Tom Milam recently sent me this excellent podcast from Relentless Healthcare Value which led to this post. The picture above is of one of my heroes, W. Edwards Deming who led the Japanese car quality revolution. When I was a child, most automobiles lasted for about 100,000 miles. I am still driving a Honda CRV that has over 200,000 miles on it. No problem. Automobiles are better today because of quality improvement.
American healthcare quality efforts occur on the backside of production. Let’s use the diabetes example. We use population health tools to identify care gaps or triggers. Then we close those “gaps” after the fact. Which patients with diabetes don’t have their blood pressure controlled to a level of 130/80 or less? (It is a big number) Only 44% of Americans with hypertension have a pressure less than 140/90. Once that trigger is identified, we contact the patient and adjust their medication. Most quality improvement efforts don’t result in better blood pressure control. This type of rework is expensive and ineffective.
This backside approach violates the third of Deming’s 14 rules of quality improvement. “Cease dependence on inspection to achieve quality. Eliminate the need for massive inspection by building quality into the product in the first place.”
Identifying and closing care gaps is a form of massive inspection that results in rework which is inefficient and much more expensive than getting it right the first time.
Optimal medical therapy (OMT) for diabetes is a product that can be industrialized, systematized, and scaled. Cars are produced on an assembly line that has been refined over time by the production team to deliver a car with minimal need for rework. The primary care Chronic Cardiometabolic Condition Clinic is the medical equivalent of an assembly line and it is designed to produce OMT consistently by using protocols and systems. The diabetic needs a pressure under 130/80, an LDL under 100 on a high intensity statin, a hemoglobin A1c under 7, an eye exam, a foot exam, a urine test, best practice diet and exercise recommendations, on aspirin if high risk, off tobacco. Certain medications like lisinopril, losartan, spironlactone, metformin, statins, and empagliflozin protect cells and organs more than they lower the risk factor. It is very complicated and in usual care it is not done very well at all.
Fewer than 20% of Americans with diabetes achieve the goals for pressure, sugar, and cholesterol concurrently while not smoking and on an aspirin. That is a massive amount of rework if the practice is even looking at care gaps. In Chronic Cardiometabolic Condition Teams the systems and protocols bring that number up to as high as 75% which translates into on fourth as many heart attacks and one sixth as many people going on dialysis. It does not take a doctor’s expertise to be certain the pressure is under 130/80 and the patient has had a urine test. A medical assistant can do that. Every member on the team has an assigned role. We can have better health at lower cost now. These are proven approaches. Let’s do it. whbester@congruityhealth.com 423-782-0372
Bill: I think this is a theme that you should continue to dig into deeply, namely how the US health care system abandoned Deming’s methods for quality improvement, continuous quality improvement. You might examine the role of the Institute for Quality Improvement, IHI, founded and led by Donald Berwick, and its initial successes and then demise as health care provider organizations strayed away from this proven method. It’s a tragic story of for-profit medicine taking over from a model that still had public health as an element of its principles and goals. You are well positioned to write on this topic and bring it to bear on OMT.
Great post Bill, eager to develop more protocols around advanced primary care that incorporate these principles and generate the needed outcomes.