BETTER CARE BY DESIGN
What makes care better? How can you tell if you’re getting better care? How can a provider tell if they’re delivering better care? We answered these questions in two steps. Step one was to develop a methodology for creating care delivery programs with consistent performance that assure quality. Step two was using this framework to design programs that can be personalized to meet specific needs of individual patients while also meeting the needs of individual healthcare providers and their organizations. The result of our efforts is called the B.E.T.T.E.R. Care framework because it centers around six fundamental attributes we believe best define the presence of two-tailed quality (for both consumers and providers).
By creating specific metrics designed to measure the benefits, effectiveness, timeliness, targeting, efficiency, and reliability of a program, we believe the presence of quality can be assured. The concepts behind the B.E.T.T.E.R. Care framework are not new. In 1999 the US Institute of Medicine published a scathing report on the state of healthcare at that time. They documented the unacceptably high number of annual deaths related to medical errors and the the virtual absence of patient safety systems in place to mitigate them. To point the health system in the right direction, the IOM published a follow up report, Crossing the Quality Chasm, which suggested six aims for improving healthcare program quality: safety, effectiveness, timeliness, patient-centeredness, equity, and efficiency. Unfortunately, many healthcare programs never got past safety.
Everything in healthcare for the past 20 years has primarily focused on the safety aim. However, it’s important to remember, patients don’t come to doctors and hospitals to be safe. Patients come to get better. As such, the focus of healthcare programs should therefore be on making them better. But it’s not, it’s on keeping them safe. Patient safety has dominated the patient care landscape to the point where quality and patient safety are almost synonymous to most healthcare providers.
To be clear, patient safety is and should be a critical part of every healthcare program but it shouldn’t be the focus of the program. Are we seriously going to keep giving surgeons or hospitals credit for not cutting off the wrong leg or not leaving a needle in a baby after an operation? We shouldn’t but we do, and, worse, we considered that quality. This seems absurd. It’s like giving the pilots of New York to LA flights credit for not landing in San Francisco. Safety is the minimum benefit patients should expect from a well designed program not the maximum. Safety is the floor not the ceiling as they say.
With the B.E.T.T.E.R. Care framework we wanted to create programs focused on getting patients better. The metrics for each domain are not complicated. Each of the six domains can be readily evaluated on the fly by frontline healthcare workers to determine if the primary goal is being met.
Development and implementation of the B.E.T.T.E.R. Care framework was based on the seminal work of Avedis Donabedian and Kurt Lewin. In Donabedian’s structure, process, and outcome framework it is understood that within the myriad of processes and subprocesses there must exist key processes which have an outsized influence on overall quality of the outcome. Kurt Lewin’s research established the tools needed to identify those key processes which then allows managerial decisions to be made in such a way as to optimize the structure directly related to the key processes thereby assuring quality. The goal of this method of healthcare program development is quality assurance-that is quality is built in during design and deployment and does not need to rely on onerous quality measurement regimes after the fact to determine if it’s there. Lewin’s research also provides a roadmap for creating program workflows that simultaneously nurture and fulfill the provider while satisfying the patient’s needs. In other words, our work doesn’t have to burn us out.
In subsequent posts we will delve deeper into the development and deployment of the B.E.T.T.E.R. Care framework. For now we introduce the basics of the six quality dimensions (at a very high level). We will dig deeper into each one later on.
the six domains of B.E.T.T.E.R. quality
The first attribute of quality in our model is benefits. The benefits of a health care program should never be presumed or assumed. Benefits are, by our definition, an affirmative attribute of every program. Benefits should be obvious to recipients, easily enumerated, and readily measurable. In a sense, this attribute encompasses the IOM’s patient safety concerns and views them as a fundamental benefit of a program along with all the other benefits associated with getting better. The benefits of B.E.T.T.E.R. Care are two-tailed and the metrics must measure both benefits to patients as well as benefits to our providers and organizations. In designing a program we go to great lengths to be certain that all levels of users obtain measurable benefits.
Effectiveness is a key attribute of the IOM framework and the B.E.T.T.E.R. Care system because it delivers on the purpose of care. Effectiveness is how we deliver the benefits. Patients come to us to get better and our effectiveness metrics allow us to answer the question of whether or not they are better. These metrics are designed to assess how well individual program components are performing separately and together for the current patient (indicator metrics) and how well they will perform for future patients (outcome metrics).
Timely delivery of care was one of the domains of the Institute of Medicine’s Quality Framework. We include it as a domain in B.E.T.T.E.R. Care because heart failure and other chronic care condition programs are of little use if they don’t provide what a patient needs when they need it. Patient access is a critically important component of the timeliness domain but it’s not the only one. Timeliness also encompasses the consumption of time during care delivery. The cycle time of a clinic visit, surgery, cardiac catheterization, and all other processes are very important considerations of the timeliness domain of quality. Resource availability ties timeliness, effectiveness, and efficiency together in program development.
The IOM domain of patient-centeredness is one of the more challenging to operationalize. We chose targeting in our framework because it encompasses many of the things the IOM was trying to get at and is far easier to conceptualize and operationalize. The ability to target patients with specificity to deploy the appropriate level of care is a critical part of any well-designed program. Targeting intersects frequently with effectiveness and efficiency domains during program design. Targeting is particularly important in chronic condition management where periods of stability alternate with periodic deterioration. Targeting permits intensification of care as the patient’s condition demands and reducing treatment to a lower, maintenance level when they are doing better.
The Efficiency domain is where concepts like LEAN six sigma are used in B.E.T.T.E.R. Care program design. This domain is also the place where we integrate cost of care and stewardship of patient as well as organizational resources. The relationship between cost and value weighs heavily in program design using any framework. We purposely consider this domain late in our process because discussions of cost can sometimes stifle imaginative solutions. The work of the late great Avedis Donabedian clearly shows us that providing the best care is not the same as providing the most expensive care. Donabedian wisely cautions designers to pursue the optimal benefit not the maximal benefit. In other words, the best care means the most appropriate care under the circumstances and which balances benefits and harm.
Reliability is the final domain of B.E.T.T.E.R. Care in many ways. Reliability is a key quality attribute in every engineering design framework but, surprisingly, was not one of the IOM’s six domains of healthcare quality. In our view the absence of reliability in a healthcare program means the program is waste. That is, if the time, effort, and resources that went into developing and executing a program creates no lasting value it meets the definition of waste. Reliability essentially assesses how long the benefits of care last. Reliability means someone knowledgeable answers the phone and tells you the right thing. Reliability means care received in the hospital lasts longer than 30 days. Reliability means patients who get better stay better.