Process Improvement in Healthcare
Introduction
Americans continue to die each year as a result of medical errors. It is estimated that over 7,000 annual deaths are attributed to medical errors which far exceeds the number that die in other industries like aviation. Experts posit that the media has largely increased the skepticism in airline travel which in turn has led stakeholders to continuously improve safety since World War II. Even workplace injuries lead to about 6,000 deaths which is also far less that those experienced in healthcare. Medical errors not only occur in the hospital setting but are also common in nursing homes, pharmacies, outpatient surgical centers and physician offices. The costs that are attributed to medical errors are humongous. It is estimated that these losses oscillated between $17 billion and $29 billion annually in the period between 2003 and 2010 (Schoenbaum, 2006). In 2003 alone, there was an estimated $300 million extra costs that was paid to hospitals by Medicaid in order to cover five common adverse events. However, this figure represented only 0.3% of the total cost eventually paid off to treat these events. The losses incurred are not only monetary but also include loss of morale among healthcare givers who view the medical liability system as a hindrance to the learning process from errors.
Problem statement
There is a need for the use of scientific data in order to improve healthcare processes and foster consistency in the outcomes from physician intervention. Physicians have the capacity to measure processes using scientific evidence and compare the outcomes of similar scenarios so as to develop standardized healthcare process. The need for case-mix adjustment, for example, is one of the reasons measuring quality indicators is difficult since it is based on process measures that are methodologic. The major challenge in measuring processes in healthcare is that all care is based on physician judgments and is rarely evidence-based. These individual judgments do not contribute to development of standardized indicators which would help in the overall standardization of care and predict outcomes far more easily. The fact that there is no evidence that links processes to outcomes is a major challenge which is what this paper seeks to change.
This paper advocates for the use of electronic medical records instead of the administrative databases in use today. There is need for the prompt access to medically relevant data for individual patients in order to speed up diagnosis and ensure consistency in care. Additionally, it is important to have electronic records as a severe case can be comprehensively handled in a different healthcare outlet based on stored records. For example, pneumonia measures are blood cultures, pneumococcal vaccination, oxygenation assessment, smoking-cessation counseling and the mean time required for a patient to be placed on antibiotics. The first four measures are discrete meaning that they simply indicate absence or presence (Zhan et al, 2006). Having an electronic database would help a physician access relevant data quickly which might be the difference between success and failure of his/her intended intervention.
Drivers of change
There are many reasons for the occurrence of medical errors. Variation of services is central to increased errors as evidence-based care has not been extensively embraced. There is also underuse of services where millions of Americans still suffer from needless complications that have simple remedies. A Medicaid study found that the number of heart attack patients who had been administered with beta blockers was 21% (Zhan et al, 2006). It is a fact that the mortality rate of those administered with these beta blockers reduces by 43% meaning that these services are grossly underused. Additionally, patients that received beta blockers were far less likely to die during surgery than those that did not.
Overuse of medical services is also a major contributor to errors. It is reported that a sizeable population receives unwarranted services that endanger their lives and increase costs. One example is the number of number hysterectomies performed on women; revealing that one out of six of the operations is inappropriate. Additionally, the use of expensive antibiotics to treat ear infections in children is also excessive. Medical services are also largely misused resulting in injury and sometimes death. A study into surgeries done in New York reported that there were 3.7% adverse effects with 13.7% of these leading to death and a further 2.6% leading to permanent disability (Hampton, 2006). Negligence was found to contribute to a quarter of these cases. There has also been a steady increase in the number of deaths resulting from medication errors. Finally, errors occur due to disparities in the quality of services given. The University of Alabama found that use of thrombolysis to treat heart attacks was low across all races but was especially lower among blacks.
Variation, underuse, overuse, misuse and disparities in the healthcare services provided led to increase in injury, death and losses. The need for increased efficiency, improved safety, satisfaction of patients and adherence to regulations are some of the major reasons and driving forces behind the change advocated herein.
