in fragmented care and dysfuntional workflow across the healthcare organization. Rather than organizing care around specialty departments and special services, care should be organized around medical conditions with multiple subspecialties and teams converging on the specific patient condition. In the current system, effective synchronization, collaboration, and communication are often not present and are more often than not the cause of rework, mistakes, complications, and wasteful spending.
The quality paradigm. In the traditional quality paradigm, quality was defined by the provider and by the effectiveness of care. In this view, quality is achieved when the right treatment is administered in response to a specific recognizable pattern, and results in the elimination of the disease condition. This long‐held view of quality ignored additional dimensions of quality care, such as the need for efficiency, timeliness, and patient‐centeredness (IOM 2001). Focusing only on effective care resulted in a healthcare experience that fell short of patients’ expectations. The traditional quality paradigm, a lack of oversight, and the inability of physicians to regulate their own profession has had a significant impact on the quality of care. As a result, we have seen unethical practices, high rates of patient injuries, and injustices in the ability to access care (Berwick 2016).
The physician compensation model. Incentives for payment have been completely misaligned with the goals of improving the quality of care. Providers and healthcare organizations have been paid for number of procedures performed (volume‐driven payment) rather than for the outcome and quality of care (value‐driven payment). This has resulted in excessive and unnecessary procedures, overly used diagnostic services, increased insurance premiums, and procedure‐related complications.
THE CHALLENGES TO IMPROVE HEALTHCARE
Efforts to improve the quality of care have focused on performance metrics, complex incentive formulas, and increased scrutiny from regulatory agencies. These and other measures have not addressed the real problem and, for the most part, have not significantly improved the quality of care. Patients continue to be disappointed with the healthcare experience, and staff and providers are getting increasingly burned out from the overwhelming day‐to‐day administrative burden. There is a generalized frustration among providers working in a system that is inefficient, overcomplicated, and seemingly at odds with the mission of providing high‐quality care. Despite significant efforts to improve, we have not achieved our goals. Accountability based on metrics developed by outsiders has failed to engage physicians, and too much of the efforts of healthcare organizations is spent on submitting reports, preparing for accreditation surveys, and ensuring adherence to regulatory mandates. Meeting the objectives of specific organizational metrics has become an all‐consuming activity, rather than developing a strategic and comprehensive improvement agenda. There is no question that the work involved to ensure survey readiness and regulation compliance is important, but too much effort is directed at achieving core measure targets and not enough on system redesign. By prioritizing improvement initiatives that address the underlying processes related to the regulatory compliance and core measure targets, we could address both regulatory mandates and improve the healthcare experience.
Quotable quote: “We are faced with a series of great opportunities brilliantly disguised as insoluble problems.” John W Gardner
Healthcare organizations continue to invest resources to improve the delivery of care but face unique challenges that impact the effectiveness of the improvement efforts they pursue. Process improvement is not easy, and it requires a clear understanding of the barriers:
The culture. The primary role of a healthcare organization is to provide care to patients, a high‐stakes undertaking that may exacerbate patients’ clinical conditions if errors occur. As a result, healthcare professionals are risk averse, conservative, and hesitant to try new things compared to other industries. When quality improvement (QI) teams and organizations try to implement changes, they often encounter a resistant culture that labors to maintain the status quo. Incongruously, providers and staff often resist the adoption of standards and other evidence‐based guidelines that support improved patient outcomes in favor of time‐honored, and sometimes outdated, traditional approaches to patient care.
Silos. Improvement initiatives are difficult in healthcare organizations unaccustomed to leveraging teamwork across silos to accomplish their goals. Silos not only exist within the clinical specialties but also exist between the clinical and the operational areas in healthcare organizations. These silos often cut from the top of the organization down to the front line staff members. They impact the effectiveness of any improvement initiative, ultimately leading to a fragmented operational approach that focuses only on individual tasks and departments without considering the entire patient experience. Coordination and collaboration give way to “suboptimization,” where every unit pursues its own “targets” independent of the needs and aims of the organization as a whole.
A lack of IT support. Improvement initiatives depend on and should be guided by data. But QI teams often find it difficult to get their basic needs fulfilled, having to allocate additional team resources, or rely on manual data collection to obtain the data they need. It is difficult to understand why staff and providers have to struggle to get a report of the same data they just entered into the hospital’s electronic medical record.
A lack of active participation of senior hospital leaders. The role of the leader is to legitimize improvement projects and facilitate the work of the improvement team. The leader establishes priorities for competing initiatives; provides resources for the team; resolves cross‐functional issues, and removes roadblocks that impede the success of the project. Senior leaders in healthcare are often not visible, active, or engaged in QI projects. When leaders are not present, projects flounder, have difficulty reaching their objectives, and often fail. Leaders are vital in building a coalition of key sponsors to achieve project success and facilitating change.
A lack of improvement experience. Healthcare professionals often lack the experience and formal training needed to address the complex performance problems of the healthcare delivery system. Postgraduate healthcare education continues to be almost exclusively focused on the acquisition of scientific and clinical facts, and has not included the knowledge and skills that define competency in improvement work. QI competency needs to be developed with rigor, heightened focus, and consistency like any other discipline. Because they lack experience, often staff and providers rely on their subject‐matter expertise to complete a QI project. They fail to follow the required structured systematic approach and cannot achieve the goals of the improvement initiative. Improvement knowledge does not come as a natural evolution of clinical expertise. Improvement capability is not a natural ability!
The team dynamics. QI teams in healthcare are often multidisciplinary in nature and are convened in an ad‐hoc manner, from different areas or departments. There is usually very little time to ensure cohesive functioning of the team members to avoid “silo” mentality. Physicians, nurses, staff, and administrators are brought together and expected to work as a team, even if they have never done so in the clinical arena.
A top‐down approach to improvement. With multiple competing clinical priorities, improvement projects are often left in the hands of leaders and small teams of specialized subject‐matter experts (SMEs). This traditional model is no longer effective and cannot achieve the operational improvements in the large scale that are needed in today’s healthcare organizations. Engagement of the front line is critical to succeed and, yet, is not always present. This traditional approach to QI perpetuates the belief that process improvement is the responsibility of a small number of individuals in the organization and it does not have the same critical nature as the “clinical side” of care. Even when the front line is engaged, organizations don’t provide sufficient time, resources, or support. It becomes challenging to convene regular meetings with key stakeholders who must juggle their clinical and nonclinical responsibilities with project activities.
Lack
