Dr. Marc Berg
Principal, KPMG in the US, and Global Health Practice
Even the most advanced organizations acknowledge that they are on a journey to achieving high reliability, and need to address the following four essential building blocks:
- A culture devoted to quality
A number of hospitals around the world have allowed themselves to develop cultures of ‘normalized deviance,’ where (below) average performance becomes the norm, people are afraid to speak out and leaders are either unaware of or deny failure. Such weaknesses have led to high-profile disasters. In a culture of excellence, on the other hand, the board leads by example, sets the tone at the top and refuses to accept anything but the highest standards. No individual can feel that he or she is above the rules, and leaders must have the courage to challenge anyone in the organization, including clinicians and administrators.
Although the organization exercises zero tolerance for safety breaches and diversion from standards and procedures, failures or errors are not blamed on single individuals (unless in cases of individual rule-breaking, for example), but, rather, viewed as vital learning experiences. Most importantly, healthcare providers must acknowledge mistakes and poor practices, and empathize with patients and their families. In building such a culture, boards may need to go through formal training that emphasizes their role in overseeing quality and safety.
- Responsibility and accountability
Defined individuals should be responsible for the clinical and financial outcome of patient pathways, and accountable to senior management. All information should be distilled as it flows upwards, to keep leaders informed but not overwhelmed with data, with appropriate levels of detail for each audience. In some of the best examples, quality and safety are built into the strategic goals and become a central part of all board meetings, supported by robust internal audits to verify the established high standards of governance, as with financial audits, are consistently applied.
- Optimizing and standardizing processes
Doctors have typically been deeply resistant to standardization, believing that every patient is unique. However, such an individual-by-individual approach actually increases the likelihood of errors. Leading providers have achieved dramatic results by implementing standard guidelines and operating procedures, increasing patient survival rates and cutting the cost of care significantly.
The path to standardization can, however, be slow and painful, with staff at all levels reluctant to change behavior, resulting in a frustrating lack of compliance. Clinical leaders must be relentlessly vigilant in checking and double-checking adherence to protocol, making those on the front line directly accountable and stressing that guideline adherence is not a loss of professional autonomy, merely a replacement of pure individual autonomy by more collective autonomy. Results should be fed back to the pathway owners, whose task is to continuously improve the performance and thus the quality of care.
Information technology (IT) plays a vital role in measuring outcomes and improving processes. However, some of the most impressive breakthroughs have occurred in organizations where the IT infrastructure was still unsophisticated, so technological limitations are no reason for inactivity.
Leading healthcare organizations measure quality relentlessly, with systematic reporting and monitoring, real-time feedback, and regular benchmarking against peers and industry best practices. This inquisitiveness extends to understanding the drivers behind low- or high-scoring measures. Staff at all levels are encouraged not just to measure, but to measure the outcomes that matter most to patients.
Once a standardized database has a critical mass, it can be a big catalyst for improvement, as clinicians see what works and what does not. Published performance data also breeds competition, as clinicians strive to be top of the rankings, which again raises standards.
The journey towards a ‘high reliability’ organization
‘High reliability’ organizations
The definition of a high reliability organization extends beyond patient safety to encompass quality care – and ultimately value.
Despite representing many of the world’s foremost healthcare organizations, none of the leaders interviewed for this paper were confident that their institutions had reached a state of ‘high reliability,’ which entails a journey through four phases (below).
A strong focus on quality care will raise clinical standards and reduce costs. Ultimately, one of the best ways to demonstrate control over quality care is to produce consistently excellent outcomes over time.
Becoming a high reliability organization will not happen overnight, and all the leaders contributing to this paper acknowledge that their organizations have some way to go. The journey involves four stages, with most current providers operating within Phase 0 and 1, which are characterized by a lack of standardized measurements and controls, with individually operating clinicians dominating the culture.
Over time, with the right culture and strategy established by the board, quality and safety take on greater importance and gradually become institutionalized. By Phase 2, key outcomes and their drivers are routinely measured and reported, and a zero tolerance culture predominates, with clear responsibility for outcomes. In Phase 3 – which is likely to apply only to specific departments such as intensive care – there is a total focus on preventing failure and continuously improving care.
