Here is a riddle for
you. When is a person like a car? It is not a trick question and the answer is
exactly what you think. A person is never
like a car.
A car doesn’t care how it is
made. The person making the car might be
interested in things like keeping errors to a minimum, cost, efficiency, but
the car doesn’t care. It just rolls
along the production line being prodded and bolted and sprayed and polished
until it is done. People do care how
they are made; at least that is what modern investigation tells us through the
magic of MRI and other cool instruments.
The fetus displays all sorts of signs of adverse reaction to noxious
stimuli.
Similarly when a car is
being repaired, the car doesn’t care if the repair folks are inept and use poor
procedures and cheap parts to put the thing back like it was. The car doesn’t know or care about costs and
efficiencies. Again the owner cares at
both ends of the spectrum, either when it costs too much or too little. But for the car it is just another day.
It is kind of a silly way of
trying to make a point, but there is a point.
People really care when they are the subject of repair. Patient satisfaction makes all the difference
between a happy hospital and a hospital mired down in civil suits and bad
press. Patient satisfaction
differentiates between the choices of malpractice or no malpractice. People care.
While this is intuitively
obvious, there is nothing better than documented study to make a statement go
from “well duh” to “and that’s a fact”.
And that brings me to a recent article in ASQ’s Quality Management
Journal: Cost-Quality Trade off in Healthcare; Does it Affect Patient
Experience (QMJ Vol 22, No 3/ 2015, ASQ)
.
Basically the author (Sriram
Venkataraman) was able to look at two sets of information, one being scores on
patient satisfaction (aka “experiential quality”) as measured by the Hospital
Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a formalized
satisfaction survey.
The other set of data came
from information on physician-to-patient ratios, nurse productive hours,
outlier payments, weighted Diagnosis Related Group (DRG) and other information
including patient mix, and setting (rural, urban, large urban) and number of
staffed beds.
When the comparisons were
made, across the board, hospitals that had the greatest cost efficiency had the
poorest satisfaction, and the longer the person stayed in the hospital the poorer
the satisfaction level.
To go back to the beginning,
while Lean and cost efficiency is effective in industry with particular
application to Toyota (ergo the riddle about the person and the car) patients
do not like institutions that Lean out (or chisel out) every nickel.
Healthcare has made a number
of strides towards Quality. Fewer
pharmacy accidents happen now, as do fewer nosocomial infections, although to
be accurate there are still lots of pharmacy accidents and infections. There are probably a lot less wrong legs
being cut off.
It we use crude markers of
success, cost efficiency has reduced the number of lives lost due to hospital
care. But it is at a cost. Patients do not get much sense of well-being
while being hospitalized patients.
Previously in this blog I
have commented on patient satisfaction.
Given the state of healthcare today, the greatest “killer of quality” is
the association of an endless supply of new patients with no impetus to
providing good care and no consequence to giving poor care. [see: http://www.medicallaboratoryquality.com/2014/12/competition-and-quality-partner-dynamic.html
] We see this regularly in Canadian
healthcare across the country. What
patients put up with is just astonishing.
Unclean facilities, indifferent staff, and facility management that is
deeply deeply committed to cutting every nickel they can.
There are lots of reasons for
how we have reached this point, many out of them control of management. The reality is that the global economy has gone
through a pretty gruesome downturn that has not rectified itself in now 8
years. Governments are strapped, and
revenue in healthcare facilities has not kept pace with expenses, or indeed
anywhere in the social safety net. There
are fewer staff and the ones that are there many are tired and frustrated. They don’t want to be there anymore than the
patients, except for the fact that they are all making a lot of money.
As I see it (as does the
author) cost efficiency creates as many problems as it solves. In Canada, a litigious free zone, there is little
expectation of ever returning to better
satisfaction. But in the US, at some
point the level of dissatisfaction will become a significant issue that needs
addressing. And that will not be done
through the “affordable care act”.
In the next entry I will
tell you what I think can make things better.
