Chapter 1
Introduction
The challenge of performance improvement in health care
Jan Walburg, Helen Bevan, John Wilderspin and Karin Lemmens
KEY POINTS OF THIS CHAPTER
- Why existing approaches to quality improvement, in isolation, will not deliver sustained performance improvement
- The need for an integrated approach to the application of quality of care tools
- The potential of outcome management in healthcare
INTRODUCTION
Health care organisations are busy with efforts to improve the quality of care on a number of fronts. Many institutions are conducting āimprovement projectsā. Typically these involve the formation of a team around a specific problem and then using the Plan- Do-Study-Act (PDSA) cycle to make changes (Langley et al. 1966). Other institutions are applying the principles of quality management and frequently make use of the European Foundation for Quality Management (EFQM) Excellence Model. These quality improvement measures are currently applied at the corporate level of the organisation.
In addition, various professional groups are involved in active efforts to improve the quality of work carried out by their professions through training programmes, registration schemes and the development of evidence-based guidelines and protocols. Similarly, the health care sector is very active with respect to quality certification. Numerous hospitals and healthcare organisations now participate in an accreditation trajectory, for example.
Other institutions are investing in certification with the aid of the International Standard Organisation (ISO) system which has been specially adapted in a number of cases for use within the field of health care.
Despite all these efforts, a huge gap exists between the potential for quality improvement in health care and the reality. Health care systems are characterised by variation in clinical care, lack of responsiveness to usersā needs, waste, delays and financial challenge (Institute of Medicine 2001). Current quality improvement efforts are typically not delivering enough change, at a fast enough rate. What stands out most is the difficulty of implementation and the fact that efforts to improve the quality of care tend to remain at the level of the organisation and thus receive insufficient expression at the point where clinicians actually treat patients. Part of the background to this book is the all-toocommon scenario of āunder shootā in corporate quality programmes. Although no studies comprehensively document the outcomes of large-scale quality programmes in health care, experts agree that most organisations are left with disappointing results (Bate et al. 2004). The current top-down quality systems are mostly oriented towards systems and processes, which means that the efforts of the relevant professionals and the efforts of organisational leaders are not sufficiently attuned to each other and thus inadequate.
What we need is corporate quality improvement strategy aimed at concrete results in terms of patient care. At the same time, there are risks when clinical teams embark on a myriad of grass roots local improvement projects if such projects are not aligned with the goals and priorities of the corporate organisation. A situation can be created where clinical teams work on one quality agenda and corporate leaders focus on a completely different set of priorities. Opportunities to spread best practice on outcome improvement and organisational learning are diminished (Bate et al. 2004). This must be based on the intrinsic motivation of individuals and teams, with the professionals and corporate leaders largely in agreement. Current practices typically do not come close to meeting these requirements. When we look at managers, we see that they often devote considerable effort to the implementation of quality systems. At the same time, however, their own management systems are often exclusively aimed at operational management and finances. Operational management and finances are the predominant topics used for accountability in annual reports.
The result of this is that the social environment (society) may look favourably upon a health care organisation which reports staying within its budget while meeting productivity targets but hardly be enthusiastic about the organisation. Such an approach can lead to confusion within the organisation as well. That is, the corporate leaders say that they are going to implement quality policy but act on the basis of productivity and financial figures. An orientation towards financial data is, of course, critically important in the management of a care organisation. However from the point of view of most of society, it misses the point because the performance of the organisation in the area of care is of primary importance.
When we look at treatment providers, we see that they generally already have their hands full with the conduct of their daily clinical work. They may, at times, attempt to improve the way they work on the basis of the guidelines provided by professional groups and on the basis of certification and accreditation schemes. But the implications of these efforts for the outcomes of the care process are not yet really known. Care professionals typically receive no systematic reporting with regard to their outcomes. And if they do receive such feedback, it typically involves a very high level of aggregation which makes it impossible to understand or interpret clinical performance at the level of the individual care giver or clinical team. Feedback may be provided with regard to patient satisfaction, for example, but only at the level of the organisation.
The purpose and significance of the care professionalās work lie predominantly in the treatment of the individual patient and his or her reaction to treatment. A professional can therefore be inspired by being given direct insight into the results of his or her diagnostic and treatment efforts. Declining team results or evidence that a team is performing less well when compared to another team may be very disturbing and indeed downright unacceptable. However, when the care results are later seen to improve, the provision of such feedback constitutes a real source of satisfaction.
We can conclude that the many instruments available to measure and improve the quality of care only gain their significance and really become a part of the normal functioning of the care organisation when their impact on the care results becomes clearly visible to the treatment provider, the patient and the corporate leader. While the manager and the care professional typically have their own distinct objectives, with the one aimed at organisation and the other at content, focusing their orientation towards the continual improvement of care outcomes can provide a shared objective. We are therefore of the opinion that the isolated application of quality of care ātoolsā in the form of projects, certification or models such as the EFQM has had its day. We believe that the tools must not only be applied in an integrated manner but also clearly directed at the outcomes of the care given to patients.
