How good could it get?

Scott Endsley, MD, MSc Charles M. Kilo, MD, MPH

VOL 105 / NO 3 / MARCH 1998 / POSTGRADUATE MEDICINE

Change in healthcare has never been more rapid or far-reaching than it is today. But change comes at a price. Healthcare costs continue to skyrocket; scientific knowledge expands exponentially; demands from well-informed patients increase; the need for services escalates with our aging population; commercialization of medicine continues with direct-to-consumer advertising; and alternative medicine booms. Simultaneously, demands for physician productivity increase.

With the greater call for clinical productivity comes closer monitoring of physician performance. Physician profiles, outcomes tracking, and organization benchmarks by groups such as the National Committee for Quality Assurance reflect a growing interest in the examination of healthcare providers and the quality of care they give. In the Journal of the American Medical Association, former editor George Lundberg declared, "The time is right for quality improvement to become the driver of the Ameri-can health care system (1)."

A focus for improvement
To emphasize the national need for improvement in quality of care, the US Department of Health and Human Services established the Forum for Health Care Quality Measurement and Reporting. The resulting report, The Challenge and Potential for Assuring Quality Health Care for the 21st Century, identified four areas in our current medical practice that should provide focus for improvement efforts: underuse of appropriate services, overuse of inappropriate services, misuse of services, and inappropriate variation in use of services.

• Underuse of services. Failure to provide needed healthcare services can lead to preventable outcomes and complications, increase morbidity and mortality rates, and raise healthcare costs. For example, only 28% of eligible adults receive pneumococcal vaccine (2), and only 16% of diabetic patients have hemoglobin A1c measured annually (3).

• Overuse of medical services. Excessive and unnecessary healthcare services increase costs without improving health outcomes. They also place patients at greater risk for adverse events. For instance, 32% of carotid endarterectomies (4) and 20% of pacemaker placements (5) in Medicare patients are deemed inappropriate, as are 23% of tympanostomy tube placements in children (6).

• Misuse of medical services. Errors in healthcare services can cause unnecessary injuries, delays in diagnoses, and cost increases. Of all hospitalized patients, 3.7% experience a preventable adverse event, resulting in an estimated 180,000 preventable deaths annually (7). Similarly, upper respiratory tract infection is a self-limiting condition requiring only supportive therapy, yet 16% of all prescriptions written are for these infections (8).

• Variation in medical services. Geographically, the provision and use of health services differ significantly. Such variation cannot be explained by differences in patient mix, resource availability, or patient preference. For instance, diabetic patients in the Middle Atlantic States are 2 1/2 times more likely to have hemoglobin A1c measured than are their southern-state counterparts (3).

A look into the future
Imagine waking tomorrow and stepping into the 21st century. Your office practice is specifically designed to meet the needs of you and your staff, your patients and their families, the community you serve, and the payers from whom you receive support. What does such a practice look like? How does it operate? How does it differ from practices of the previous three decades?

The central change is that the system of care is specifically designed to achieve optimal performance levels in every aspect, including access, intraoffice flow and efficiency, provision of clinical care, and coordination of care. Such an office system puts a premium on the two core businesses of healthcare: building and enhancing clinician-patient relationships and assuring that the best available knowledge is used. In these systems, teams of caregivers work together to coordinate and provide care. Their goals are to manage acute and chronic illness and to promote health and well-being in the patients they serve. Key to the success of such systems is a detailed understanding of the characteristics and needs of the consumer population.

This futuristic office practice extends beyond the brick and mortar of its buildings to offer care whenever and wherever needed, such as the workplace or home. It includes health educators, home health personnel, and social workers who provide coordinated and integrated care. Links to patients and their support networks are made by telephone and through computer-based programs and outreach activities. Patients and their families are more involved in clinical decision-making and care-management processes, and health interventions are tailored to their preferences. Access to care is open, minimizing waiting time. Access to information is also open because patient education and information sharing are core functions of the office practice.

Patient care is evidence-based, and processes are in place for culling the best evidence from diverse sources, which allows innovative application of this knowledge. Performance of key processes of care, health outcomes, and patient satisfaction are regularly measured and tracked by physicians themselves, and this information is used to continually improve clinical practice and reduce wasteful services.

Finally, contributions of all members of the office staff are sought and respected. It is the cumulative knowledge of staff members that provides the most comprehensive understanding of how the office works.

How will we get there?
Author Peter Senge has said, "We have to stop trying to figure out what to do by looking at what we have done (9)." The first step in moving to a new level of performance is recognizing that physician responsibility lies not just in caring for patients but also in improving the system of care (10). As physicians, we need to learn from what we do in order to better the healthcare system. We do this on a daily basis in the management of our patients; it is time we do the same in the management of our care system. This will entail use of measurements in our practice that routinely track key processes and outcomes of care. Providers can then use the information to devise tests of change.

