren’t simply adopted, they must be adapted. Even if the solution has proven successful elsewhere, adaptation is required, and it is an expensive process that calls upon local heroes to successfully shift the organization to the new clinical approach.

It became our conviction that QI scale is hindered by two cultures. The clinical culture is hesitant to change processes. Physicians are apt to believe in a system in which hard work, by competent people, delivers the best patient outcomes. We need a change agent that will risk reputation and expend great efforts to demonstrate that even better patient outcomes are possible through QI. The financial culture of the hospital is hesitant to invest in projects which disrupt the current model. Reluctance can be overcome by a salesperson who understands the hospital’s financial drivers, and uses those drivers to connect their offering to better business outcomes. We need a similarly equipped salesperson for QI.

Understanding these barriers to scale, and the capabilities needed to surmount them, we considered the equipment which would enable physicians to overcome them. We aim to refine our blueprint and begin to fabricate these tools over the next 8 months. However, ours is not a “if we build it, they will come” type solution. Only participation by QI Physician Leaders will substantiate our vision. Therefore our first step was to garner support for our concept from the American Medical Association. We drafted a resolution which describes the problem we identified and our approach to a solution, and presented it to the AMA medical student section (MSS) to ask for promotional support. The MSS formally adopted our resolution at their national meeting in New Orleans one week ago. It’s a milestone we are excited to share. The next step will be for physicians to debate this resolution on the floor of the House of Delegates, at the AMA meeting in Chicago this summer. Passage would be a strong catalyst to improve collaboration between QI leaders.

Price doesn't equal Value (Fishbone Diagram)

Product Place and time Price Promotion Process People Productivity Purpose

When setting prices, a business avoids going too low. Of course, we understand this fails to maximize profit. More importantly, consumer behavior demonstrates that a product which is sold for a lower a price than its competitors, is first considered a value. Eventually, the price difference becomes too great. Then the discount is no longer judged to be a better value, and begins to suggest that the product is inferior. For many consumers, the product which they believe has the most value is the second most expensive. For this reason, a business will develop a luxury version of their product. While it may manage to sell a few of these highest end items, more benefit is derived by the now second most expensive item being perceived as a better value.

The price schedule for the AMA is cheap when compared to other professional organizations such as that for trial lawyers. Could the low cost lead many physicians to question how relatively inexpensive professional organizational fees can return value? What if the annual dues were doubled? Would physicians anticipate more value and respond by joining the AMA?

Zane highlighted that much of the cost of participating in the AMA is incurred by traveling to the national meetings. His recognition again raises the question whether a national organization is needed. Or, perhaps Annual and Interim meetings are not regularly required. More productive work may be invested in local improvement, rather than preparing for the next national meeting. When the total cost of participation is largely related to travel expenses, then the disconnect between price and value widens further.

Reviewing the price we find a lot of wasted value. This concept of waste, arises repeatedly in medicine. In the case of the AMA annual events the waste takes the form of travel. Going to Chicago is a fun time, no doubt. However, many physicians would just assume take a legitimate family vacation. Travel to Chicago for CME and professional development workshops allows value to dribble away as hotel receipts, cab fares, and hasty lunches.

Instead, physicians could receive more value by attending regular meetings at which local financial consultants educate attendees on choosing a medical equipment loan from options locally available. They would attend such conferences with neighboring physicians and discuss the local problems they face. Rather than mulling over what they'd like to do about those problems, then only delivering their decision as a single vote to a national legislative body, they could take action--locally and immediately. Of course there are national problems physicians face which require a national organization. One such problem is how to best adopt EMRs to achieve the furtively defined, "meaningful use." Perhaps a local forum in which physicians can offer lessons learned from their adoption of EMR would be more beneficial. As more and more small clinics merge to grapple with increasing overhead, the need to know local fellow physicians increases.

Now, we'll put more meat onto our Fishbone Diagram. The new problems identified:



By picking apart price, we have noted additional problems with Place. Creating a fishbone diagram should allow this sort of active brainstorming. We can quickly categorize this newly identified problem under its appropriate Place label as we fill in the Fishbone Diagram.

Political or Practical (Fishbone Diagram)

In his recent post, David shared reactions to the recent AMA Annual Meeting in Chicago. Its dwindling membership has led us to question the direction the organization is heading. While we at Two Directions agree there are numbers in healthcare which should not rise, we look to reduce costs and would prefer to increase participation.

To analyze the problem we’ll use the Fishbone Diagram tool, and hope to accomplish the aim of this blog: to demonstrate how QI tools are used so they can be more widely applied to healthcare. In doing so, we also hope to consider solutions to the AMA’s dwindling membership. Given that several of us writing are members, we hope this process can inform our own engagement with organized medicine.

Fishbone Diagrams are a tool to conduct root cause analysis. Here, we’ll look for the root cause of the problem: why do so many doctors not participate in their main professional organization? To analyze this problem, we will organize our brainstorming into categories. This structured approach to problem solving is a technique for physicians to approach QI. To be not only creative, but effective, brainstorming often needs to follow a method; especially when working with a group. Because the AMA is essentially offering services to members, we will seek root causes by organizing our thoughts into the following service oriented groups.

