Evaluating the Processes of Neonatal Intensive Care: Thinking Upstream to Improve Downstream Outcomes
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What is quality? Sooner or later, discussions about improving the care in the NICU touch on the notion of quality.
How do you define quality? That which emerges when the most resources available are brought to bear on a problem? That which emerges when the most skilled people are involved in a process? Might it simply be whatever a patient parent says it is?
Perhaps quality is what a consumer buys for the dollars spent in the NICU. In this context, some people believe we should know which NICUs provide better value for money. Serious and widespread quality problems exist throughout American medicine. These problems, which may be classified as overuse, underuse, and misuse, occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care.
Very large numbers of Americans are harmed as a direct result. Quality of care is the problem, not managed care. Current efforts to improve will not succeed unless we undertake a major, systematic effort to overhaul how we deliver health care services, educate and train clinicians, and assess and improve quality. The powerful statements, well documented in the report, clearly call for reconsidering old beliefs, and changing what we do. Precisely how does the IOM define the notion of quality? The IOM calls quality of care: … the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
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It is robust. Here again, I suggest a second reading. Notice that it implies a causal relationship between health services and health outcomes. Recall this definition of quality as you engage with the entire set of tasks involved in neonatal care, and as you measure causal events and end-results. How we will approach quality improvement? We will take a systems perspective, to explore how the systems we create allow or even facilitate errors and waste. We will eschew an all too common habit of blaming individuals for errors when all they were doing was what the system demanded of them.
We will examine processes and outcomes, indicating the importance and need for process data and showing limitations of some outcome data.
Remarkably, the English language health care literature and the Ministry of Health in Tokyo offered no comprehensive explanation for the phenomenon. Japanese auto manufacturers were then a focus of attention in the US, and my hunch was that the efficiency of the Japanese health care system was a reflection of a Toyota-like approach to delivering health care. Surely, I thought, such good health outcomes at such relatively low cost must reflect an advanced production process.
This was correct, but not primarily with respect to the hospital-based neonatal health care process. I learned that the advanced production process resulting in low infant mortality rates was based more in the cultural norms of everyday life rather than in the organizations directly delivering health care. The Japanese way of living appeared to produce healthier babies. As a result, demand for the more expensive component of the infant health care system — newborn intensive care — was low, and so was total resource use for neonatal care.
Further, low demand sectors understandably experienced little pressure to become organizationally advanced. Today the health care systems of many countries are under pressure to develop advanced and more efficient methods. This company has successfully inverted the relationship between quality and cost that originally obtained in the automobile industry.
No longer do economists maintain that as quality improves cost must increase. Craft production entails highly skilled workers making a particular thing that a client commissions. The craftsperson and the client are usually pleased with the work and the results, but the process is expensive. Mass production was developed early in this century in an attempt to bring goods to more people at lower cost. Mass production turns out a large number of standard products at relatively low cost. In this case, workers often complain of unfulfilling work conditions while the consumer, given the choice, often seems to prefer a version produced by a craftsperson better quality.
Why, you may ask, do we seem to digress and now discuss producing cars?
We do so because factors that turned around the fortunes of Toyota after World War II illuminate important premises in our story about evaluating and improving neonatal care. Lean production is a way of making things that involves continuous improvement. Mass producers and lean producers think differently about their products.
Their quality focus is downstream, on the end results.
They inspect what appears at the end of the production line and make final adjustments by reworking the end result. For lean producers, on the other hand, the focus is rather diffuse — they look upstream and downstream.
They alter end results by adjusting upstream processes, preventing the problems that mass producers discover during final inspection. Lean producers are after perfection. They know this goal is unreachable, but using it as the standard underlies their success.
Aiming for perfection changes the way people work, the way they think, and yes , even the way they live. The NICU is truly a production facility. And we have much to learn from the experience of others working with the problems of producing things. Clarifying our understanding of what we make, why we make it, and how we can make it better, can improve NICU outcomes.
In later chapters we will talk about a variety of outcomes. For now, we can broadly categorize NICU outcomes as patient end-results and resources used. Improving end-results for patients is a tenet of medical professionalism. For some professionals, concern for the resources used in achieving the patient end-results may seem irrelevant or even unethical. I believe such attitudes reflect incomplete understanding of the aims of an individual NICU we will expand upon the notion of aims in a little while. Indeed, many parallels may be drawn between the perspectives of American automobile manufacturers during the s particularly, and the perspectives of many health care professionals trained during or before the same period.
When we deny the need to continually adapt to a changing environment, to changing inputs, and to changing customer expectations, we open a niche for a shrewd competitor. The niche would not be there to fill if the changes in the environment were not real. The American automobile manufacturers took a long time to recognize this, but they eventually did. It now seems that American health care professionals are experiencing pressure to alter their world view. We can deny that costs must decrease and patient results and satisfaction levels must improve.
Yes, we can deny it, but because the once-protected market status of health care no longer exists, I think the changes in results and cost will happen anyway. Who among us will embrace these changes? Who will lead? And what will the outcomes be like? Toyota discovered fundamentally not the knowledge for making cars; they discovered the underlying knowledge for making things.