The second step is to understand that a complex set of processes constitutes the care system (11). The key tenet of improvement is that every system is perfectly designed to achieve the results it gets. To improve care, we must improve the systems that provide it. The failures noted earlier are not, for the most part, related to individual failures of physicians or others but to the systems in which these professionals work.

Finally, care can be made better by applying the science of improvement. Developed in industry, this is a robust science that has been both poorly understood and poorly used in healthcare--until the last 10 years. Already, there have been several successful applications of this science in improving care (12).

To employ this science, three fundamental questions need to be addressed: (1) What are we trying to achieve? (2) How will we know that a change is in fact an improvement? (3) What changes can be made to achieve betterment (13)?

Understanding what you would like to improve and having a mechanism in your practice for measuring what you do will allow you to undertake small-scale tests of change (14). The goal for your practice should be to improve the appropriateness of care in order to provide better outcomes for patients, including health status, service quality, and cost.

A case in point: Larry Staker, an internist in Salt Lake City, Utah, was concerned by the level of glucose control among his diabetic patients (15). In particular, he noted that his diabetic patients had a mean fasting blood glucose of 189 mg/dL and a mean hemoglobin A1c of 10.8%. Both levels were much higher than he had anticipated. After examining how diabetic patients were treated in his practice, Dr Staker found that two things stood out. First, his patients did not have a way of knowing when they were in control. Second, they received variable care from himself and his colleagues.

In response to the first problem, he developed a patient-maintained control chart that displayed daily blood glucose measurements on a time line that used a red line to indicate the goal (110 mg/dL). He instructed his patients on how to use the chart and asked them to bring it to each visit. In response to the second problem, he developed a diabetes care guideline and a diabetes encounter sheet that specified goals and the clinical examinations, such as hemoglobin A1c measurement, retinal exam, and neurosensory testing, required to achieve them.

Three years after beginning this process, the mean fasting blood glucose for his diabetic patients had declined to 166 mg/dL and the mean hemoglobin A1c had decreased to 7.2%.

Taking action
Our patients, our payers, and our national leaders are clearly mandating improvement in quality of care. To change the healthcare system, start with an examination of your own practice. Where do your outcomes fall short? Where are the inefficiencies and waste? What are the pressing needs and preferences of your patients? Adding quality improvement methods to your clinical skills will give, in very measurable ways, true value to the care you provide.

References

1. Lundberg GD, Wennberg JE. A JAMA theme issue on quality of care: a new proposal and a call to action. JAMA 1997;278(19):1615-6
2. Centers for Disease Control and Prevention. Influenza and pneumococcal vaccination coverage levels among persons aged > or = 65 years-United States, 1973-1993. MMWR Morb Mortal Wkly Rep 1995;44(27):506-7, 513-5
3. Weiner JP, Parente ST, Garnick DW, et al. Variation in office-based quality: a claims-based profile of care provided to Medicare patients with diabetes. JAMA 1995;273(19):1503-8
4. Chassin MR, Kosecoff J, Park RE, et al. Does inappropriate use explain geographic variations in the use of healthcare services? A study of three procedures. JAMA 1987;258(18):2533-7
5. Greenspan AM, Kay HR, Berger BC, et al. Incidence of unwarranted implantation of permanent cardiac pacemakers in a large medical population. N Engl J Med 1988;318(3):158-63
6. Kleinman LC, Kosecoff J, Dubois RW, et al. The medical appropriateness of tympanostomy tubes proposed for children younger than 16 years in the United States. JAMA 1994;271(16):1250-5
7. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991;324(6):370-6
8. McCaig LF, Hughes JM. Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA 1995;273(3):214-9 [Erratum, JAMA 1998;279(6):434]
9. Senge PM. The fifth discipline: the art and practice of the learning organization. New York: Doubleday, 1990
10. Reinertsen JL. Physicians as leaders in the improvement of healthcare systems. Ann Intern Med 1998;128(10):833-8
11. Nolan TW. Understanding medical systems. Ann Intern Med 1998;128(4):293-8
12. Berwick DM, Godfrey AB, Roessner J. Curing healthcare: new strategies for quality improvement: a report on the National Demonstration Project on Quality Improvement in Healthcare. San Francisco: Jossey-Bass, 1990
13. Norman CL, Nolan KM. The improvement guide: a practical approach to enhancing organizational performance. San Francisco: Jossey-Bass, 1996
14. Berwick DM. Developing and testing changes in delivery of care. Ann Intern Med 1998;128(8):651-6
15. Staker LV. The pursuit of clinical excellence: hitting the high notes. Presented before the 10th National Forum on Quality Improvement. Orlando, Fla: 1998

Dr Endsley is director of research and quality improvement, department of family medicine, Mayo Clinic, Scottsdale, Arizona. Dr Kilo is director, idealized design of clinical office practices, Institute for Healthcare Improvement, Boston. Correspondence: Scott Endsley, MD, MSc, Department of Family Medicine, Mayo Clinic, 13737 N 92nd St, Scottsdale, AZ 85260. E-mail: endsley.scott@mayo.edu.

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