Over the years, analogies to various manufacturing and service industries have highlighted opportunities to improve the quality, outcomes, and costs of health service delivery.
Specifically, healthcare providers have been advised to emulate the high quality achieved in auto manufacturing, the safety realized in the airline industry, and the consistency and low cost of the food service industry by standardizing processes and training employees in quality improvement.a Manufacturing a car, piloting an airplane, and preparing restaurant meals are all processes that have been likened to healthcare delivery.
Analogies between health care and other industries can be enlightening and helpful. Highly respected organizations like The Joint Commission, the Institute for Healthcare Improvement, and the Institute of Medicine have recommended that healthcare providers learn lessons from other industries on achieving enhanced value and safety. Certainly, healthcare providers have successfully borrowed methods from other industries to improve processes and outcomes. Medical homes, physician scorecards, and disease registries are among the innovations with roots outside traditional health care. But analogies between health care and other industries have limitations.
Health Care Versus Hamburgers
Upon closer examination, the comparisons between health care and manufacturing and food service break down due to differences in complexity. Complexity science suggests that simple, complicated, and complex activities differ in significant ways, as shown in the exhibit below.
Fulfillment of fast-food orders is a simple task that has a defined set of ingredients. Product and service reliability are reasonable and expected, and poor outcomes are experienced linearly and immediately by customers, who also happen to be the payers. Customers can express their disappointment by taking their business to any of a number of competitors. Their expectations of quality are largely determined by the price, which is clearly specified and directly experienced by the customer. A customer who is well satisfied with a $5 hamburger would be highly dissatisfied if the same hamburger under the same circumstances cost $50. But the same customer might be well satisfied with a $50 gourmet hamburger served in a beautiful setting with attentive staff and other amenities. Another customer might be outraged by a $50 hamburger in any setting. In such instances, standardization and control of product inputs help ensure consistency and reliability, and value is determined immediately and independently through customers’ ability to experience immediate costs and outcomes of their decisions.
Health care operates in the realms of the complicated and complex for several reasons. First, healthcare delivery does not have a defined set of ingredients. Although physicians have a defined (albeit growing) armamentarium of treatments, the complexity rests in matching those treatments to a patient’s genome, mixture and interactions of comorbidities, social and economic environment, family support structure, and individual responses. Each of these patient characteristics is unique,uncontrollable, and not entirely predictable. Bad outcomes may manifest themselves disproportionately to the scope of a medical intervention, and may occur at a future time, with permanent consequences. Furthermore, a patient may be responsible for a portion of the cost of care, but the value of care provided may not correspond with its price. A Medicare beneficiary might experience the same out-of-pocket cost for an unnecessary MRI as for a life-saving heart bypass operation. Insurers, which pay for most healthcare costs, may experience value differently than patients.
Several service industries also operate in the realms of the complicated and the complex. For example, banking and airline services must be carefully matched with customers to meet their needs. As with healthcare delivery, a mismatch can result in devastating outcomes at other times and places—not just when and where the service is delivered.
But healthcare delivery is different. For one thing, providers cannot narrowly define their customer base. Healthcare providers must treat those who are engaged in their therapy and those who resist it; providers treat patients despite their use of tobacco products or engagement in other risky behaviors. Furthermore, although money, or at least credit, is required to access risky financial services or to travel by air, healthcare providers often must treat patients regardless of their ability to pay. Finally, in banking and air travel, customers generally have a choice about whether to use a service. In contrast, death is sometimes the only alternative to accepting medical treatment.
The Way Forward
Despite these differences, healthcare organizations should do as manufacturing and other service organizations have done and apply scientific methods to improving their processes—in this case, the methods of healthcare delivery science.
It is important to recall that fast-food manufacturing was not always a simple process. Vast improvements in industries as diverse as agricultural genetics, harvesting, beef production, refrigeration, transportation, and IT all converged to ensure that intermediate products with consistent quality were dispatched on time, and in the right condition. Only through the development of new knowledge could standardized inputs be processed using the right technology, in the right environment, to deliver a final product with reliable and measurable quality, cost, and value.
The best way to move health care quickly along the complexity spectrum toward greater simplicity may be through cooperative learning. The High Value Healthcare Collaborative—a consortium of leading U.S. health systems that are using administrative data to examine differences in care delivery practices to improve the value of care—serves as an example of how healthcare organizations can accomplish this change.b The consortium seeks to improve value within the nation’s healthcare delivery system by:
- Encouraging all constituents to work together to identify and implement best practices
- Determining which processes are necessary to achieve optimal outcomes, and which of those can be standardized
- Creating a definition of quality that incorporates input from patients, providers, and payers
- Measuring, monitoring, and reporting on value creation from multiple perspectives
- Developing incentives to enhance value creation
- Studying the impact of interventions on outcomes
Through such cooperation, collaboration, learning, and careful evaluation, the healthcare industry can accelerate the development of processes that consistently deliver high-value care.
William B. Weeks, MD, FHFMA, is professor, The Geisel School of Medicine, Hanover, N.H., and a member of HFMA’s New Hampshire-Vermont Chapter (firstname.lastname@example.org).
Eric B. Wadsworth, PhD, CPA, is assistant professor,The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, N.H. (email@example.com).
a. Berwick, D., Kabcenell, A., and Nolan, T., “No Toyota Yet, but a Start. A Cadre of Providers Seeks to Transform an Inefficient System—Before It’s Too Late,” Modern Healthcare, Jan. 31, 2005; Kohn, L., Corrigan, J., and Donaldson, M., To Err Is Human: Building a Safer Health System, Institute of Medicine, 1999; and Gawande, A., “Big Med,” The New Yorker, Aug. 13, 2012.
b. Weinstein, J.N., Nesse, R.E., and James, B.C., et al., “The High Value Healthcare Collaborative. A National Collaborative to Improve Value in Healthcare Delivery: Structure, Process, Challenges, and Early Lessons Learned,” Health Affairs, May 9, 2012.
Publication Date: Tuesday, January 01, 2013