Driving Quality in Hospitals: Is it Process or Outcome?

As a consumer and life science industry professional I have always had an interest in understanding the differences between process and outcomes in a hospital setting and how they impact quality of care.  Are hospitals indeed developing adequate processes that can significantly improve outcomes? 

Multiple factors such as mandatory reporting (e.g., core measure reporting), payer reimbursement and incentives, value-based purchasing, and increasing transparency (hospitalcompare.com, LeapFrog) have proven to be a strong impetus for the improvement of the healthcare delivery process with a particular emphasis on quality.  One of the central tenets driving multiple initiatives is that if you develop and then implement a comprehensive or improved process that will yield better outcomes.  

Snowfish has recently analyzed this issue by reviewing conversations that we had with 100 hospital-based healthcare professionals to better understand the nuances between the two concepts of process and outcome.  Our discussions with Chief Executive Officers (CEOs), Chief Operating Officers (COOs), and Chief Nursing Officers (CNOs) yielded some fascinating insights.

Before I discuss some of our findings, I will offer a little bit of background on process improvement.  I recall my class with W. Edwards Deming at NYU Business School.  Deming studied process at length in the manufacturing environment in the late 40s and 50s in Japan and was integral to the post WWII emergence of Japan as manufacturing powerhouse.  He noted that by identifying failures in process and literally stopping the manufacturing line until the process was fixed you, could significantly  reduce overall defects and therefore create a more consistent and reliable products.  He noted that the key is to practice continual improvement and think of manufacturing as a system, not as bits and pieces.  He further posited that when people and organizations focus primarily on quality the quality tends to increase and costs fall over time.  He also noted that when people and organizations focus primarily on costs, costs tend to rise and quality declines over time.   GE borrowed many of Deming’s concepts when they developed the six sigma concept which is in essence the idea that 99.99966% of the products manufactured are statistically expected to be free of defects (3.4 defects per million).

So has improved process yielded better outcomes in the clinical setting?  I would like to first start to answer the question with what defines process in the clinical setting.  

Process in hospitals starts with staff training.   Through dozens of conversations and additional outside research we found that hospital professionals will define training differently.   Training programs usually are a hodgepodge of different programs and formats pulled from various sources.  The preference at most hospitals is on free resources.  Approximately 66% of training respondents expect to pay between $0 and $100 per person/year for best practices training. The training formats cited most often include lunch and learns, in-services and web-based programs but also include conferences, checklists, documentation training, newsletters and a host of other random elements.  So training itself is not really standardized from one institution to another or even within the same institution and spending less than $100 per person a year really does not provide for robust training opportunities.

Another challenge is how is the effectiveness of training measured?  Unfortunately, there is not a consistent way to assess that the information was effectively learned and will likely affect behavior. Currently defining success in training can vary significantly from simple attendance (and not falling asleep during the class) to documentation and compliance with best practices (usually core measures) all the way up to demonstrating knowledge by using simulation technology. So the simple answer is that training is not even measured equally and effectively at most hospitals. 
An even larger question is whether all the critical elements that mark a successful process that drives superior outcomes (events, readmissions) are identified and being incorporated into the training.  To be fair, the hospital environment is far more complex than a manufacturing environment.   However, based on our discussions the hospital industry is still in its infancy in developing processes that will significantly improve outcomes.  For example, only one-third of hospitals are even measuring outcomes to evaluate the effectiveness of their training programs.  Clearly, a lot of work needs to be done.

So in response to the basic question I started with: are hospitals developing adequate processes to improve outcomes?  I would have to say it is a work in progress.  Clearly, things are improving but we are clearly in the early morning hours of a long day.    Just today, I heard Medicare is going to start reimbursing hospitals based on patient satisfaction surveys.  A high patient satisfaction rating will merit higher reimbursement from Medicare.  Lower satisfaction scores will reduce reimbursement.  Outcomes matter.