Qmentum Quarterly, July 2010, Volume 2 Number 3

Qmentum Quarterly: Quality in Health Care is new publication produced by Accreditation Canada. This month’s issue (July 2010) is focused on Emergency Health Services in Canada, including pre-hospital and in-hospital care. I contributed a piece called “Enhancing Organizational Performance Through Process Improvement” (pp. 18-20).

Using an ST Myocardial Infarction (STEMI) cases as an example of a care process, the article discusses the importance of approaching improvement with Deming’s System of Profound Knowledge as your underlying theory and then provides guidance on several considerations important to any improvement project, including:

• selecting a project,
• choosing project sponsors,
• forming a good team,
• developing an aim statement,
• defining measures,
• learning in action, and
• spreading changes.

Unfortunately, the article is not available online for free. Copies can be purchased here.

After many years of always carrying around some earmarked textbook and a file folder of articles, of squeezing in writing around family and typing away in hotel rooms on client trips, and of wondering when it will ever end, I finally finished the doctoral journey. The dissertation is finished and approved, the defense is complete, and the administrative checkboxes are filled in. My research will soon be published in the ProQuest UMI Dissertation database and add to the learning about patient-centric systems. In the meantime, here is the official abstract. Thank you to all who have supported and encouraged me over the years. I really appreciated it. –Dr. Dave.

Abstract

THE INDIVIDUAL, ORGANIZATIONAL, AND SYSTEM OBSTACLES TO PATIENT-CENTRIC EMERGENCY MEDICAL SERVICES SYSTEM DESIGN

David M. Williams

Saybrook University

Research regarding emergency medical services systems design is inadequate and is largely focused on individual components or patient conditions (e.g., cardiac arrest) rather than on an interconnected system designed to serve the patient. In addition, patient demand has expanded from life-threatening illness and injury to include general medicine, which current EMSSs are not designed to serve. The purpose of this research was to examine the individual, organizational, and system obstacles to developing a more patient-centric EMSS design.

Fifteen factors potentially associated with patient-centric EMSSs were identified from clinical and systems literature. Using a multi-case study, five United States EMSSs, representing five major design models (fire department, hospital, private organization, public/third-service department, and public utility model), were studied. Data collection included four sources of evidence: (a) data metrics, (b) document review, (c) interviews (n=11), and (d) archival records. Data analysis involved coding 582 independent obstacles into 38 distinct categories and using a Pareto distribution to identify the leading obstacles to each patient-centric feature. Fifty percent of interview transcripts were externally reviewed for reliability. Results were presented in written narrative and displayed in Pareto charts.

The top five categories, representing 33.5% of the total obstacles identified, were cost/funding, data measurement, process/outcome focus, systems view/design, and public information/education. Six recommendations resulted from the findings, including quantifying a reasonable cost, changing the funding model, developing an EMS research consortium, initiating data measurement to improve, integrating quality improvement as an operational strategy, and documenting and sharing learning on practices that work and do not work.

This inquiry provided new insight into the current state of EMSS design, how it aligns with patient-centric factors, and what obstacles exist for medical directors, operational leaders, and policy makers in positions to transform future EMSS design and operations. The obstacles identified provide information for additional EMSS research and the results will further the vision of creating a more patient-centric EMSS design that better serves patients through prevention, reduction of morbidity and mortality, and facilitating access to the most appropriate care.

I’ve been catching up on my reading and am sifting through a stack of magazines on my office shelf. In the March 2010 issue of Fast Company is a great article about an ad agency based in Rochester, NY – Partners + Napier – that applied process improvement to their business and realized amazing results. They report being able to trim the time to complete a project from eight weeks to just three, save the client 40%, and increase productivity by 3.5%. The company has become much more nimble and billings have increased 300% in five years. Frequently slow adapters to the potential of applying process improvement claim that it doesn’t work in the service industry. Here’s one example where it has. To read the Fast Company article, click here.

Read the NY Times story here.

Photo: alamosbasement

Today, I had the pleasure of speaking to a group at the University of Texas LBJ School’s Center for Health and Social Policy about prehospital emergency health services systems. As a former paramedic, EMS research, and organizational systems improvement advisor with my colleagues at Fitch & Associates, I was able to share a unique understanding of the history and evolution of EMS systems in America. The Institute of Medicine’s 2006 report Emergency Medical Services at the Crossroads served as a framework for the discussion. It’s not often I’m invited to present this information to audiences outside of the EMS and public safety industry and it was great to see people engaged in the topic and asking great questions about quality, performance, system design, and public policy. Copies of the slides should be available soon on the CHASP website here.

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Paul Levy, CEO & Blogger - Running a Hospital

One of the first banners I saw as I entered the IHI Forum had a blue Twitter bird logo with instructions to “follow” the hash tag #IHI09. By placing this hash tag in messages posted or “tweeted” on Twitter, your messages shows up in a search of folks communicating about the Forum and its content.

Over the last year or so, we’ve seen a rapid emergence of the use of social media like Facebook and Twitter. We’ve also seen it become an interesting communication tool for businesses and real people to share ideas and information. It feels as if we are only beginning to see the potential of these relatively new mediums.

