At the crossroads of healthcare: Quality, safety, value and outcomes

A look at the four major elements that are fundamental for the transformation of healthcare.

October 14, 2019 Dr. David Jaimovich, President, Quality Resources International and Former Chief Medical Officer and VP, JCI, Chicago, U.S.

Despite the advances and improvement in promoting patient safety and quality of care around the world, these issues remain an important public health challenge. Research and policy development have shown that tackling this is much more complex than previously thought. In addition, the pressure on healthcare organisations to have greater accountability and deliver better outcomes, for less cost has created a new paradigm in the process of transforming healthcare around the world. This is compounded by a global shift in health focus with ageing populations and the rise of chronic diseases, which are shifting the focus of the healthcare industry away from curing diseases in the short term and moving towards the long-term improvement of outcomes.

This type of evolution will require a shift in the way governments, providers, payers and others interact, therefore moving to integrated healthcare delivery systems to coordinate care and services for all patients, including the most vulnerable. There are four major elements that are fundamental for the transformation of healthcare – Quality, Safety, Value-Based Healthcare and Outcomes.

Quality

There has been a steady rise in the cost of care without a parallel, measurable increase in the quality of the healthcare delivered to patients. This has led to a situation of low-value care and for a demand to change into an evidence and value-based healthcare system.

The drive for providers delivering healthcare based on facts and disease-specific, sound research has grown dramatically and is expected to continue on a global basis. This is essentially founded on the demands of a much more educated patient, payors and government agencies asking healthcare organisations to be more accountable for their outcomes.

For healthcare organisations wanting to improve quality with value-based delivery of care, there needs to be an environment of collaboration and team mentality. This means that providers must work together as a team, involve patients in order to provide ‘patient-centred” care, and create a situation that is appropriate to each individual’s overall needs. This strategic change has been shown to provide higher quality in the delivery of care; founded on a care experience for patients that is more focused, coordinated and ultimately more efficient.

One of the foundational elements of success with this strategy is for healthcare providers to “think outside” of their disconnected, “siloed” approach and encourage them to work within a community of providers utilising “best practices” in order to offer the most appropriate and cost-efficient care for patients.

Safety

Historically, change in healthcare has happened in a reactive, fragmented manner with each crisis that arises, as the primary driver for that change. A way of responding to the current changes occurring in healthcare is to consider every change an opportunity to influence the path an organisation desires to be on throughout their transformational journey.

Healthcare leaders are responsible to establish the path that their organisations will take, to that effect, one of the primary directives is to envision how patient safety will be in the future and how it will impact their respective organisation. In addition, they must foresee the changes needed between the present and the future in order for their vision to become reality.

With a macro-level view of where organisations need to strive to be, there are a number of initiatives that have to be undertaken in order for patient safety to not just be a priority, but to be a part of every moment that healthcare is delivered to a patient. These initiatives include:

A well-designed environment of healthcare delivery – needs to be safe, efficient, and designed to provide patients with healing aspects within the facility with advanced technologies that will support clinical care delivery. The environment will be safer by greater compliance with hand-hygiene guidelines, reduced patient falls and improved medication management. Construction materials need to be free of toxic materials and more effective in reducing contamination with infectious organisms. It is paramount that the development of this environment be throughout the organisation including the ambulatory setting.

The best way to ensure that the investments necessary for the development of these healthcare environments are commonplace, is the implementation of evidence-based design and the right investments for the organisational transformation. Likewise, there needs to be a revision of the usual accounting practices of separating operating and capital expenses, which make it difficult to implement strategies that optimise the life-cycle cost of a building.

Health Information Technology – provides a platform for healthcare organisations to establish solutions that will influence the speed and character of the technologic implementations. A direct interface between health information technology (HIT) and patient safety has been long established. This has evolved in the form of electronic medical records (EMRs), computerised physician order entry (CPOE), an electronic medication administration system (e-MAR) and electronic prescribing (eRx).

Four decades ago, the promise that HIT would make the delivery of healthcare safer, faster, better and more clinician friendly was a viable vision, yet, since that time our enthusiasm has stalled. In spite of the opportunities that HIT holds, we also have to be realistic of the difficulties in its interoperability, data standards and storage safety and how to best apply it for improving patient safety. Because we want HIT to provide us the long awaited and promised patient safety solutions, we often overlook the difficulties that technology amplifies or complicates. The IT industry needs to develop a digital infrastructure that provides healthcare organisations with data liquidity. This would allow for a common format that would support medical research, boost efficiency and improve patient safety.

A new collaborative relationship needs to develop between the companies that develop HIT systems and the global clinical community. Therefore, this new technology environment would keep patients safer and would ultimately promote the purchase of safer HIT systems that would be truly valuable to the transformation of healthcare organisations.

Patient-centred care – although many organisations around the world believe that they embody the definition of “patient-centred care” by delivering what patients say they want; it doesn’t completely represent safer care or the much broader concepts that “patient-centred care” embodies.

A model of co-creation and true partnership with patients is necessary to strengthen a culture of safety in a healthcare organisation. This relationship is based on mutual respect, trust, transparency, accountability and shared decision-making. This re-design of healthcare delivery will not just involve the patient and the healthcare team, but also take into account the patient’s perspective, thoughts, behaviour and of course participation. This new model can drive guidelines’ development, funding, solutions, ethical initiatives, research and policy development. All of these qualities of the healthcare delivery model will assure that the healthcare system is safe, compassionate, just and efficient.

A more comprehensive “patient-centred” programme needs to have a complete understanding of the dynamics of the communication of risk and the impact on patient engagement. In addition, a robust patient reporting system for medical errors, reengineering of safety solutions and best practices, with an unwavering support from executive leaders, will significantly contribute to patient safety.

