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Healthcare Performance Improvement: Yesterday, Today, and Tomorrow (Part 1)

Submitted By: Dan Chauncey
Categories: Healthcare


How does an integrated approach to performance improvement in healthcare differ from historical quality improvement? First let’s do a quick look back at quality improvement. Within healthcare we could go all the way back to Hippocrates, but let’s stay a little more contemporary. Most people like to start with Dr. Ignaz Semmelweis or Florence Nightingale.

In 1847, Dr. Semmelweis studied the transmittal of puerperal fever, an infection occurring in post-partum females. Dr. Semmelweis was able to document that physicians and medical students would perform autopsies, and in the same clothing (dirty aprons and all), frequently, merely wiping their bloody hands on their aprons, and then perform gynecologic examinations on the new mothers. By instituting hand washing with chloride of lime prior to examining the females, the infection rate dropped over 80%.

During the Crimean War (1853-1857), Florence Nightingale recorded that in the first seven months of the campaign, 60 percent of the soldiers died from infections. She and her team focused on improving cleanliness, sanitation, nutrition, administrative order, and patient care. In the following three years, Nightingale and her team drastically improved the conditions for the care of soldiers, reducing the death rate among patients.

In my experience, I have found that the historical underpinnings of quality improvement in healthcare were largely reactive in nature. Semmelweis’ recognition of the disparity in puerperal fever between two seemingly similar hospitals, or Florence Nightingale’s refusal to accept the non-combat death rates during the Crimean War.

Another venue where healthcare quality was impacted is through academic research. Examples include Avedis Donabedian, who collated the growing literature of health services research as it appeared through the 1950s and early 1960s and presented his findings in a lengthy paper in 1966 with the title “Evaluating the Quality of Medical Care”. In it he sets out the necessity of examining the quality of health provision in the aspects of structure, process and outcome. Another example of quality research is the volume-outcomes relationship initially described by Luft et al in 1979.

As healthcare moved into a more localized application of quality improvement, many organizations began applying the PDCA model. Although plan-do-check-act (PDCA) was developed originally by the father of statistical quality control, Walter A. Shewhart, W. Edwards Deming, who was his student, later went on to develop Total Quality Management (TQM) and became a founding father of management science in his own right. Deming’s application of PDCA (and PDSA) called for managers to hypothesize, develop, and plan improvements; implement and do the improvements, almost as if performing a scientific experiment; checking, studying, and evaluating the outcomes and results; and then acting based on considered analysis to instill the change on a continued basis until it could be improved further. In so doing, Deming applied the principles of scientific management to the aim of perpetually improving organizations.

Shortly it became apparent that PDCA was more of an implementation approach that began with a hypothesized solution. In the 1980s the Hospital Corporation of America added yet another acronym to the vernacular—find-organize-clarify-understand-select (FOCUS). In the FOCUS-PDCA paradigm, preceding PDCA, FOCUS calls for finding an improvement opportunity, organizing an improvement team, clarifying the current state of the process, understanding the causes for variation in the process, and selecting the improvement. This was the first complete methodological approach to improving quality that ranged from problem identification to implementation of the solution.

Many hospitals still apply FOCUS-PDCA supplemented, in some instances, with an industrial engineering approach to quality improvement. This outside-in—using industrial engineers—approach allows only a minimal involvement of clinical staff. The staff members, who do the work, know the process, deal with the problems, and need to be a part of the solution. While this is evident, some model still exclude them.

A quality revolution began in the 1980’s. It began in manufacturing, transitioned to transactional industries in the 1990’s, and by the turn of the century was slowly making inroads into healthcare.

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