Support for the integrated application of quality of care tools comes from a comprehensive review of the literature on the influence of various instruments on the quality of care. When Grol (2001) reviewed the use of a number of strategies such as professional guidelines, professional development, feedback with regard to care results, increased involvement of the patient and total quality management to improve the quality of care, he came to the conclusion that the different methods were only partially successful. When it comes to improving the quality of care, Grol concludes that integrated methods applied to the care process itself appear to be most effective. Care outcomes improve when guidelines are carefully implemented, care professionals are intensively but personally educated and the care organisation applies quality of care policy on a broad basis. Quality of care policy aimed at the improvement of actual care results also appears to be of critical importance.
We describe this as āoutcome managementā in the book, and it is based on the two principles:
- the integrated application of quality of care principles, and
- a strong and consistent orientation towards the improvement of actual care results.
We define outcome management here as the continual improvement of outcomes for the best possible care processes.
In this book we also talk in terms of āperformance improvementā. This is based on the premise that performance management in health care has traditionally focused on finances and operational management. As such, it has been of little relevance either to clinical professionals, or to the users of health services. Taking the disciplines of performance management, but relating them to the outcomes of care, seems much more relevant to both clinicians and users. This must be applied in a way which leads to continuous improvement in outcome for patients, hence performance improvement.
The design of the book is based on a staged approach to factors of importance for the realisation of outcome management and performance improvement. The first four chapters provide an introduction to learning in organisations, which is the foundation stone for improved outcomes (Chapter 2), to the model for outcome management (Chapter 3) and to the steps that healthcare leaders can take to create the organisational conditions for performance improvement to flourish (Chapter 4). The building blocks for outcome management are then described in the following ten chapters:
- the importance and impact of effective teamworking for performance improvement (Chapter 5);
- how performance can be improved by focusing on processes and systems (Chapter 6);
- how to define āoutcome of treatmentā in multiple dimensions (Chapter 7)
- the importance of patient characteristics as variables in the outcomes of care (Chapter 8);
- benchmarking as a mechanism for comparing our own results to those of other teams (Chapter 9);
- effective mechanisms for feeding back data in ways that will lead to action (Chapter 10);
- how outcome management and performance improvement can contribute to a holistic disease management perspective (Chapter 11);
- issues pertaining to the public disclosure of performance outcomes (Chapter 12);
- actions to strengthen the scientific value of outcome measurement (Chapter 13);
- a summary of the major themes covered by the book and potential future directions (Chapter 14).
In the various chapters in this book, the different components of a model of outcome management are considered. The aim of doing this is to provide support for the efforts of teams and institutions to attain better care results. With the conscientious introduction of outcome management, health care can gradually develop a focus on the continual improvement of care results.
Teams receive information with regard to their results and can then compare this information to the results of others. Competition is no longer a question of who has the most beds or the largest care region but who attains the best results. Healthcare professionals are therefore supported in their natural predisposition to provide the best possible care for patients. With outcome management, care organisations can also contribute to the substantive scientific development of clinical disciplines on the basis of hand-on experience and not just research conducted within the artificial context of double-blind clinical trials. Finally, patients and society can be more thoroughly informed of the results of care with the widespread introduction of outcome management.
CONCLUSION
This book is an international cooperation between Dutch and British authors. Our healthcare systems are very different; one is social insurance based, the other is tax based. The structures and stakeholders are hard to compare. Yet we face many of the same problems and recognise the potential for outcome management in healthcare, whatever the national or cultural context.
There is a need for systematic, integrated approaches to improving the quality of care. Such approaches need to help corporate leaders deliver corporate goals at a strategic level. They also need to engage individual clinicians and clinical teams in the continuous improvement of their care and, in doing so, liberate the natural energy and creativity of the healthcare workforce.
The principles in this book can help your improvement journey whether you are an individual clinician, or student of healthcare or a corporate leader.
DISCUSSION QUESTIONS
1 To what extent is your existing approach to quality improvement delivering the results you require in the timescales you require?
2 What are the opportunities to develop a more integrated approach to the quality of care?
3 Which of the topics covered by the chapters in this book seem most relevant to your local situation?
REFERENCES
Bate, P., Bevan, H. and Robert, G. (2004) Towards a million change agents: a review of the social movements literatureāimplications for large-scale change in the NHS. NHS Modernisation Agency http://www.modern.nhs.uk/
Grol, R. (2001) Improving the quality of medical care: building bridges among professional pride, payer, profit and patient satisfaction. Journal of the American Medical Association, 286(20): 2578ā2585.
Institute of Medicine (2001) Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press.
Langley, G., Nolan, K., Nolan, T. and Provost, L. (1966) The Improvement Guide: a practical approach to enhancing organisational performance. San Francisco, CA: Jossey-Bass.
