If one performs a “Google” search with the key words: “health reform” and “US OR America” for 2007, one will find about 160,000 links. If one does the same for 2010, there will be over 2.5 million links. Quite a difference!
This is not surprising, since the Affordable Care Act (ACA) is going to affect the life and well being of almost everybody. It affects the uninsured, it affects the insured, it affects children, it affects adults, and it affects the elderly. Initial debates, prior to the President signing the ACA into law, were about its affordability, implication on quality of care, etc. Then, it became a divider between both parties and frequently was about which party is “better” for people. That was a time of “death panels”, “communists” and “fascists.”
“Small details,” like feasibility of the ACA, and the technical support necessary for its success, have gradually been moving to the back burner. Unfortunately, the need for attention to these “details” is still there. A perfect example of this is the progress, or lack thereof, in patient safety efforts. In particular, it is time to focus on the neglected but crucial area of hospital operations management.
Why Is Patient Safety Still Not Adequate?
For over ten years since the ground breaking and long overdue IOM report To Err is Human citing 98,000 annual preventable deaths, there has been a national movement to improve quality of care. If one adds to the above Google search “quality OR safety”, the number 2.5 million links is reduced to a still impressive number of over 1.6 million links. Currently, we probably have more quality specialists in the healthcare delivery system than the number of avoidable annual deaths, and yet, the results are far from satisfactory. Many researchers, policy makers and administrators have analyzed plausible causes of such lack of significant improvement, but one “elephant in the room” – hospital operations management – is still overlooked.
Traditionally, failure by the individual clinician was seen as the main source of medical error. The proposed remedies were appropriate education and training, emphasizing constant individual vigilance, and reinforcing the message with the threat of punishment through the malpractice system. More recent thinking shifts the emphasis away from blame directed at individual clinicians and toward the systems in which clinicians work. We applaud that, but believe that current strategies must be broadened to address the design of major hospital operational systems that affect patient load if progress in ensuring safe, high quality care is to gain leverage.
Managing Hospital Operations
If instead of “quality OR safety” one adds to the above mentioned Google search just two words “operations management”, 1.6 million links would shrink to just 400! This is a perfect evidence of our continuing unrealistic attempts to improve the healthcare delivery system and to add to it millions of uninsured, without analyzing its operations. There is no other industry (except maybe education) that is improving its product without optimizing its operations. In any industry, with no exceptions, operating systems have a huge impact on work climate, staffing, financial results and customer satisfaction (see for example two well-known Harvard Business School case studies: McDonald’s Corp. and Burger King Corp.), and yet we are trying to change our health care delivery system without changing its core operations. We are trying to achieve the results we want just by changing the reimbursement system, by asking different parties to collaborate, etc. By focusing on reimbursement and ignoring operational realities, we might inadvertently achieve the exact opposite of what we desire: higher costs and lower quality of care.
One hospital-level factor (“condition”) experienced everyday by the system and caregivers that is particularly crucial to patient safety is patient volume. The number of patients who must be treated in any given time period is a key condition under which a health care system must operate. Yet surprisingly, many hospitals ignore this key dimension in their improvement efforts. Variation in patient demand strongly affects both the quality of care and its cost. It becomes more difficult to maintain quality of care as the number of patients needing care increases relative to the number of clinicians available, even with state-of-the-art clinical protocols and informational technology. Even the best protocols cannot be consistently observed when the organization is overwhelmed with patients, and when staff therefore must take shortcuts to cope, or delay attending to some of those who need care.
In a recent Health Affairs publication, Maureen Bisognano of the Institute for Healthcare Improvement and I addressed this issue, describing a very specific practical way of how these costs could be eliminated while simultaneously improving quality of care significantly by smoothing variability in the number of patient treated. We also provided examples of a few hospitals that achieved these results through smoothing artificial peaks in patient demand created by mismanaged operations rather than by patient needs. What would such an approach mean nationally?
A National Opportunity
Suppose we let hospital operations to be managed the same way they are being managed now with the same level of Emergency Departments overcrowding, the same number of medical errors, etc. As has been demonstrated in the recent Institute of Medicine publication, even if we do not improve any of these characteristics, adding 32 million uninsured to the delivery system would result in hundreds of billions of dollars in incremental capital plus operational costs (without counting other hospital expenses for radiological equipment, Operating Rooms, etc.). We do not even consider here availability of additional nurses, which itself is very questionable.
On the other hand, a scientific approach to managing patient flow would make these costs unnecessary. In addition, it would result in significant improvements in patient safety and quality of care that could be simultaneously achieved.
Now, while many are watching the debates on the Capitol Hill on health reform, the reform is quietly repealing itself by mismanaged hospital operations. This manifests in multi-billion dollar waste, overcrowded Emergency Rooms, stressed nurses and unsatisfactory quality of care. Streamlining hospital operations should become an intrinsic part of reform implementation if we want to cover an additional 32 million people without throwing hundreds of billions of dollars at the health care delivery system.
Addressing this issue would make Senator Schumer’s recent call for bi-partisanship a reality: “We have the best health care system in the world and the most inefficient. If we can work together on cutting those costs without damaging the good health care that people get, that’s an area for bipartisan agreement.” This is the very issue that could unite both parties, and addressing it would greatly benefit all of us.