TQM In Intensive Care

What Happens When Quality Is Job 1?

The metrics say he's the best.

The metrics say he's the best.

Edward Deming redesigned Japanese industrial methods in the aftermath of WWII. When the Ford Motor company struggled to overcome the debacle of the Pinto and compete with the rising Japanese auto industry, his Total Quality Management became their operating principle, and “Quality Is Job 1” their slogan. The profitable Taurus-Sable line was the result.

Now the Quality Movement is about to be applied to medicine. Perhaps it’s time.

From what has been called a perfect storm of disgruntled patients, legislators and medical professionals, the quality movement in health care has been born.

Thanks to its efforts, those hospital walls are slowly becoming transparent. Revealed is a world of tangled routines, many obsolescent, many downright stupid, that no one had carefully examined. The reformers are out to streamline the routines, retrain the workers and keep them permanently on display — an ant farm behind clear glass — to make sure things never get out of control again.

Would you care? Would it help if you could directly compare hospitals, the comparisons made using numerical metrics that together revealed the quality of care a patient might receive? I suspect that in many cases, the answer is “You betchya!” Abigail Zuger, M.D. tells us more as she reviews the book The Best Practice How the New Quality Movement Is Transforming Medicine By Charles Kenney.

That is just the first installment of such data on display. Soon both hospitals and individual practitioners will be publicizing their own report cards. Insurers will be paying them for good grades, penalizing them for bad. Incentives to minimize errors, complications and inefficiency will mount. Health care will become perfectly safe, perfectly smooth, perfectly perfect.

But yes, of course this is just a bit too good to be true. Consider that NASA too adopted TQM methodologies in the aftermath of the Challenger explosion. It did not – could not – prevent the Columbia tragedy. Ford survived the Pinto, but would you really want a Fusion over a Civic?

But readers should be aware that Mr. Kenney’s story ignores a wide array of questions that have some thoughtful members of the health care world a little troubled by the quality evangelism.

What does quality care mean, for instance, in cases of hopeless illness? When the outcome of care will not be good, how should good care be redefined? Suppose patients sabotage their own care, as so many unwittingly do. Who takes the blame?

And most important, what does it mean when science impudently undercuts accepted quality benchmarks

That last is interesting. What does it mean for – not only health care, but for patient confidence and for TQM itself when it’s discovered that they’ve been measuring the wrong thing with their metrics? Or when (not if, but when) the science tells them that they’ve been giving the wrong treatment perfectly?

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3 Comments on “TQM In Intensive Care”

  1. Scott Hodson Says:

    Many American health systems are significantly underinvested in quality management Infrastructure, Process, and Organization. To achieve breakthrough improvements in quality, patient safety, and resource utilization hospitals and health systems must develop a “world class” quality management foundation that includes:

    Strategy: including a clear linkage of quality and patient safety to the organizational strategy and a Board-driven imperative to achieve quality goals.

    Infrastructure: incorporating effective quality management technology, EMR and physician order entry, evidence based care development tools and methodologies, and quality performance metrics and monitoring technology that enables “real time” information.

    Process: including concurrent intervention, the ability to identify key quality performance “gaps,” and performance improvement tools and methodologies to effectively eliminate quality issues.

    Organization: providing sufficient number and quality of human resources to deliver quality planning and management leadership, adequate informatics management, effective evidence based care and physician order set development, performance improvement activity, and accredition planning to stay “survey ready every day.”

    Culture: where a passion for quality and patient safety is embedded throughout the delivery system and leaders are incented to achieve aggressive quality improvement goals.

    My firm has assisted a number of progressive health systems to achieve such a foundation, and to develop truly World Class Quality.

  2. Paul Says:

    Even if better quality standards could be achieved, there is still a more insidious issue: that of cheating the metrics, whatever they turn out to be. It is clear (by many reported examples) that professional educators throughout the country cheat on school testing in order to avoid penalties associated with the No Child Left Behind measuring system (as flawed as that measurement system is).

    A generalized medical quality system applied nationwide is not immune to poor, misunderstood or misapplied metrics; even the best established quality systems will fail (read: NASA after Challenger) if they are not measuring the right parameters and correcting the right deficiencies. Like NASA, modern medicine suffers from business compromise, and as long as profit motive and budget are factors, the very best, established quality systems will suffer from decisions based on profit. You can’t reach perfection on a budget.

    So instead, would profitless socialized medicine generally raise the quality of medical care in the U.S.? Probably not. Would privatizing all hospitals and simply having them compete based on outcomes work? Probably only as well as the U.S. energy oligopoly has helped stem dramatic oil price increases, which is not at all.

    While I think it’s noble to try to raise the quality of medical care, I don’t see an easy solution; hell, I don’t see any solution. The target remains blurred behind clouds of medical staff, pharmaceutical companies, hospitals and other businesses all demanding their slice of the profit pie, without enough to go around.

    BBD

  3. joe Says:

    To Scott – You’re optimism in noted, but I must say that I’m unconvinced in the face of real-world problems faced by the health care industry that even TQM will do much. The list mentioned by BBD – “clouds of medical staff, pharmaceutical companies, hospitals and other businesses all demanding their slice of the profit pie, without enough to go around.” doesn’t state half the problem, as I see it. Along with insufficient resources, add in the burdens of the law (that is, government) and then add the economic clout of the insurance companies whose interests are often at cross purposes with the hospital’s, and it’s hard to see why anyone would subject themselves to such a system.

    BBD – I agree that socializing medicine in this country is not going to help anything (and probably make it worse – see this pathetic story), but I can’t see how even a free market solution works. What happens to supply and demand when our demand is essentially infinite?

    I’m afraid I know the answer. The lawyers and the insurance companies take over.


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