Product Place and time Price Promotion Process People Productivity Purpose

As a happy coincidence, each group starts with P. A few notes about them:

• The first 4 P’s listed above are the classic 4 P’s of marketing
• While QI analysis usually considers “Process” in the scope of a product delivery or manufacturing, in this post we want to focus on the AMA’s legislative process. In a sense, it is a manufacturing process for crafting its organizational objectives
• Since the AMA acts as an advocacy organization, its Purpose is an important factor in determining its quality

To begin filling out this bare-bones diagram, consider how the AMA’s products alienate or fail to meet the needs of potential physician members. As we begin to fill an empty white board, we'll recognize that the product faults we identify are better categorized into another group, such as Place and Time.

CPT Codes. The use of the Current Procedural Terminonology codes to bill insurers is responsible for a large part of back office overhead. Physicians are often required to use these codes to receive reimbursement. Since the coding system changes often, physicians must hire employees who maintain this specialized skill.

Yet, the process adds no value to the Patient-Physician relationship nor does it improve patient health. Sometimes regarded as a cozy monopoly fostered by the AMA and insurers, CPT codes complicate the relationship between physicians and patients. The complexity of the coding system edifies the overhead expense of a medical coder, and facilitates the insurer practice of holding up or denying legitimate claims. Despite this detriment to physicians and the practice of medicine, CPT licensing generates annual revenue on the magnitude of tens of millions of dollars for the AMA.

Advocacy. Many physicians feel the AMA advocates for positions which they don’t agree with. Rather than advocate, the AMA may do better to inform. Individual physicians could then better assess how the actions of Congress fit with their personal views. Rather than pay professional lobbyists millions of dollars, the AMA could further shift its focus towards empowering physician's to use their voice in public forums. Again, the AMA's current approach fails to add value for physicians but does reward the lobbying firms the AMA retains. (Product)

Development.The AMA purports to be a professional organization, but has been overtaken by physicians with a fetish for politics. My own experience at A-11 had few opportunities for professional development. The main event was the legislative process. Medical students were exposed to JAMA, AMPAC, pomp and circumstance, but essentially no guidance on the transition from medical education to medical professionalism. A review of the AMA website points to some professional guidance. However, much of it seems to reinforce other AMA products such as the CPT codes. Google is appreciated by its users because the new technologies it offers are designed with the intention of making Google more useful. The AMA is unappreciated as its products seem to only reinforce its necessity.(Product)

The AMA does provide a generous experience to get involved with politics. Participation would likely bolster professional skills; politics and marketing have much in common. However an intensive course, set in Washington, D.C. is impractical to the demands of medical training and practice. (Place/Time)

Continuing Medical Education is a component of a physician's ongoing training which does have the potential to add value to the Patient-Physician relationship. CME offerings compete in a crowded market. The AMA offers CME credits through JAMA and via its Annual and Interim Meeting. Overall, a physician's specialty is typically more successful at meeting educational needs by offering more relevant CME topics. (Product & Place).

A fishbone diagram could capture and portray this analysis as:

The Many Faces of Organized Medicine

Two weeks ago, the AMA met for its 160th annual meeting in Chicago; this year with 12,000 fewer members than during the 159th annual one year ago. At the meeting, I heard many physicians express a growing concern: the membership of this national professional organization has dwindled recently, and now represents less than 10% of the physician voice in America.

Speculation has suggested two reasons for the loss of membership. First is the controversial position of “support” that the AMA gave two years ago to the PPACA. Second is the inconsistency between AMA policy voted upon by its House of Delegates (HOD) and the actions taken by AMA’s Board of Trustees on the organization’s behalf. Rather than leveraging the election and legislative processes to reign in these problems, 12,000 doctors have chosen not to renew membership in their national professional organization.

What would happen if our national legislators decided not to participate in the democratic process because they disagreed with an election or policy vote? Arguably, it would be quite counter to effective democracy. Having observed the policy creation process in the AMA’s HOD, it is clear that the process makes great efforts to entertain the minority opinion prior to a vote. Perhaps for dissenters, the more effective approach to strengthening representation would be to recruit like-minded physicians to pledge membership and run for elected office, rather than leaving the table all together.

Medical politics, like those of our federal government, continue to grapple with unwavering and polarized points of view. Many AMA southern delegates proclaim freedom from government regulation of any kind, while northern delegates are generally more comfortable complying with some terms of the PPACA in order to achieve greater access to healthcare. During debate on more benign policies, like the one requiring physician excuses from physical education in grade school, southern doctors dogmatically proclaim freedom from exercise mandates, while northern states judged such colleagues as holdouts to fighting our nation’s obesity epidemic.

One of the most contentious votes during the last four national meetings of the AMA has been on the healthcare mandate prescribed by PPACA. Prior to the A-11 meeting, the vote in the HOD has been evenly split 50/50 along state and ideological lines. In this meeting, however, almost 60% of the House passed a resolution with language endorsing current AMA policy D-165.966 (find it on AMA policy finder). This policy will provide state governments the freedom to decide how to best cover the uninsured. A state-by-state implementation is already enacted by PPACA, but will not take effect until 2017. The Wyden-Brown Senate bill, currently under debate, would move this deadline to 2014 if adopted by the US Congress.

There are many medical associations representing specialty medicine, regional interests, and national politics within medicine; but only one association - the AMA - purports to represent ALL physicians. Arguably, based solely on membership numbers, the AMA is already a long way from that claim. What’s undeniable, however, is that for this professional organization to continue, new ways to connect new members are required. What are the best strategies for doing this? And how can the AMA empower physicians such that they feel like their concerns are addressed? Is our nation so polarized and the practice of medicine so regionally variable that no one organization can truly represent all US doctors?

We look forward to exploring these questions more in coming weeks. In the meantime, we look forward to reading your input and ideas.