As soon as I heard about President Obama's recess appointment of Dr. Donald Berwick to head up Medicare, I ordered a copy of
Curing Health Care, a book written by Dr. Berwick with Dr. Blanton Godfrey, a well known Total Quality Management (TQM) expert who headed up The Juran Institute for a number of years, and writer Jane Roessner. The book is an easy and affirming read for anyone who is familiar with and has used the TQM teachings of Dr. Joseph M. Juran and Dr. W. Edwards Deming and would be a simple and informative introduction to the concepts for anyone who has been hearing about TQM but has no idea what it is all about and wants to know more. It’s a bit over-priced at $37, maybe because it has been used as a text book, but I found a used one on Amazon for $18.
It is somewhat disturbing but not surprising that the subject of the book,
The National Demonstration Project, an ongoing effort initiated in 1987 to introduce TQM concepts to the health care industry, did not mark any turning point for the better in either of the three Key Result Measures (KRM’s) for that industry which, as far as I know, from reading books, articles, and news reports about the need for health care reform, are:
- Life Expectancy (78.2 years, a year or two less than in some European countries)
- Total Cost as Percent of GDP ( about 15% and growing compared to 10% or less in Europe)
- Percent of the Population Not Covered by Insurance (about 15% compared to 0% in the UK)
Usually there is some KRM of customer satisfaction, but, putting aside that question because of some confusion over who the customer is, it appears that if we could get life expectancy of 80 years with total health care cost at 10% of GDP and insurance coverage of all citizens, government would be satisfied because we would compare well to the health care industries in some European countries and Cuba. Patient satisfaction may be unimportant because health care doesn’t or eventually won't cost anything, except to taxpayers, and we won't have much right to complain about "free" stuff. (Check
this story.)
So, now, 23 years after that introduction of TQM to the health care industry, why has there been only deterioration in those three KRM’s? In my opinion, after several years of trying to practice TQM in management jobs at Eastman Chemical Company, a Malcolm Baldridge National Quality Award winner, the fundamental problem, when widespread use of powerful TQM tools fails to fundamentally improve the performance of the total organization, is lack of understanding and application at the highest levels of the organization. Many teams may be at work within an organization documenting processes, identifying problems, making changes, improving their work lives and job satisfaction, and getting good results without any of those results showing up on the bottom line of the total organization if the senior management is failing to capitalize on the cumulative effects of such team activities or is making strategic decisions that completely overwhelm them or is failing to make needed process changes that only they can make. As described in the Berwick/Godfrey book, the NDP is focused on such small cross functional teams, in the Juran tradition, and pays little attention to the Deming focus on senior management responsibility to improve the results of the total enterprise top down.
Let me digress a moment to say that both Deming and Juran are heroes of mine.
Joseph M. Juran (1904-2008) remained active until his death at 103. He had a series of videotapes outlining the basics of TQM which were heavily used at Eastman and at many other companies to get teams started on the right track. The Juran Institute today is testimony to his legacy.
W. Edwards Deming (1900-1993) seemed less organized and a bit more abrasive than the very gentlemanly Juran, but he was an inspirational speaker focused on the inability of “willing workers” to change the systems they were working in and the responsibility of top management to use his
Fourteen Points to do so. We brought Dr. Deming and his super-sized traveling bed to Eastman for a week-long seminar for several hundred managers. His requirement to conduct the seminar was that our CEO be present for the entire time.
I think it is that lack of senior management understanding and leadership that is the fundamental problem with efforts to improve the health care system in the United States. As pointed out in the Berwick book, hospitals have both administrative and medical hierarchies which complicate the answer to the question of final responsibility. Insurance companies have their own hierarchies as well. And the established health care system often seems to pit the hospitals, doctors, and insurance companies against each other in a struggle that leaves patients sitting on the sidelines. But now, with passage of the new health insurance reform bill, it is clear that, because it holds the purse strings, US Health and Human Services is Senior Management for the health care industry, the US Congress is the Board of Directors, Kathleen Sebelius is the CEO, and Dr. Berwick is, at least for a year or so, the COO for about 35% of the business. At least someone is now in a position to make structural improvements at the top to reduce waste and improve efficiency and effectiveness.
