Health care quality and patient safety are not dependent upon a singular factor. Rather than addressing the system and its processes in a methodical, incremental fashion, the current model focuses improvement in a single area, rather than addressing the system as a whole—this is where the industry is failing. Organizations are seeing functions such as patient safety, provider safety, patient experience and satisfaction, utilization and others, rather than an intricate web with the patient and direct care providers at the center.
In health care, quality improvement is seen as the domain of clinical staff. Look at the profiles of people in quality improvement roles, and you will see most are RNs, MDs, or DOs, thus sending the message that the onus of quality improvement is on the clinical staff alone. This prevailing attitude is sabotaging the ongoing efforts to improve quality and ultimately impacting patient safety and experience.
What the typical health care approach to quality improvement (QI) fails to consider is that health care is a system made of disparate processes. Processes that feed into multiple areas and functions, far beyond direct patient care. It is an intricate web, that gets results. Whether good or bad, systems will always have the result that they are intended to and confining quality to the domain of clinical staff and their leaders is a huge failing that many organizations are still perpetuating.
The rigidity of roles in health care have created siloed efforts of improvement. Yes, there are state and regulatory compliance issues around licensure and scope of practice, but some of the restrictions in improvement work has been self-imposed by outdated attitudes and practices that no longer reflect the quickly changing field of health care. This impacts communication and can result in harm to our patients.
As health care continues to adapt Lean and Six Sigma into its QI practices, the industry is falling into the trap of only using Lean tools, but not following the spirit of a Lean culture. A Lean culture empowers everyone to work across departments and functions, make changes to improve quality, and add value to our patients. Risk is inherent with change, but with Lean, blame is never assigned—mistakes are seen as learning opportunities. Whether or not an organization uses this methodology, the mind shifts that must occur are imperative to improving care and having a true culture around continuous improvement. Thirty years ago, the New England Journal of Medicine ran a piece called “Sounding Board.” In it, the author describes two cultures: one that is punitive toward mistakes (Bad Apples), and the other is collaborative, with management acting as coaches who encourages honest dialogue about errors, with staff feeling supported to learn from them. The second was far more effective than the first. Why, after thirty years, is health care is still struggling to adapt continuous improvement?