Sunday, July 12, 2015

When is a person like a car?

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: ] 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.