The end of quality improvement?

Don Berwick, an inspirational leader, announced his departure as administrator of the Centres for Medicare and Medicaid Services (CMS) after his confirmation was blocked by the Senate.  He has probably done more than anyone to raise the understanding of quality in the delivery of healthcare.

But  the news led me to reflect on his achievements and I was left with a couple of questions - what is value? And what has the quality improvement movement achieved to increase it?

To take the second question first.  Robert H Brook announced in his article in JAMA the end of the quality improvement movement

"more than 40 years after the birth of the quality improvement movement, there is still not much known about what has been accomplished. There is little information about whether quality is better in one state or country than another; what the relationship is between the amount a country spends on health care and the quality of care provided in its health care system; whether a business case for quality actually exists in an individual institution or physician’s office; and whether the amount of money spent on improving quality is too little or too much".

It's a provocative statement.  40 years of quality improvement and we don't know if it has made any difference?  His prescription?  Focus on value.

So what is value?  Well Brook, Porter, Gray and others would say that the value equation goes something like this:

Value = Improved outcome/cost

It sounds very plausible doesn't it.  After all, who wouldn't want to know where you can get the biggest bang for your buck from.  And in the current lingua franca all these elements make a great deal of sense.  But is there anything wrong with the equation?  Does it really describe value?

My biggest concern about this value equation is that it does not describe value, at least from a users point of view, at all.  For in this equation value is increased when costs go down.  I don't agree.  It seems to me this is an "inside out" view which describes value for money, not value.  And this is important because this colours our perception of what good looks like and implicitly and invisibly restricts our ability to transform services rather than polish them.

Taking improved outcomes, undeniably if you can stop people cutting off the wrong limb, that has to be better for patients.  Personally, I would value that.  But in terms of how people experience illness, it seems to me that judging outcomes is a devilishly difficult thing to do.

Take the following scenarios.  Scenario one; a woman in her early 50's is diagnosed with a rare and aggressive cancer.  The medical profession can do things to prolong the womans life and she undertakes four courses of chemotherapy, the gaps between each course being extended every time to allow the burns on her mouth to heal and for her to recover her strength as she finds the treatment incredibly debilitating.  So much so that she spends much of her time in bed and has little energy or inclination to play with her grandchildren or socialise with friends and family.  Increasingly dependent on others for support with even the most basic of daily living needs eventually she is admitted to hospital where she is sent to ITU, intubated and, after nearly two weeks, passes away having drifted in and out of consciousness during that time, but largely unconscious.

The family are grief stricken.  They had so wanted her to survive long enough to see her youngest son marry.  There was also some guilt and recriminations over the last few months of her life, with some wishing she had never been put through the ordeal, others wondering if enough had been done.  But her life had been extended so, from that perspective,  the tens of thousands of pounds spent on treatment were worth it, weren't they?  Value, in terms of improved outcome as measured by extended life or survival rate has been increased.

Scenario two; the same woman, agrees to undergo a course of chemotherapy.  She doesn't get on with it very well but feels a sense of obligation to continue.  She wants to live after all.  Well, at least long enough to see her youngest son marry in 6 months time, she tells her oncologist.  That chance remark sparks a conversation in which the truth of her diagnosis is honestly discussed.  It becomes clear that the woman fears the treatment at least as much as the cancer, which she knows is going to kill her anyway. The family, until then apparently equally supportive of extending her life, helping her to survive, also air their concerns about whether this is the best course of action.

The resolution?  The wedding is brought forward and the chemo stopped.  The inevitable decline is managed palliatively and the woman passes away, surrounded by loved ones, each of whom she has been able to say a few final cherished words to.

My question is, in terms of value, which scenario has created the greatest?  And does the equation help us understand value in this context?

In the week that the Government announced that it was to make trial drugs available to patients a year early I was reminded of what Atul Gawande said in his excellent article in the New Yorker - "We've created a multi-trillion dollar edifice for dispensing the medical equivalent of lottery tickets - and have only the rudiments of a system to prepare patients for the near certianty that those tickets will not win.  Hope is not a plan, but hope is our plan".

In applying the Vanguard Method in health I have been struck by how damaging the focus on costs is.  I have seen how relationships and continuity over time have been broken and how, for vast numbers of people, this creates a flightpath to dependence and all the cost that goes along with that.  I have seen medicine attempt to do too much when sometimes, as Gawande says, it needs to do less.  And I have seen how this has created a quality improvement movement that has focussed it's attention on improving processes at the expense of understanding people in the context of how they live their life.

For me, there are many commentators who talk about the austerity of the current economic climate.  This may be true, but my concern is that the answer lies not in cost reduction but in better understanding value from a users perspective.  Then we may be able to support both users and carers in reaching the right decisions for themselves.