But back to those three KRM’s, life expectancy, cost, and coverage. One has to be very careful with identification of KRM’s because errors at that point can lead to some very bad strategies and processes. It would seem to be quite easy, for example, to accomplish the 80 year life expectancy, 10% of GDP cost, and 100% insurance coverage goals by reducing end-of-life medical care options and availability of expensive procedures such as joint replacements and organ transplants for older folks and forcing everybody to a healthier diet. I suspect that is where we are headed, and think that it is not all bad.
If an individual is in the last stages of a terminal illness, it is probably not better for that person to be hospitalized, connected to various tubes and machines, undergoing continuous expensive tests and procedures and never able to get a good night’s sleep than to be at home or under hospice care with a good supply of codeine or marijuana, a big screen TV, and regular visits from friends and family who see the person as something more than a medical problem. (This is not to suggest I have any comfort with anybody in government making such choices for us.) And, as long as there are some black markets for salty and fatty foods, those of us hooked on them will be able to survive and those who want to eat healthier will have an easier time doing so. (We are so weak!) On the other hand, telling an octogenarian with life expectancy of five or ten years that joint replacement is not available due to age and that the future for him or her is wheelchair occupancy and that he or she should call up The Scooter Store which has just been taken over by Health and Human Services and get on their waiting list would not be judged satisfactory by the American people.
I do believe, however, that such a health care rationing and food supply strategy would fail because the basically flawed structures and processes in place would respond to incessant demands for other medical services to replace those end-of-life care options and expensive procedures and increasing numbers of non-medical people would be employed in the health care industry to monitor, control, and manage, and costs would continue to increase. There would be a great uproar from citizens believing that their aging parents are not being treated fairly by Medicare or that they themselves are not getting the latest and greatest treatments for whatever infirmities they are suffering, or that the waiting list at The Scooter Store is too long and Congress would respond with concessions. And everything would get worse. There will never be any relaxation of demand for “free” stuff or of willingness of Congress to meet those demands in return for votes.
It's not that there aren't better ideas. Sophisticated analyses of the problems with our current health care system including recommendations for major system, process, and structure changes that would actually reduce costs and improve access are provided in
The Innovators Prescription by Harvard Business School professor Clayton Christensen and
Flatlined by neurosurgeon Guy Clifton, both of which I have reviewed and commented on in this blog. The key process changes needed are
- segmentation of the health care industry based on customer (market) needs,
- establishment of the patient as paying customer to be satisfied,
- separation of insurance for major medical expenses from pre-payment systems for routine checkups and minor ailments,
- transparent, bundled, advertised, competitive pricing to replace those mysterious multi-page itemized bills and established reimbursement rates for procedures, and
- some system for providing medical care for those who can prove they are unable to do it themselves.
Hopefully Drs. Berwick, Christensen, and Clifton are good friends and are collaborating on the best steps forward now that Dr. Berwick has the job and are going to invite Dr. Godfrey to assist them.
By the way, here are two KRM's I would like to see added to the three above:
- % of total health care industry employees who are practicing doctors
- % of total health care industry employees who are practicing nurses
I have an uneasy feeling that these also have been going in the wrong direction since 1987.
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Postscript: Two hopeful items in this morning's paper about fundamental process re-engineering in the health care industry with the potential for cost reduction and improved customer satisfaction. One has to do with a possibility of
flu shot patches that could be mailed out rather than having us line up at doctor's offices and clinics to get annual shots. The second is a
proposal to expand pharmacist responsibility in drug based management of chronic diseases. Both proposals would reduce physician workload and free them for more challenging health care.
