Engineering: The Key to Achieving Quality in Medicine

By Jon A. Hultman, DPM, MBA, CVA

Agoal consistently mentioned by everyone proposing change in healthcare delivery is quality; yet, few physicians understand the definition of this term as it is applied to the practice of medicine by employers and third party payers. Some physicians argue that they provide a superior quality of care and, therefore, should be paid more for the care they give; however, these doctors are usually unable to demonstrate what it is that sets their care apart as being “of higher quality” – why it should be considered to be worth more. John M. Burns, former Vice President and Medical Director for Honeywell, Inc., summed up what large purchasers of health care products define as quality: “Quality in health care should be defined in the same way that all services and products are acquired, on the basis of the specifications of the purchaser.” For a period of time, Americans considered Japanese autos as inferior to ours. When higher quality cars at affordable prices began arriving from Japan in the United States, opinions changed because people could “see” the difference. The quality of a service, however, is less easily “seen” than the quality of a product, and quality is especially difficult to “see” in medicine. As stated above by John Burns, in highly competitive businesses, the customer is the one who defines “quality.” The same will be true for medicine. This means that quality will be defined by all of medicine’s “customers”: patients, employers, government, and other third-party payers. At one time, quality was defined as the absence of defects. In today’s more competitive markets, quality has become the basis of competition, with its achievement requiring more than this simple “absence of defects”. In their 1991 book, Quality or Else, authors Lloyd Dobyns and Clare Crawford-Mason define quality as, “a better way of producing goods and services, a way that eliminates waste, gives employees pride in their work, and keeps the customer coming back for more. As you produce quality, productivity automatically goes up and

costs automatically go down.” This definition is equally useful as it pertains to the delivery of health care, especially since doctors “compete” in the arenas of both quality and price. Both doctors and patients perceive good treatment outcomes as quality, and this is not in conflict with the use of statistical measurement. Once a majority of doctors are able to agree upon a desired outcome, that outcome can be quantified in terms of how consistently, and at what price, it is achieved by each doctor. Quality treatment becomes defined as that which consistently achieves the desired outcome at the minimum cost. The fact that a “world renowned surgeon” performs a procedure at a “world class hospital,” is irrelevant if a “lesser known” doctor at a competing institution can achieve the same, or better, outcome consistently and at a lower cost. The key to improving consistency, and thus raising quality, is standardization of the process tasks utilized by a practice. The McDonalds Corporation is a useful example of effective process standardization. While McDonalds may not deliver your idea of the best hamburger in the world, the company has determined the quality level of the hamburger it wants to achieve and has implemented standardized processes that consistently deliver this pre-defined quality. Jet Blue is another company that has been well served by its use of standardization. When the company was a startup, its goal was to do a better and cheaper job than its competitors. To achieve this goal, Jet Blue focused on standardization. One of its strategies was to fly the same model of plane for all its routes, thus making it possible for pilots and crews to handle any flight, for maintenance to be expedited, and for errors to be kept to a minimum. Creating this type of standardization which achieves consistent, superior outcomes in both clinical and business processes, can also help a medical practitioner achieve better results while lowering costs. The term “customer focus” is often used when defining quality in medicine. Doctors believe that customer focus simply means that they should have compassion for their patients, delivering the best level of care they are capable of. This, however, is merely expected doctor behavior. Any doctor who participates in a contract or network is expected to be well trained and render compassionate, high-quality care; this is the entry level qualification necessary just to “play the game.” True quality care is also customer focused. In today’s medicine, customer focus is not simply defined by these expected, entry-level attributes; rather, it is a desired outcome that can be measured statistically by cycle time (the total time a patient spends in the treatment facility). Patients value their time, and when they encounter a medical facility that in addition to providing quality treatment, recognizes the value of their time, they perceive that the practice is offering them total quality care. The primary patient complaints

regarding HMOs have not been about the quality of the treatment received, but about the poor access to that care and the length of time spent in facilities after arriving at an appointed time. Several years ago, when national news agencies were focusing on “bad quality” at VA hospitals, the focus was not on the actual care that patients received, but rather, on how long it took patients to access that care and how long they waited to be seen after arrival at the facility. Doctors who are able to reduce their patients’ total cycle time will be supplying the most efficient care – the kind of high quality and cost-effective care that is valued by patients. The first step to achieving this higher level of quality is to identify inefficiencies in a practice’s business processes. Procedures are constantly changing in medicine, and doctors understand the need to “keep up.” Today, some treatment procedures learned in medical school ten or twenty years ago might even be considered malpractice! Doctors must be aware that what is true for the medical procedures performed by their practices is also true for its business components; business processes too must be continuously monitored, updated, and made more efficient. Fortunately, the same basic sciences that doctors have studied in their premedical training can be applied to evaluate business processes as well. In a medical practice, treatment procedures, unlike business processes, are under the direct supervision of the physician throughout regular business hours. For this reason, they are easy for him/her to manage and/ or change and are generally of high quality. On the other hand, managing business processes is difficult for many. The typical practitioner has received little business training in medical school, and compounding this obstacle is the fact that a practice’s business processes are usually “out of the doctor’s sight” during normal business hours, with him/ her being unaware of their progress. Because of this, s/ he experiences difficulty in supervising or changing these processes, and they easily become more lengthy, complex, and inefficient. It is important for a doctor to understand and become more involved in monitoring these constant, underlying business processes. With effective process monitoring, an efficient, well-run practice will allow a doctor more “patient time” – a win-win outcome that increases both physician productivity and patient satisfaction. In spite of the fact that doctors are well versed in scientific laws that can be applied to create efficient workflow in a medical practice, they often create business processes unscientifically – ones that often defy the laws of physics. Because the high cost of practice overhead is due in large part to the inefficiencies that are created in processes that are spiraling out of control, streamlining these processes is the most important thing doctors can do to increase the quality of their patient care, raise levels of patient satisfaction, lower overall costs, and increase the profit of their medical practices. As they have done with medical treatment, doctors must learn to apply scientific laws to the business processes in their practices, keeping in mind that these laws remain “relatively fixed” in spite of the constantly changing economic environment. Laws of physics that can be applied to accomplish the kind of quality that matters to doctors, patients, and payers will be covered in my next article in the California Podiatric Physician.