3 facts about US healthcare that won’t change with the inauguration
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Many of us look toward to January as a time of change for our country. With Dr. Tom Price soon to be at the helm of the Department of Health and Human Services, the media — and each of us as citizens — are left wondering in what ways our healthcare system will change.

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With our focus on January, let’s take a moment to remember three key facts about healthcare in our country that serve as a map for the waters Dr. Price will help navigate:

(1) Medical errors occur when multiple factors line up.

The nurses, advanced practitioners and physicians who make up our healthcare system are often featured in the news and television dramas — especially when they face what to do with a medical error. (Cue deep introspection and dramatic music.) But the manner in which medical errors occur in real life is often verydifferent from how they are portrayed on television. Here’s how.

In real life, some combination of factors across six categories usually line up to produce an error. These categories, nicknamed the “6M’s of quality” include:

  • Man: Human factors like the ones dramatized on TV are important, yet in most medical errors I’ve reviewed as part of quality improvement, human factors alone did notproduce the error.
  • Materials: What the patients bring to their physicians (such as their age, chronic health conditions, diet, exercise,and lifestyle choices like smoking habits) are other important components of whether errors are more or less likely. Consider a patient with a previous stroke who is non-verbal. He or she may be unable to tell the surgeon that the wrong arm has been marked pre-operatively.
  • Machine: The machines and other physical tools providers use, in their design, maintenance and utilization, can each contribute to the chance that an error occurs.
  • Methods: The processes by which medical care happens can set both staff and patient up for certain outcomes. “Abad system beats a good doctor any time,” as some say. However, in other, more subtle ways, poor processes of care lead to not only dramatic failures but to missed opportunities.
  • Mother nature: Yes, even the weather plays a role in healthcare errors. For example, one bus crash owing to icy weather can cause an emergency room to be over-run with trauma patients, and that stress of multiple casualties can make the probability of an error muchmore likely.
  • Management / measurement: It turns out that how we manage a system and howwe measure quality in healthcare is very important. The ability to tell whether we are making progress on quality is dependent on what we choose to measure, how we measure, and how often we measure. The ability to detect and fix medical errors is related to our management / measurement system; this one of the 6M’s is often not appreciated as a contributing factor to why an error occurred in the first place.

Even though all factors on the list may not be controllable — preventing ice and snow from Mother Nature in many parts of the country is not likely — our healthcare system often does nottake time, or have the ability, to recognize in a data-driven way that factors line up to produce a medical error.

At best, higher-functioning medical centers recognize that medical error “defects” occur owing to multiple factors. Some may recount the Swiss cheese model of medical error that highlights just how several factors line up to create an issue. At worst, our healthcare system still too frequently looks for who “screwed up” and how — more akin to a TV medical drama than a deep root-cause analysis of what really happened. Only rarely do centers take advanced steps, like combining true root-cause analysis with data to make the probability of medical error significantly lower.

In any event, no matter exactly what happens during and after January, it’s important to remember that medical errors occur when several items line up to create a defect. And in healthcare, even though that idea is growing in acceptance, the field is still very focused on a limited understanding of the true roots of medical errors. That’s how it usually works in real life.

(2) The cost of poor quality is rarely appreciated.

In addition to a limited understanding of why errors happen, healthcare currently has a hard time measuring how much waste and other quality problems are in our systems. How should we measure the waste? Preventable deaths owing to medical error? The number of wasted devices, hours of a staff member’s time, or some other metric are all candidates. A standard one that we don’t use often is called the COPQ, or cost of poor quality.

It could be because, for healthcare providers, expressing metrics in dollars may seem, well, somehow wrong. It could be our lack of business training or some other barrier but, no matter why, expressing waste in terms of dollars doesn’t feelgreat to many in healthcare. After all, how could we even express waste in terms of dollars?