Today, I sat across from Hospital CEO & Blogger Paul Levy (Running a Hospital) as he shared with an interested group of faculty “this thing called Twitter.” In addition to providing real time blog posts and tweets about the Forum, Paul is delivering a session on Wednesday on Using Social Media to Pursue Quality and Patient Safety. Sarah Fraser is also doing a mini course on Monday on Using Social Media to Improve Health: Techniques and Applications. Who would have guessed a year or two ago, these topics would be on the agenda?

In addition to scheduled sessions, IHI Forum participants are self organizing for informal “tweet ups” around topics like patient safety. For the first time, attendees can quickly network with people with like interests, from around the world, that they might not have ever met in year’s past. Fantastic!

I’m still testing and learning to use these tools, but am intrigued. When Paul finished his Twitter demo, one of the faculty asked him something along the lines of: “What’s the point?” He replied, “I’m not sure yet, but for now, it’s kind of fun.” I agree. What do you think? Where do you think this social journey will lead us?

Screenshot of IHI Improvement Map

This morning’s Faculty/Staff Mindwalk at the 21st Annual National Forum on Quality Improvement in Health Care, included an introduction of the IHI Improvement Map by Maureen Bisognano, Executuve VP and COO at IHI. The map is a free online resource for hospitals to sift through the best available knowledge on key process improvements to enhance care. With a few clicks, users can access information based on criteria like cost, time, evidence, and difficulty. The tool is quite amazing and what’s even more impressive, it’s free. The intent is to get the information to those that can lead change.

Check out the improvement map and learn more here.

Commonwealth Ambulance, Springfield, MA (1996)

As the health care debate continues, political pundits, as well as hacks, talk in sound bites about insurance reform without understanding many of the challenges that face the system and add to its cost. Imagine if the discussion was about solutions to real problems instead of hot button, polarizing topics. What if we were truly using the Pareto Principle to identify the vital few improvements that would really enhance health care in America?

In a former life, I worked as an urban street paramedic. Few people realize that, in addition to responding to heart attacks, shortness of breath, elderly falls, and fender benders, much of EMS work involves serving those who are uninsured and plagued with chronic health problems. EMTs and paramedics are the street level primary care and public health safety net for many.

A select segment of these patients are very high utilizers of ambulances and emergency rooms for their health care. Labeled, “frequent fliers,” they can sometimes call multiple times a week. Most paramedics see them as just a part of the job. Some systems have viewed them as a nuisance and have developed programs to deny them service or even have them arrested for 9-1-1 abuse. Few have looked at helping them.

A colleague today sent me a great article in the Washington Post about a “frequent flier” in the DC Metro system. The journalist did one of the best jobs I’ve seen of profiling these people, explaining the reality of the problem, and talking about programs like San Francisco Fire Department’s HOME Team. The San Francisco Chronicle once estimated just 362 patients resulted in $11.6 million in ambulance and emergency department charges during an 18-month period. It’s a big issue and one I firmly believe is a wonderful opportunity.

What if health care improvement was focused on helping them too? Please read the full article here.

Image: www.lumaxart.com/

In an interview for the Gallup Management Journal, Jim Clifton, Chairman and CEO of Gallup, predicts the end of the Deming, Six Sigma, process improvement era. He describes process improvement as one of the big evolutions of leadership, but that it has reached its plateau as organizations have maximized efficiencies and have run out of things to improve (i.e., GE & Jack Welch).

Mr. Clifton tells how he believes the next evolution of leadership will require leading with “in-depth understanding of states of mind.” He says, the new economy is driven by innovation, talent, and entrepreneurship and an understanding of behavioral economics or mathematically describing states of mind will be essential for future leaders. My summary doesn’t do him justice, so read the complete, thought-provoking interview here.

As an improvement advisor and one whose work is heavily engaged in process improvement based on Deming’s theories, you can imagine I might disagree with Mr. Clifton. The short answer is yes and no. I do agree that organizations need to have a stronger understanding of ‘states of mind’ and being able to quantify them. As he indicated, we need to move from relying on anecdotes to having hard data. Where I disagree with Mr. Clifton is in his claim that process improvement is not still an essential aspect of the evolution of this leadership. What is missing is an appreciation that his central thesis is actually part of Deming’s theory of Profound Knowledge and his specific attention to psychology. Process improvement is about learning in action through testing changes and much of that learning involves studying the people and their human behavior in systems. Understanding how they do things, what influences them, and what they want. Process improvement, with an understanding of psychology and change complements Mr. Clifton’s theory.

We all are feeling a shift around us as technology rapidly evolves our world, what we know, and what we are capable to do. The differences in each generation is evolving at a rate like we’ve never seen and organizations and their leaders are going to need to be constantly changing to meet customer and workforce needs. If you look at process improvement as only an opportunity to reduce costs and improve efficiency, Clifton’s assertions may be right. But, if your coming at improvement and change from Deming’s Profound Knowledge lens, the playing field and the customer may be altering, but the tools are just right to meet the challenge.