Method and timeline
Our organizational approach is threefold. First, there is going to be a concerted effort to shift patient records from administrative databases to electronic format so that patient history of illness and diagnosis can be comprehensively charted and evidence-based interventions applied (Baldwin, 2006). The advantage of this is that there will be a drastic reduction in the time needed to diagnose patients in the sense that caregivers will easily determine the conditions. Moreover, there will be a reduction in the injuries and deaths associated from misdiagnosis or in the administration of contradicting medication. Patients’ medication history will be easily accessed in order to avoid instances where two conflicting drugs are administered. Second, patients will be more involved in the creation of their own electronic medical profiles so that the information is accurate and within the parameters set in law; for example, privacy. Patients with chronic diseases in particular will be regarded as co-managers in their own health matters which will decrease the avenues for misdiagnosis hence reducing chances for errors. Lastly, medical practitioners will be paid according to the level of service they offer. Although this fee-for-service structure has been in effect for a long time, the measurement of the effectiveness of the interventions by caregivers was inaccurate. In the improved format, there will be electronic record-keeping which will help track the progress of every caregiver and pay and appraise him/her depending on the level of care given and the effectiveness in the development of indicators that might be used in the standardization of care.
The implementation of the above interventions will be fast tracked and all current records for patients with chronic illnesses should be electronic in the first six months of the system’s operation. This action is expected to help the healthcare facility reduce the number of misdiagnosed cases by more than 50%. This is in turn expected to translate to a significant drop in the number of injuries and deaths. Additionally, this new system will save on the time spent on individual cases as a result of the presence of reliable and accessible medical records which will mean more time for caring for more cases. Within the first year of operation, medical records for all patients that have visited the facility will be electronic.
Six sigma model
Reduction of errors is the basic objective of the new healthcare system. Companies like Motorola and GE have had previous endeavors aimed at the reduction of manufacturing errors using the six sigma philosophy. The basic idea behind this change model is the reduction in the variation of processes leading to a standardized method of doing things that reduces defects and errors (Chase et al, 2006). This method is reliant on scientific data for the solution of problems. The basic tenet here is reduction of variability in the diagnosis or processes involved in healthcare. This can be done through the development of standard indicators that can be used in the entire healthcare system in the country. Electronic record keeping is one of the tools that will be key to the development of standard measures that will be used throughout the industry in similar or slightly varying interventions. Lanham and Maxson-Cooper argue that the use of the six sigma model in nursing has the possibility of reducing errors to 3.4 errors per a million cases which translates to a 99.9996% success rate (2007). Just like models in other industries, six sigma requires continuous improvement to be supported by a team of competent individuals that exchange information on a regular basis and are continually pushing the envelope to ensure that there are new and improved ways of conducting business.
PDCA cycle
The PDCA (plan, do, check, act) or Deming cycle is a continuous cycle of improvement in designing and delivering the requisite care to patients with minimal errors. This cycle decries continuous improvement and does not consider improvement as a separate activity but rather as a part of the work process. It involves the planning phase where the specific patient needs are analyzed by examining the data available from previous diagnosis to present conditions and all other treatment parameters. This data is collated and need gaps identified. The Do part then aligns the healthcare systems to the specific needs. In this case, since consistent and accurate data is needed for the development of standardized processes, the healthcare facilities start by making their records electronic for ease of access and collation. The healthcare facility then actualizes these requirements by installing requisite systems. Check then entails assessment of the effectiveness of the installed systems and whether they meet the goals set forth in the planning phase. Progress reports are constantly generated to monitor the success or failure of the systems. The Act tenet then standardizes the process so that it is repeated to achieve maximum results. Since PDCA is a cycle, there must be constant assessment and reassessment of the stages in order to ensure that the best outcomes are guaranteed.
Conclusion
The safety of healthcare in the US is a much debated topic. This attention has been focused on ways of standardizing healthcare processes for the sake of having more predictable outcomes and reducing errors that sometimes lead to injury and death. Electronic means of recording and storing data guarantee accurate indicators. This coupled with the participation of patients as co-managers of their own health interventions, and an improved pay-for-performance initiative for caregivers guarantees a change in the way healthcare is run and puts more emphasis of repetition of standardized interventions to guarantee quality and reduce errors.
Reference
Baldwin, K. (2006). Evaluating quality of primary care using the electronic medical record. Journal of Healthcare Quality, 28, 40-47
Chase, R. et al. (2006). Operations Management for Competitive Advantage 11th ed. Burr Ridge, Illinois: McGraw-Hill/Irwin
Hampton, T. (2006). Health agencies update. Journal of the American Medical Association, 296:384.
Lanham, B. & Maxson-Cooper, P. (2003). Is six sigma the answer for nursing to reduce medical errors and enhance patient safety? Nursing Economy, 21, 39-41.
Schoenbaum, S.C. (2006). The patient safety movement finally is saving lives and raising hopes. Medscape General Medicine 8(4),16
Zhan, C. et al. (2006). Medicare payment for selected adverse events: building the business case for investing in patient safety. Health Affairs, 25,1386-1393.
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