Archive for category Quality Rules
It sounds like a paradox: science studying itself. But, that is exactly what is happening in medicine. Basic research has led to applications of the research and the applications are studied for effects, benefits and cost. For example: invent robotic surgery and apply it to patients, then set it up as a program in an operating room and try to improve the technique and patient selection, and finally evaluate the program to see if it meets stated goals of quality and cost and decide if it should continue and under what conditions.
This huge simplification helps with terms doctors and hospitals often talk about:
- Discover and apply — called research.
- Try to improve — called quality improvement (QI).
- Continue the effort? — called program evaluation (PE).
Patients can be subjects of research. But, participation in research requires explicit permission since the outcome is not known and it could be bad.
If we knew what it was we were doing, it would not be called research, would it? (Albert Einstein)
Patients are hopefully impacted by quality improvement since the purpose is to make things better and thus no patient permission is required. As part of QI a hospital may try to make sure antibiotics are given before surgery because there is research evidence the practice reduces infection. Quality improvement focuses on a cycle of planning, doing, study and revision. QI has become a huge area of study with numerous books and journals on the subject. Virtually every hospital has a quality manager who is charged with improving the care at a hospital.
Patients are only indirectly affected by program evaluation. Clinics and hospitals constantly evaluate programs for positive or negative effects. Whether programs continue depend on such studies. People may read about evaluation of medical programs like care at VA hospitals and may be impacted by decisions of policy makers based on such evaluations. PE is likewise an important and growing discipline.
The concepts of research, quality improvement and program evaluation do tend to overlap. One could imagine using QI techniques to improve the quality of research. And, one could imagine research to find the fastest way to do program evaluation. However, research is mainly for the purpose the researcher decides. Whereas QI and PE are mainly for patient care, business or institutional purposes.
Quality healthcare depends on QI and PE. Patients often don’t see these efforts in action. But, ineffective QI and PE are hazardous to your health. Although doctors and hospitals don’t like the idea: law suits are a warning flag of inadequate QI and PE.
According to “The Fix” blog by the Washington Post the VA has problems making timely appointments for patients to see a care provider. The issue “hit the fan” when it was reported veterans died while waiting for appointments. So, can an effort to provide quality care exist in an environment where funds are limited?
The first rule of quality management is the outcome that a process or system delivers is exactly what it was designed to deliver (this is only obvious in retrospect). The second rule is to change the process rather than blame the people involved if the outcome is not what is wanted. The third rule is to change the process when needed. The fourth rule is to be fair and allocate resources according to need.
The VA has a huge job. But, it is often congratulated for delivering very good care at a price less than standard insurance based care for similar diseases. Before firing the managers of the VA ask what the waiting time is for appointments at your local psychiatry office or local internist? And, how many people die while waiting for those appointments — lots.
Like it or not the VA is socialized medicine. The congress sets the budget and sets the benefits veterans may receive. The VA is not an open system, it has cost constraints. For the US Congress to suggest otherwise is disingenuous (a lie). The truth is Congress must manage the VA, must set the budget, must monitor cost, must decide what benefits to offer, must limit the medications to be used, must bargain for good medication prices and must provide access on a timely basis — to be fair.
Short waiting time for a needed appointment is a quality goal. Monitoring the goal and correcting the process to meet the goal is essential. The process needs tweaking frequently. If the active military doctor says the discharged veteran needs to be seen within 2 weeks then make it so! If other services with less impact on care need to be cut back then make it so! Initial evaluation is very important because without evaluation the need for care can not be known and the fairness to deliver care to the ones most in need is lost.
Anticipating the need for care is also essential. VA care is part of the cost of war. 300,000 soldiers suffered traumatic brain injury in the Afghanistan and Iraq wars. It does not take a brain surgeon to realize the VA will need funds and staff to meet the care obligation. If we need to train more doctors, nurses, PA’s and nurse practitioners then make it so! Training takes many years which needs to be anticipated by Congress. If the boat has a leak don’t wait until it is about to sink before doing something.
Back to the basics. The very notion the VA problems should or could be fixed by firing someone is counterproductive and uninformed. Should the process of evaluating recently discharged veterans be changed? — absolutely. Throwing more money at a problem without changing the system is doomed to failure. Punishing people is not the answer. What the VA needs is quality management with guts! The VA can and does deliver good care with appropriately limited resources.
Addendum (5/30/14) General Shinseki tendered his resignation today and his second in command (on the job for 3 months) will take over. One would hope the chaos that it causes will be temporary until a more experienced manager takes over (time will tell). So what should be done? The VA needs a manager familiar with quality care who also knows how to manage health care within a budget (that may require someone from outside the country!) A few realistic things that could be done:
1. Commission a lean engineering study to make binding recommendations for improved efficiency.
2. Put the VA care statistics on-line. Make the VA care transparent.
3. Get rid of financial incentives for people who have no control of the process that needs to be changed.
4. Award innovation. Awarding “employee of the month” to the person who just got to work on time is not innovation!
Another thought (6/11/14): the VA should participate in Medicare Hospital Compare. Obviously they do not require Medicare but they could submit the same data as other hospitals in the name of transparent care. The current criticism centers on outpatient wait-times. It might be interesting to know what wait times might be for other outpatient care clinics like Kaiser Permanente or other vertically integrated systems.