System governance: assuring quality
What do the interviewees mean:
- methodically measuring care outcomes,
- understanding the key drivers of these outcomes,
- understanding how to make these outcomes best of class,
- systematically preventing avoidable harm to patients.
In recent years, the stakes for sound reporting have risen. This puts pressure on providers, but also on regulators and payers/commissioners. The response has been to increase the range and volume of activities that providers have to publicly report, including quality and patient safety.
Despite the time and effort that goes into compiling, submitting and analyzing such data, negative events continue to happen. Regulators and providers need to reassess what goes into reports, so that the content offers a meaningful and accurate picture that signals serious failings, as well as being a driver for improved standards.
The tension between internal and external reporting
As the volume of required measures rise, healthcare providers feel under siege, forced to allot more and more valuable staff time to compiling reports, rather than providing care. Worse still, many believe that much of the data required for external reporting is of little or no use, as it concerns detailed, low-level activities that offer no indication of overall performance.
The way forward here lies in a relentless focus on reporting the key outcomes that matter from the patient’s perspective. In many cases, establishing and reporting on these measures is simpler than is often assumed.
Making measurements simpler and more relevant
Much of current regulatory reporting centers around processes and activities. However, there is growing agreement that the most important measures are outcomes, such as survival, quality of life, minimal symptoms and exacerbations, or a return to full physical fitness. Key measures are often already available for common conditions such as diabetes, breast cancer and hip arthrosis, but are also required for patients with co-morbidities and frail elderly patients.
Healthcare boards, patients, payers, governments and other stakeholders need to shift their focus towards this goal, with internationally standardized measures the ultimate aim; areas such as oncology and cardiovascular surgery are leading the way. With a more focused, set of measures, it should be easier to assess whether an organization is in control of quality, and benchmark against peers. Of course, this aim introduces a key challenge, as care often involves several different care providers, with limited ability to exchange and use data. But in the 21st century, not having oversight over patient outcomes over the total episode of care can no longer be seen as acceptable.
Assuring the reliability of reports
The collection and presentation of healthcare data lags behind that of financial data, with insufficient guidelines, lack of standardized procedures, and little or no segregation of duties between recording and reporting. Software is also relatively unsophisticated and, with few controls, much of the information is not dependable. Instances of ‘massaging’ data have been observed, further reducing trust in the numbers.
Independent assurance can help verify the reliability of quality measures, and internal and external audits are becoming more commonplace in some countries. To meet such scrutiny, healthcare organizations will have to govern clinical activity with the kind of controls that are standard in financial reporting, including penalties for incomplete or inaccurate submissions.
Reliability can be tested by verifying consistent applications of established controls as well as looking for unexpected patterns and volume of co-morbidities and, for example, making comparisons with similar organizations.
In the wake of a number of incidents, patient safety is high on regulators’ agendas, with hospitals and healthcare providers under pressure to prove that they have preventive measures in place, and can act quickly should any incidents occur. However, safety is proving a headache for public reporting, as negative outcomes are often too rare to be statistically valid, and too diverse to be measured cost-effectively.
Measuring harmful incidents can be useful for internal purposes, but patients, citizens and payers are typically uninterested in lengthy lists of what could go wrong. Arguably, certification is the way forward for this domain of quality, as it can assure common standards across all providers. Several safety-specific accreditation schemes exist and are emerging in Canada, the US and Australia, helping to create some common standards.
Regulatory demands are likely to change significantly, as providers, payers and commissioners acknowledge the need to converge internal and external measurements and reporting around what is best for the patient.
Standardized outcome measures should emerge at an international level, and safety should rise up the agenda. Auditing quality should become more regular and will adopt the same standards as financial assurance, to give regulators, providers, patients and other stakeholders confidence in the accuracy and completeness of the levels of quality and safety being achieved and reported.
The organizations studied in this paper are all making progress along the path to ‘high reliability,’ and in the following chapters we explore how they have adopted some or all of these actions.