Does Deming Focus Help or Harm US Health Care?
In past decades Deming and others have worked closely with corporations in the US and in Japan to improve quality and efficiency. Their work has been a mixed blessing. I have great respect for concepts such as the matrix of relationships shaping quality. All who are employed should work toward better process and outcomes. The problem is the greater complexity of health care interactions.
Holding providers accountable for areas that are
may be a major contributor to consequences such as
The business of making things is different than the application of quality improvement across multiple matrices of relationships, especially in a nation where most of the population is stacked inherently to lower outcomes with dozens of drivers of those poor outcomes. Health care quality improvement involves more than a model limited to product, process, employee, and employer. Most importantly the complexities of the populations most behind have long been difficult for leaders to grasp across access, plans, situations, home environments, practice environments, facility environments, employers, communities...
A major theme of my work is that lack of awareness of Americans most behind and their health care is a major problem shaping basic health access deficits. It is hard to see any policy helping for the last 40 years with most worsening the situations by design. Policies always have winners and losers.?Most Americans are losing most. Few Americans are winning most. The health care and economic designs appear to be similar in focus. The losses of hundreds of hospitals is most specific to 2621 counties most behind where concentrations of the worst public and private plans cannot help but close and compromise. Countless practices, delivery team members, and leadership losses have transpired as the employees of hospitals and practices plus their spouses have been lost from health care and other community leadership roles.
The GAO people in charge of having Deming and others speak to them, were proud of their reports. But in health care there are clearly some major problem areas.
How do you maximize profits and not marginalize those who deliver the care or those receiving care?
Why expect delivery team members to tolerate more to do of increasing dimensions of complexity, and to do this in less time, and with fewer team members, and with steadily less experienced team members as continuity and experience is lost in specialty, team member, practice, community, and patient?
How do you survive with lesser revenue and higher costs of delivery forced on you by those that assume that micromanagement is cheap, does not impact delivery team members, and proceeds without worsening access to care?
How do you make sense of the various federal, state, and employer based "payers" that are often not complementary and where their standards of practice are among the lowest in any corporation (see Office of Inspector General report Global Audit of Veterans Affairs Claims - BCBS )?
Why go into medicine with such a horror story worsening year to year? https://www.dhirubhai.net/pulse/do-go-medicine-robert-bowman/
Why go into primary care with the Depersonalization of Primary Care in American dominant for decades and driving MD DO NP and PA graduates away from basic health access? ?And why go where most Americans most need care only to find that they are most abused by design as well as those like you that remain to serve them.
Why put up with value based care that value you and your patients least? https://www.dhirubhai.net/pulse/depersonalization-personal-primary-care-america-robert-bowman/
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Who will ever address the deficits of health access shaped where the worst Medicare, Medicaid, and private plans (and employers) are concentrated?
Why kill hospitals, practices, economics, jobs, better health plans, and local leadership where our nation is growing fastest in 2621 counties (blue line)?
Given the weakest states and their weakest plans and the weakest employers, how are vast regions of the country going to improve without major economic and employer improvements?
Why do we segment best quality health plans by socioeconomics such that we concentrate the worst plans where health care is most behind and concentrate the best plans, most lines of revenue and highest payments where the population is growing slowest?
Why is this so hard to see that deficits are most prominent in the 30 weakest states and the 2621 counties with concentrations of elderly, poor, lower income, disabled, and worst employers?
Until this awareness goes mainstream along with an understanding of the worst situations, conditions, determinants, and outcomes concentrated in these populations, there will only be worsening designs. ?How can we help most Americans most behind if primary care organizations past, present, and future fail to act to improve the financial design and tolerate ever more abusive micromanagement?
The micromanagement bandwagon has proceeded with few delays. It has its own media and has deeply penetrated state and federal government, associations, foundations, institutions, the research literature, and the media. Not surprisingly the quality improvement focus has gone too far as even Don Berwick has indicated. To Err is Human applies to the humans pushing the micromanagement bandwagon.
Each micromanagement entity acts in ways that support one another and all resist the fact that outcomes have not significantly improved while the costs of delivering care have gone up (best seen in Kip Sullivan Obsessive Measurement Disorder review of Muller book , more at Kip Sullivan links at Muckrack ) Few mention the consequences of micromanagement focus that hit the people who deliver the care the most. Few link micromanagement focus to burnout, turnover, and worse. None point out that distortions of practice budgets away from personnel to pay for micromanagement is a bad design.
In the US, it appears that the quality improvement movement and the cost cutting movement have unified together. They impact directly and indirectly on the team members that deliver the care via the budget outlays, the time required, and the human abuse impacts.
More Clearly We See Quality Improvement Focus as
1. Resulting in little change in outcomes as outcomes are about the patient and their situation and environment and social determinants. And the US is declining in many outcomes as the disparities between those doing well and those doing poorly increase.
2. Resulting in higher costs of micromanagement leaving less in the budget to support the team members and shaping fewer and lesser delivery team members, especially where finances are worst in rural and lower concentration counties. Not only is the budget distracted, but the focus of the practice becomes metrics and measurements, not people as Sullivan indicates across recent decades .
3. Resulting in more for the delivery team members to do, thus reducing productivity and time for interaction with the patient/family/caregiver
4. Resulting in burnout and higher turnover in the delivery team members as the finances no longer support them, they have more to do that they often realize is meaningless, and they cannot interact in ways that they consider most important. They also see the financial changes and little future in basic health access careers least paid with worsening finances - by design.
And of course all of these impacts hit hardest where most Americans are inherently most behind in outcomes, workforce, access, social supports, and delivery team members. This is the small and medium sized practices with fewer physicians that have higher costs per physician for usual disruptions, micromanagement types, medical homes, supplies, and services. They also tend to have lowest revenue by design due to lower payments and worst quality health care plans (for them and their populations).
Any decent review of past decades reveals that single minded pursuits based on assumptions are out of control and lack of systems thinking is a major problem. These 17 practices from Linder and Frakes were reviewed specific to health care design at https://www.dhirubhai.net/pulse/lack-systems-thinking-why-our-health-care-designers-fail-bowman/