Here’s how: the COPQ. This under-utilized tool expresses the waste in a system and is commonly used by my colleagues who work on quality in manyother industries. (In fact, there are many standard quality tools that we just don’t use very often in healthcare.)

The COPQ is composed of four “buckets,” and the value of each bucket comes right from the profit and loss statement (nicknamed the P&L or income statement) for the hospital or health system. Recently, a colleague and I wrote up how to apply the COPQ to Healthcare for The Healthcare Financial Management Association. These are those four buckets:

  • Internal failures: This bucket of costs incurred owing to poor quality includes problems that happen but never make it to the patient. Have to waste a medication because it was prepared for the wrong patient? That’s an internal failure.
  • External failures: This bucket includes costs seen where a defect doesmake it to the patient. Such failures are more often catastrophic and more often visible, such as administering a medication to a patient who is allergic to that medication.
  • Surveillance: The surveillance bucket is made up of costs seen because of the need to watch over a defective process. If you have to hire an additional staff member to watch a medication dosing system in order to avoid mis-dosing of medications, that’s a cost of poor quality. If the system worked much better, you wouldn’t need so much surveillance.
  • Prevention: This is the onlycomponent of the COPQ that has a positive return on investment — meaning, if you spend one dollar on preventing quality issues, you typically see much more than one dollar returned to you because the other costs associated with poor quality substantially decrease. I’ve always found it interesting that most healthcare quality projects performed by healthcare systems do not include spending on prevention.

Fast fact: even at smaller hospitals, the average healthcare quality improvement project easily recovers more than $250,000 in terms of COPQ.

The bottom line is, come January, healthcare colleagues need to tackle how to recognize and measure the amount of waste and poor quality that exists in our system. Whether we adopt a tool with a dollars-as-waste-measure such as COPQ or a similar standard metric, we need to make sure quality is measured in a way that resonates with healthcare providers, third-party payers, patients and healthcare administrators.

(3) Healthcare is at least a decade behind other high-risk industries in its attention to basic safety.

This point is well known in healthcare quality improvement circles, and comes directly from the Institute of Medicine (IOM). In 1999, the IOM published “To Err Is Human,” which codified what many quality experts in healthcare already knew: In terms of quality improvement, healthcare is at least a decade behind.

More recently, a widely criticized paper from Johns Hopkins cited medical errors as the third leading cause of death in the United States. Even if you don’t agree that medical errors are the third leading cause, the fact that medical errors even make the list at all is obviously very concerning.

Here, then, is the situation: Healthcare continues to be a decade or more behind other high-risk industries in terms of quality improvement. Standard quality techniques, like the COPQ for waste measurement, are not commonly used, and the fact that medical errors are the result of many different contributing factors is also typically not appreciated.

We look forward to a time of great change in our country. As January approaches, it’s useful to realize the current state of U.S. healthcare quality. If we believe, as many do, that U.S. healthcare is the best in the world, let’s take a moment and ask ourselves if being the best in the world is good enough or whether there is room to improve.

These three important facts about U.S. healthcare are unlikely to change before or on Inauguration Day. As Americans, let’s work with Dr. Price and President-elect Donald TrumpDonald John TrumpAssange meets U.S. congressman, vows to prove Russia did not leak him documents A history lesson on the Confederacy for President Trump GOP senator: Trump hasn't 'changed much' since campaign MORE’s leadership to make sure each of these important issues improve afterward.

 David M. Kashmer (@DavidKashmer) is a trauma & acute care surgeon. He is a nationally known quality improvement expert who focuses on Lean & Six Sigma in Healthcare. Dr. Kashmer is the author of the recent Amazon best-seller “Volume to Value: Proven Methods for Achieving High Quality in Healthcare,” which focuses on the use of standard quality improvement tools in Healthcare. He writes on quality improvement in healthcare for TheHealthcareQualityBlog.com and Insights.TheSurgicalLab.com in addition to contributing for The Hill.


The views of Contributors are their own and are not the views of The Hill.