Footnote:  out of interest I searched for the word "value" in the operating framework.  It comes up 11 times in the 50 page document, 7 times related to value for money or financial value.

Using numbers to win the game

"We are card counters at the blackjack table" Billy Beane - The Oakland Athletics Five years ago I read a book called Moneyball, and as long as I live I will never forget the core message, in fact it's one we should all try to take to heart. The book is about forty something baseball team General Manager Billy Beane, who's dream is to win the last baseball game of the year - the World Series. They made it into a movie with Brad Pitt and in the opening scene, having just lost his best players, Billy sits around the table with his talent scouts discussing who they should approach for the next season's team. He listens to the same tired clichés being trotted out about who they should pick, "this guy is great looking, and this guy has a great build, what about him he's really muscular...", and on it goes. But the GM has had enough, he looks the head of the scouting team right in the eye and says the immortal words "you're thinking about the player attributes in the wrong way, all that matters is the numbers." Later on in the movie the head scout screams at Billy that he is "A stupid *******, there's more to baseball than the numbers". But Billy persists and hires an economics major to help him pick the team. He chooses players for very specific skills: one is chosen for his ability to get on base, another for his ability to pitch - even though no other team will touch him because his pitching style is weird. The scouting team and the management of the club then fight him every step of the way. They go behind his back to play the team in a way that it should not be played (think of it like hiring Lionel Messi for your fantasy football team and putting him in goal). For the first nine games the team get creamed, and everyone laughs at Billy. By this point he's had enough and decides to take matters into his own hands and puts the team back in the positions for which they were hired. And guess what happens? The Oakland Athletics win 20 straight games in a row, the longest winning streak in history. Eventually in the last game of the season they get beaten. But the team that won that year had spent an average of 1.2 million dollars per game to win; Bill's team had spent an average of just 237,000 dollars per game. The owner of the Boston Redsocks then approaches Billy and offers him 12.5 million dollars to run his team. The events of both the book and the movie are based on real life and Bill's strategy persisted in getting high league performance for low running costs. And if you think about it the Redsocks owner wasn't really trying to buy Billy's skills, he was paying for Billy's system, a system that worked. But the question for me as I read the book was this, "why did so many people fight the new system?" and I don't think there is one answer but I believe that it lies in frightened people's desire to maintain the status quo, to make sure that we they keep their job, that they don't have to do any more than the minimum and that they don't break from the herd; even though what they're doing clearly doesn't work. Yet all Billy was doing was running the numbers, finding the players with the best numbers in the different disciplines and putting them together in a team. Sounds simple really, meanwhile other managers were choosing players on the strength of their jawline. But remember it only sounds ridiculous if you can stand outside the game and see in, from the inside - and when everyone else around you is doing it, it sounds sane. And I bet if you took the same bunch of baseball managers and told them that we use targets based on no scientific rational, that we put customers with different needs through the same standardised process and that we functionalise services, they would be able to see the inefficiency of it with the clear eyes of the outsider and laugh their heads off. But like them some of us keep on doing the same thing year after year hoping somehow for a different result. However the Billy Beanes of the business world are growing, and they're delivering winning streaks week after week. And just like Billy they put their secret sauce out there for everyone to see - despite resistance they look at the world through the eyes of the customer, they use measures in the right way, they differentiate between value work and waste, they see the folly of IVR machines and workflow systems, they vilify service standards and they crush the idea of the front office back office split. Because they too understand the core message in the book - think differently. And their willingness to look at their system from the outside and change it works. As their peers struggle on the innovators are getting promoted faster, earning more money and getting more respect... funny old word isn't it? This post was written by Stuart Corrigan, Vanguard Scotland http://www.systemsthinkingmethod.com/

Change thinking, save lives

So yet another report is published this week revealing the scandalously poor levels of care received by some of our most vulnerable in society.  It seems some of us are not even safe in our own homes.

It got me thinking about how many revelations there have been since I started writing about my experiences in applying the Vanguard Method in health back in July.  We've had the Panorama and Dispatches programmes on shocking abuses of vulnerable people in care homes and poor standards of medical devices, the CQC reporting that levels of care were so low in some Trusts that they were failing to meet legal standards, the Patients Association reporting on the terrible experience of our elders, the Royal College of Surgeons report on the hidden impact of targets in terms of poor outcomes and avoidable deaths for people requiring urgent care, the revelations of hidden waits as people are left untreated on waiting lists and now the Equality Commission revealing care so poor it doesn't even fulfil peoples basic human rights.

But it's OK because the Commonwealth Fund report says that we are one of the best health systems in the world and, of course, you can still get through your A&E in four hours.....