Complex systems for the delivery of care – healthcare organisations must recognise that the delivery of clinical care is comprised of complex systems and, in order for an organisation to be able to transform itself, there needs to be a deep understanding of complex systems.

To be able to do this, clinicians, administrators and legislators have to consider the delivery of healthcare as a conglomerate of complex systems. These leaders must learn to have a “systems thinking” approach. This management style and thought process is necessary when designing and implementing evidence-based changes that are targeted toward reducing harm and improving safety for patients. This requires more than just adding new processes to an unchanged existing system. Often, it requires a system redesign to incorporate new functions in order to be efficient, reliable, effective and have sustainable changes.

There must be a prospective evaluation methodology based on a continuous vigilance, measuring processes and outcomes to identify early indicators of change. Once systems thinking has been implemented, clinical practice can become dramatically safer.

A model of co-creation and true partnership with patients is necessary to strengthen a culture of safety in a healthcare organisation. This relationship is based on mutual respect, trust, transparency, accountability and shared decision-making.

Dr. David Jaimovich

Value-Based healthcare

In order to change national health policies, improve the operational performance of healthcare organisations and further improve outcomes, there needs to be advances and alignment in policy reform, improving the health system and applying health management education to organisational practice.

Globally, there is a recognised movement towards an incentive-based performance structure for healthcare providers. This is the shaping of the framework for a Value-Based Payment (VPB) system for healthcare organisations and a Reward for Performance programme for clinicians.

Although health systems around the world have different organisational, ownership and payment structures, they are all facing significant macro-level drivers of change, including rapid dissemination of HIT systems, ageing populations, cutting-edge medical treatments, escalating healthcare costs and an increasing demand for improving performance and better outcomes.

One of the first interventions that are necessary for the change to begin, is for administrative healthcare leaders to receive management training in order to be effective systems leaders; gaining specific skills and competencies to assure effective organisational and system level performance. These new, learned competencies will provide these management leaders with the ability to have a value-based approach to a budgeting and payment framework.

These competencies usually fall within two domains: the health environment and the business of healthcare. Within the health environment competency domain, there are certain health systems and organisational competencies that are most important:

  • An administrator must balance the relationship between access to care, quality, safety, cost, resource allocation, accountability, facility, community needs and professional responsibilities.
  •  Assess the performance of the organisation as part of the health system/healthcare services.

In addition, multiple business competencies are required. Special attention must be given to the financial management competencies, especially as follows:

  • Effectively use key accounting principles and financial management tools, such as financial plans and measures of performance (e.g., performance indicators).
  • Use principles of project, operating, and capital budgeting.
  • Plan, organise, execute, and monitor the resources of the organisation to ensure optimal health outcomes and effective quality and cost controls.

A very important lesson that administrators must learn is the need to adapt to the important changes in healthcare financing. There must be greater emphasis in learning about healthcare performance improvement and the measurement and metrics that will determine whether the initiatives implemented have been successful.

In the U.S., the Centers for Medicare and Medicaid Services has introduced and implemented a new VBP programme. To be successful under this new programme, hospitals have to report and present on 12 separate metrics across four domains: Safety, Clinical Care, Person and Family Engagement and Efficiency and Cost Reduction. Although this VBP programme reflects the needs of the U.S. health system, the reasons driving these policies are globally applicable. There is worldwide concern about improving quality of care, patient safety, and cost reduction. Management leaders need to be prepared to understand the metrics implemented, the impact their goals will have on their health system and how consumerism will affect their long-term aspirations as a health system. These target metrics can be exploited to negotiate with payors, health insurance systems and Ministries of Health.

Outcomes

Excellent outcomes are essential to the survival and growth of all hospitals and healthcare systems around the world. To have excellent outcomes, organisations must continuously improve their delivery of care, which is increasingly more expensive, but failure to do so can be so much more expensive.

Healthcare administrators are universally facing the challenge to improve clinical outcomes in a cost-efficient manner. Improving outcomes means improving the health of the population, the patient experience of care, reducing the per capita cost of healthcare and improving the work life of healthcare providers.

This framework for improving healthcare delivery outcomes must consider all four of these dimensions, which, require a significant level of system change. To accomplish long-term, sustainable change and better outcomes, the appropriate balance amongst the four dimensions must be achieved.

Although, each improvement initiative may not embody all of these dimensions, creating a framework that shows meaningful context that each of these are essential for success. The improvement that is achieved needs to be visible and be relevant to the objectives and goals of the organisation. The information that is collected and the results that are attained must be disseminated throughout the organisation in order to align all associates and stakeholders with the institution’s priorities.

It is important that an organisation develop the capability to relate every outcome to these dimensions, although not all may be included in the proposed processes for success. The organisational ability to have data-driven solutions for improving outcomes is a key indicator of readiness for sustainable outcomes improvement. To be able to have solutions based on data, an organisation must define and establish clear measures of improvement before any initiatives are implemented. The organisation should focus on the most common categories of measures – process, structure and outcomes. An acronym that is helpful in explaining the goals and objectives of how success will be measured is SMART – Specific, Measurable, Actionable, Relevant, and Time-based. The SMART acronym first appeared in the November 1981 issue of Management Review published by George Doran and collaborators.

All of the above-mentioned initiatives – new payments based on outcomes, better care and reliable data that can be used by clinicians and the community, are transforming healthcare throughout the world. The changes occurring in healthcare today requires administrative and clinical leaders to be ready to take well-thought out risks in order to provide the healthcare consumer with excellent, evidence-based, outcomes driven personalised care.   

The organisational ability to have data-driven solutions for improving outcomes is a key indicator of readiness for sustainable outcomes improvement.