By Fritz Hofheinz, MD
As we and the mass media wrestle with what the term “healthcare quality” means, I wanted to share some enlightening conversations I had with about 15 leading pediatricians and pediatric sub-specialists at Cincinnati Children’s Hospital in Cincinnati, Ohio. As a general rule, physicians — particularly highly accomplished ones like this group — are strongly independent and thoroughly informed when formulating opinions. As a result, some would say that arriving at “physician consensus” on any topic is a challenge. Interestingly, the open-ended question – “ What interesting quality programs have you witnessed or been a part of recently ? ” — yielded near unanimity from this group. As I continued to listen, it occurred to me these experts were describing a revolution in health care quality that might be worth listening to. In contrast to all the garbled, incomprehensible discussion about healthcare quality today, the “Cincinnati Experiment” seemed crystal clear.
Some 10 years ago, visionary leadership at the hospital (PDF) decided to bring the principles of business quality to their hospital. “We wanted to bring the lessons of Toyota to Cincinnati Children’s” remarked one specialist. Hospital leaders from the top down mandated that their staff and physicians simply become trained in “Quality” (something countless other top non-healthcare corporations have done). The physicians I spoke with described their initial reluctance, “How can I possibly have time to sit in a classroom for several days at a time when I so much work already?” and “what could this possibly accomplish?” These initial objections melted away quickly as they started to go through the program. Physicians were asked to do simple things: participate in teams that included participants from all areas of the hospital (physicians, nurses, administrators, hospital finance leaders); recognize the importance of being aware of processes they were a part of and measure things they were doing; and assign themselves “projects” to observe and measure the things they were passionate about and/or expert in. The “asks” were not vague and lectured – each team member came up with their own project, vetted it and reported progress. Non-reporting or withholding was not allowed. Everything was shared with the group, including successes and failures.
A remarkable dynamic began to occur. As passionate experts who care a lot about what they do started to observe and measure their expertise, they started to notice incredible opportunities for improvement. Two examples (from among the many I heard) included:
1) Asthma specialists noted that children discharged from the hospital after an asthma exacerbation had a significant “readmission” rate within the week or two following discharge. Why? Often times because some of the families had no easy and quick access to prescription inhalers. One astute pediatrician noted that the inhalers used during the course of a hospital stay were often thrown out at the end of the stay — a totally understandable practice. Instead, said the pediatrician, why not let children leave with the inhaler they had used in the hospital? Between this simple step and other steps to facilitate inhaler access for under-served populations, the team was able to significantly reduce the readmission rate for asthma exacerbations.
2) Rheumatology specialists noted that while the hospital had a reputation as a “center of excellence” for Juvenile Rheumatoid Arthritis there were few ways to quantify that excellence. They started to measure. Simply by observing, measuring and reporting the percent of children with “uncontrolled Juvenile Rheumatoid Arthritis” they were able to reduce the “uncontrolled” rate significantly.
Both of these accomplishments produced extraordinary benefits for patients and families involved and also significantly improved the state of the healthcare system overall. Seems like the type of thing we should focus on replicating as much as possible, right?
“So what,” some may say to the two examples. These are smart clinicians and administrators. They should be coming up with these types of improvements every day. Healthcare is constantly evolving. What is different about these accomplishments? The point is that these improvements would not have occurred were it not for the shift in training, culture and “carving out time” for passionate experts that created these opportunities. Left alone, all hospital contributors tend to focus on issues in their own highly specialized arenas. Physicians and nurses will push for the best care for their patients. Administrators will seek to negotiate the best business arrangements with their partners. It was only with visionary leadership and “retraining” that the culture shifted enough to allow cross disciplinary teams to look at (and start to enjoy solving) problems that cut across all aspects of their organization.
Healthcare quality needs to be defined not from the top down by mandate but rather from within by those passionately involved in its performance. With training and adequate cultural mandates from visionary leaders, all healthcare contributors can learn and practice the “lessons from Toyota”. I firmly believe this should a part of the ongoing “healthcare quality” discussion.