What I see when I study wellbeing systems is that it is the misguided belief in plausible but wrongheaded ideas that is the cause of these problems.  Everyone is concerned to save money and get the best value out of the system.  But it is the very focus on costs that is driving costs up and dislocating us from the most fundamental aspects of our humanity - to understand people in the context of how they live their lives and care for them with compassion.

Often the evidence of saving is based on reductions in transaction costs.  Because x is cheaper than y, we should get x - that will be better, cheaper.  Sometimes that may work, but the logic behind this approach is a fascination with unit costs and the consequential need and drive to reduce them and this is wrong.  The Nuffield Trust recently published a useful overview of the financial challenges that the NHS is facing.  Their analysis was that things are likely to get more difficult over time.  Their answer?  "The NHS will only be able to manage against a background of rising demand and an aging population if there is sustained improvement in productivity.  This means bearing down on unit costs, particularly in the acute sector".

But this simply isn't true.  And the Equality Commission report bears witness to this.  In the drive to reduce unit costs we have lost sight of what matters to people.  As a result we have consigned vast numbers of people to a life of humiliation and degradation.  And the fact that it is hidden from view and does not appear on any spreadsheet or KPI makes it no less unacceptable.

The damage that this kind of thinking does is immeasurable both in terms of unnecessary human suffering and cost.  I have seen, repeatedly, people being passed through service after service, function after function, organisation after organisation with no value for them whatsoever.  The target culture is driving the wrong behaviour, solving the wrong problems, driving in cost, causing waste and harming patients.  The solution is to understand people in the context of how they live their lives.  Not very fashionable perhaps, but no less true all the same.

What I have seen is that 1.5% of a DGH population consume about 50% of the resource.  The numbers, relatively, are tiny.  We don't need to be focussed on average length of stay.  We need to get to understand these people and design for perfect for them.

So what do our thought leaders say, the people who will work out how we start doing better things?  Well, I think I may have had something of an insight from what I heard at the Kings Fund Annual Conference yesterday.

If I have understood correctly, Sir Liam Donaldson said that it is "right and proper" that doctors are very focussed on individual patients but they must think of the wider NHS too.  I am not sure what this means.  My learning is that GPs do know their patients but, largely, they don't understand them in the context of how they live their lives.  My reflection is that GPs need to be more, not less, focussed on their patients.  A better understanding of them, as evidenced from my experiments, transforms the lives of both patients and staff.  And it happens to be a lot cheaper.  A focus on the micro impacts on the macro, as I have talked about before here.

Sir Bruce Keogh seemed to imply that to focus on the system as the reason for the problems that are reported is wrong.  With impeccable logic, Sir Bruce argued (again, if I am not mistaken - happy to stand corrected) that the system is made up of individuals.  They just need to be a bit more professional and compassionate.  So, ergo, a focus on managing the people will produce better results.

The convenient fact that is missed in this analysis is that the system is designed to prevent good people from doing good.  A focus on managing people is quite simply wrong and is a very poor strategy for change.  I hope I simply misheard and if I have I apologise to Sir Bruce.  If I haven't then it is a belief that I find very worrying.  The reality is we have designed a system that is systemically incapable of being patient centred.

Then Ali Parsa extolled the virtues of competition and the innovation that this can bring.  As I have blogged about before here, my focus isn't on public/private or market/state.  What I am interested in is understanding the "what" and "why" of current performance and how far from perfect we get.  But what I heard Ali say was that if barriers to entry are broken down then more private providers can compete and this will drive innovation.

Again, impeccable logic and very plausible.  But I was left wondering about all those people on who the system spends most of it's money (our elders) and specifically those receiving care in their own homes - care that is largely provided by private providers.

I began to wonder how many innovative ways there could be to get someone to wipe my bum, or feed me, or hold my hand, or talk to me and take the time to listen.  How much more innovative can you get in making a cup of tea or putting someone to bed?

The "real world" though offers help through a menu of service and it is through this lens that we seek to innovate.  We have reduced people to "customers" and, ironically, as a result restricted choice and our ability to solve peoples' problems.  We end up concerning ourselves with notions of rationing and prioritisation (cutting/limiting services) when, from what I have seen, nothing of the sort needs to happen.

Menu driven standardisation makes up part of the system response both to care and to rationing.  By providing a menu of service it provides the illusion of control.  What I have seen is that it, in fact, drives up costs and causes unnecessary harm.

We don't need disruptive innovation.  We need disruptive thinking.  The kind of thinking that starts by asking "what is the purpose of what we do from a users perspective" and values understanding and the development of relationships over time.  Instead of looking for answers to binary "killer questions" like "would you want you or your family to be treated here" we need to ask "what matters, from a users perspective".

What we need is to change our thinking about what works.  If we do that we will save lives.