Management must role for physicians.
Issues of quality have spent a long time moving to center stage in discussions of reform of the health care delivery system. The star for year has been costs, demanding the nearly undivided attention of policy makers and thus of providers. In the process, costs have not been contained, and there is the developing concern that quality may have been sacrified. The cost-quality equation clearly contains at least two variables, it is now realized. Determinations of value in the provision of health care services demand attention to quality as well as costs.
As the 20th Century comes to a close, the health care system is beginning to remember its purpose--the provision of services at the highest possible quality consistent with an affordable price. This new philosophical transition will not be easy. Definitions of quality that satisfy disparate interest groups will have to be achieved. Resolution of access and other peripheral but important issues will not be an easy task. In all the discussions, however, it is paramount that clinical decision-making be the prime factor. For a discussion along those lines, physician involvement will be critical.
"We have to leave where we've been. We need to go to new territory," Martin Merry, MD, a New Hampshire-based health care consultant told attendees. "We're on the threshold of what may be a new explosion in the area of health care quality evaluation and management." The new approaches--total quality improvement and continuous quality improvement--come from industry, he said, "not from a health care tradition. Our traditional approaches are bankrupt. We are not learning much about quality from traditional case review techniques, and physicians are getting tired of the paperwork and time that the process consumes." Dr. Merry said that case review will have to be a part of any final quality management system, but it cannot be the central concept. "We will have to leave it behind if we are to get a quality evaluation model that will be salable to doctors."
The secret to continuous quality improvement, Dr. Merry said, is that it assumes that quality can always be improved. "Quality improvement is a continuum. And it doesn't happen automatically. You have to plan where you want quality to be and then develop the strategies and educational efforts to achieve the goal. Then you have to check your results against the targets and take further actions to improve quality." The improvement process, he said, is ongoing. If the goal isn't achieved, reasons have to be determined and another effort made. If the goal is reached, a new goal has to be set or a different area targeted for improvement, he said.
A serious problem with the continuous quality improvement concept, Dr. Merry said, is that it is "alien to the health care system." Because it is viewed as faddish and is statistically oriented, he said, doctors will resist it. Doctors will also resist changes when they entail loss of control for the medical profession. It will have to be demonstrated, he said, that the new quality systems will have a positive effect on doctors and their practices. Another important step in gaining acceptance of the quality improvement model, Dr. Merry said, will be "detaching the quality movement from the regulators. The movement has been so identified by doctors, and it's a turn-off."
Dr. Merry believes that the obsession with "bad apples" in determinations of quality will deteriorate further, largely at the insistence of buyers of health care services. He said that industry will be increasingly influential and will plump for continuous quality improvement. "A much broader definition of quality is required," he said, "one that encompasses access, process, and outcome. Doctors cannot be the sole control. A host of interested parties will have to be brought into the discussions. And customer specifications on quality will prevail."
The trick for physician leaders, Dr. Merry said, "is to plan for all these changes. A transition model will be needed to bring practitioners along. To succeed, continuous quality improvement will have to be an integral part of each organization. When doctors see positive results," he said, "their commitment will be secured." Gaining that commitment will be the ultimate challenge for physician executives, he said.
Back to the Database
"While many of the decisions being made by practitioners are correct, many are not," David Eddy, MD, PhD, said at a Conference luncheon. J. Alexander McMahon Professor of Health Policy and Management at Duke University, Durham, N.C., Dr. Eddy said that the evidence suggests that we may be offering "suboptimal or even harmful care." His studies show that the medical literature is seriously flawed, with researchers reaching conclusions on the basis of erroneous statistics and flawed assumptions. The impression, he said, is of a profession that makes "arbitrary decisions."
He said that the delivery of health care services itself is characterized by "variations" that undermine the credibility of medical practice. There are "observer variations," he said, whereby different clinicians attach different meanings to diagnoses. Experts also change their minds over time, for no apparent reason. "A complete spectrum of opinions can be obtained for any given condition," he said. The indecision in diagnosis, he said, is compounded by confusion in recommended treatments. He suggested that the confusion contributes to the variations in practice patterns from location to location that have been reported in the literature.
"We are doing things that we shouldn't," Dr. Eddy said, "and not doing things that ought to be done." The effects of the failure can be found in malpractice suits, the cost of care, public confidence in the system, medical education, and quality assurance, he said. "We must have good, basic information, and we don't have it for most practice. Most of clinical practice is simply not supported by any controlled studies. When studies are published, they have serious problems. One researcher has asserted that half of the articles published are flawed. Many of our decisions may be wrong. We don't know."
Dr. Eddy compared the current situation for the medical profession as "driving in a car without windows. We can hear the engine and feel the bumps. But we don't know where we're going or how fast." In the absence of some knowledge of outcomes, he said, medical decisions will be made on the basis of other factors--" charisma and prestige, debating skills, peer pressure, board member whims."
Dr. Eddy said that physicians must do three things to begin to correct this problem, none of which is currently in place. "As a profession, we must recognize the problem, believe the problem exists, and build an information infrastructure for medical practice." He said that he was optimistic about the eventual outcome. "We have a tremendous amount of energy, talented people, and motivation in this profession."
Health care delivery in this country is in serious trouble, Regina Herzlinger, PhD, Nancy R. McPherson Professor of Business Management, Graduate School of Business Administration, Harvard University, Boston, Mass., tol the Conference. The failure, she said, has been one of management. Health care management has failed to fulfill its obligations and to take advantage of opportunities for success. Professor Herzlinger said that three opportunities present themselves for organizational and management success. First, managers must develop programs to control healt care costs. "There is still inefficiency in the system." Second, they must respond to the rise of new consumers who want a different system and want to be more involved in their health care. Many of these consumers, she said, demand greater control over their health. Third, biotechnology promises to recolutionize the delivery of health care services, and successful managers will be positioned to acquire and use new technology effectively and competitively.
Professor Herzlinger assured her audience that success would not be easy or automatic. She listed seven skills that will be critical for the manager desiring to capitalize on any of the three opportunities. Physician executives will have to understand management control systems, finance, marketing, human resources management, operations management, regulatory environment management, and articulation of a management philosophy, she said. While certain of these skills will be of paramount importance for individual kplortunities, she said, all will be needed. The most effective skills combination will also vary from organization to organization, she said.
None of this will be easy, Professor Herzlinger said. "Even an organization with a clear-cut purpose will need precise delineation of the skills that are needed for success." Skimping on the skills or ignoring them just won't work, she added. "A sure recipe for disaster will be thinking that the skills can just be hired. How will you know if the person really has the skills?" Physician executives, she said, "are uniquely qualified and poised to seize the three opportunities" because of their knowledge of health care technology, "if they will gain the seven skills. The system has failed for lack of physicians in these leadership roles."
Wesley Curry is Editorial Director of the American College of Physician Executives, Tampa.
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|Title Annotation:||includes information on the College's Forum on Women in Medicine and Management; American College of Physician Executives' National Conference|
|Date:||Jul 1, 1990|
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