Fifteen years after the publication of Institute of Medicine’s landmark report To Err is Human, healthcare process improvement (PI) is finally beginning to take root. Quality improvement (QI) has become a pillar of healthcare for both academic clinicians and private practice alike.
The workhorse of the Donebedian adage of “structure + process = outcome” is on standardization. In a world of static, well-defined products, proper application of PI can dramatically reduce variability.
While incremental improvement continues to be necessary in healthcare – we are a long way away from a six-sigma industry – continued standardization and scientific research alone are no longer sufficient to evolve healthcare.
More Than Quality
Despite its high quality notebook computers, IBM was forced to sell its critically acclaimed ThinkPad division. Even as Borders excelled in delivering customer service and good selection, its trade book business eventually drowned amidst the tidal wave of the internet giant Amazon.
While hospitals respond to payment reform using Level-5, 5S’s, 5Y’s, 6-Sigma, 12-Step QAPI, DMAIC, FADE, DOWNTIME, Kaizen, balanced scorecard, or Deming cycle, innovations are fundamentally disrupting healthcare by the classic Christensen definition.
Many such innovations take the form of technology. Telemedicine creeps unnoticed in the periphery of low-end healthcare reimbursement, taking opportunities in the generally less profitable healthy outpatient visits. The Internet of Things lurks in the corner with ubiquitous home and personal smart sensors primary for less sick elderly and outpatients. Big-data analytic tools take advantage of the butterfly effect, predicting large-scale epidemics from seemingly unrelated minor aberrations.
Ignored by The Improving Health System
These products are generally ignored by the typical healthcare practice because their performance sits in the blindspot of a metrics-driven organization. Telemedicine does not improve line infection rates or length-of-stay. Investing in big-data analytic may improve the hospital infection rate 10 years from now, but it will not bend curve of C. difficile incidence tomorrow. In a world where reimbursement rewards treatment of the most severe disease with the least 30-day readmission, deploying smart sensors at home seem far less cost-effective than simply performing better care in the inpatient setting.
With limited resources, a typical hospital running at 3% operating margin has little incentive to bear the risk of innovation. It is forced to meet today’s HCAHPS metrics.
Reconciling Innovation with Continuous Quality Improvement
It may seem like a Catch-22 that healthcare is expected to at once standardize (do everything the same way!) and innovate (try something different!). Indeed, the codification of specific practice patterns and clinical pathways may partly for why a larger hospital is less likely to adapt to change the same way a small clinic or start-up company can. However, the two are not mutually exclusive.
Innovation is a misnomer – it is never truly novel. Just as Picasso trained as a realist before breaking away, the greatest creative influences in technology and business model are improvements upon existing ideas. It does not need a chaotic environment to thrive. In fact, a process-optimized system makes aberrations more visible. A game-changing great idea can be more easily tested when every other factor in the system behaves predictably.
Therefore, the problem is not an inherent incompatibility. Instead, it arises from inattentional blindness at an organizational level. We become blind to opportunities that make our patients lives better because we fixate on inefficiencies and existing processes.
Innovation is the final missing link in a truly continuously improving system.