By Maureen Bisognano
The need for greater healthcare value affects us all. Employers and even local governments are recognizing that increases in healthcare costs are causing very difficult decisions elsewhere. For example, company executives may see that increases in health insurance premiums are causing them to hold wage increases down, or perhaps they are looking at the effect on productivity when employees miss work due to chronic illness and wondering if there are ways to prevent these occurrences from happening and the associated impact on productivity.
What I'm seeing is very different conversations taking place between company leaders and hospitals and between payers and hospitals. In this time of healthcare reform, people are being very creative about coming together and examining where cost increases are being driven, and how we might collaborate to reduce costs.
At the Institute for Healthcare Improvement (IHI), we define the key ingredients for improvement in this way: Leaders need to build will, ideas, and execution. First, by "will," we mean that leaders need to create excitement and urgency about the need to change. They need to not only identify performance gaps but also build engagement to do something about these gaps because change is a challenge. Second, leaders need new ideas because doing things the same way with the same models will not produce better outcomes. And third, leaders need capable execution to implement these changes.
When leaders across the industry get together through formal collaborative initiatives-such as IHI's Impacting Cost + Quality-it builds on their will, ideas, and execution. When I'm at an Impacting Cost + Quality meeting, I see the exchange of diverse perspectives and ideas as senior clinical leaders and CFOs come together, CMOs sit with CIOs, or leaders from different hospitals discuss their particular challenges. The learning system that happens among the participants is quite energizing.
Also, the sharing of data that occurs through such initiatives is crucial. I will frequently ask executives four questions.Do you know how good you are? Do you know where you stand relative to the best? These two questions are about whether leaders are really in touch with what their organizations' performance looks like and what quality looks like. When leaders are looking only at their own data, they often have a misperception about gaps between their performance and the best. In a formal improvement collaborative, executives share their report cards with one another and examine how high performers came to excel in a particular area. When leaders recognize their particular gaps compared with others, the learning can be profound.Do you know where your variation is? This question encourages leaders to really dig into their performance issues. Simply looking at average rate covers up a lot. When executives look closer, they usually locate varying levels of performers. Seeing these differences gives them new will and ideas for ways to improve performance as a whole.Do you know your rate of improvement over time? Many executives look at quarterly or monthly reports, and they recognize that they're getting better year over year. But when they actually trend data out over time, they typically get a deep sense of the need to speed these improvements.
Often, executives don't know the answer to these questions. But when they join a collaborative, the information they access from peers helps guide them. It's the combination of these questions-in a collaborative setting-that gives people the momentum to improve.
Four strategies may help senior leaders who are trying to stir momentum for improvement in their own organizations.Invite financial leadership to the table. CFOs and other finance executives should play a part in quality discussions. When I first sit with executive teams, I often find that finance people don't understand the clinical implications, and clinicians don't understand administrative concerns.
So I would advise getting the entire senior team together around a particular problem and doing a deep dive. First, they should examine the human costs of the issue: Is it delays, complications, readmissions, or the need to return to the operating room? Try to understand what the impact is from the patient and family point of view. After they share this understanding, they should similarly examine the issue's financial impact. The ability to communicate and understand an issue from a variety of perspectives in this way can be a powerful tool for recognizing and driving improvement potential.Recognize that identifying waste isn't enough. Even when hospitals are able to identify costs of poor quality or low value, they often haven't set up the necessary systems to create savings in "dark green" dollars, or dollars that make it to the bottom line. For example, leadership may identify the savings associated with a potential decrease in readmissions. But without making the right structural changes-having the right processes in place and training people to have the right skills-those dollars won't materialize.Keep the patient experience at the forefront of efforts. Improvement often works best when the patient's voice is kept at the center of design.
As an example, I recently interviewed a patient who uses a wheelchair. He was telling me about the three-week struggle he goes through when his wheelchair develops a flat tire, from obtaining approval and the prescription, to having the durable medical equipment people locate a tire, to finally getting the tire replaced. During the duration, he misses work and requires pain medication.
Many of the doctors and executives observing our conversation noted that when they get a flat tire on a car, they are able to call a service and have it repaired in an hour. Why can't we do that for this patient?
Too often, we're not seeing the cost of our failures in care. The patient's voice can be incredibly powerful in helping us locate these failures. This same individual also described having hospitalizations several times a year as a result of urinary tract infections, which resulted from not having enough catheters. The catheters are a minor expense compared with medications and hospitalization. All too often, however, we don't examine care delivery this way. We don't see the journey of the patient.
Maureen Bisognano is president and CEO, Institute for Healthcare Improvement, Cambridge, Mass.
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