Pergamon PD: buenuukmaljoumalfor Quality in Health Cart, VoL 9, No. 1, pp. 3-4,1997 Copyright © 1997 Published by Elievier Science Ltd. All rights renrved Printed in Great Britain 1353-4505/97 $17.00+0.00 S1353^t505(96)00102-0 COUNTERPOINT: CQI in Health Care: Some Comments on "Can it Really Work?" DAVID R. NERENZ Center for Health System Studies, Henry Ford Health System, Detroit, Michigan, USA Continuous improvement as an organizational philosophy Dr. Stern's concerns about CQI come in part from his own experience with a "program" of quality improvement instituted on a limited basis, as a "short-term pilot project", including an evaluation aspect and potential "long-term extension". Contrast this approach with that of an organization that makes a formal commitment to CQI as a fundamental organizational philosophy (with the full support of its administrative leadership and Board of Trustees), that commits to training all of its employees in the techniques of process analysis and team discussion (including several days of training for several CQI culture and employee incentives Some details of the CQI "culture" have a bearing on other concerns expressed by Dr. Stern, particularly the question of how to implement CQI in an environment where employees can't be dismissed for poor performance or given financial rewards for good performance. My reading of the CQI literature as it relates to organizational incentives suggests that these are not important concerns. Deming's admonition to "drive out fear" [1] is as clear a statement as one can find about the irrelevance of threats of termination to implementing CQI. The key organizational factors important to CQI include customer-mindedness, ability to work in teams, ability to think about processes in an analytic way, ability to see "systems" and understand complex causal relationships and the ability to bring the "owners" of Counterpoint is an occasional feature presenting discussion of a topic that is currently under debate in quality of care circles. We invite readers to write letters to the Editor adding their opinion on the topic. Downloaded from by guest on November 10, 2014 In his article on CQI in health care, Dr. Stern makes a number of observations about difficulties in implementing and sustaining Continuous Quality Improvement (CQI) in health care settings. Based on those observations, he raises a number of important questions about the ultimate prospects for CQI beyond some possible success in time-limited, small-scale programs. I will argue in this commentary that, although Dr. Stern may ultimately be proven right about the difficulty of sustaining CQI, his concerns are based on some misapprehensions about both the CQI philosophy and the current state of CQI in health care. He has been led to a more gloomy outlook than I believe is appropriate. Only time will tell, of course, but I believe that there is reason to be optimistic about both the impact and the staying power of CQI in health care. In making this argument, I will highlight two significant aspects of CQI that relate to both current status and future prospects. One is its status as an "organizational philosophy" or "organizational culture" rather than a discrete program. The other is its applicability to clinical process as opposed to only the administrative or support processes of "support" departments. hundred salaried physicians), that makes discussion of process improvement a regular agenda item at its Board of Trustees meetings, that invests in a core support staff of quality improvement professionals and that regularly highlights the successful accomplishments of CQI teams in employee newsletters, community publications and special "forum" presentations. Let's also imagine that the latter organization makes it clear from the beginning that there is "no turning back" — that the commitment to CQI is irrevocable. In which organization is CQI likely to "take hold'7 There is no guarantee that there will be success in the second organization and failure in the first, but the point is that an organizational philosophy cannot be implemented on a partial, trial basis with half-hearted commitment and then judged wanting if it is not adopted more widely. Specific programs and new techniques can be developed and disseminated that way, but organizational philosophies are different. CQI is an organizational philosophy, not a "program". An organization either commits to a CQI culture or it doesn't. Granted, it may be present in greater or lesser degree in different parts of the organization at different times, especially if it is a new philosophy, but it still either is or is not the official organizational view. There is no effective way to "pilot test" a philosophy like CQI on a limited, trial basis. Counterpoint: D. R. Nercnz processes together to make and evaluate process changes. In deciding whether CQI can "work" in health care, the questions I would ask have much more to do with the latter list of characteristics than about whether employees can be fired or given large bonuses. Application of CQI to clinical activities Summary There is no way to be sure whether any new idea or way of working will last and CQI is one of those things that will be most accurately assessed when most of us are retired and health care historians are the ones doing the assessment. The concerns raised by Dr. Stern are legitimate and should be taken seriously. I believe, though, that his experience with a limited-scale, pilottest implementation of CQI has little to do with the prospects for success of CQI in organizations where it has become the dominant organizational philosophy. His REFERENCES 1. Walton M, The Denting management method. New York: Dodd, Mead & Co., 1986. 2. Nugent W C, Schults W C, Plume S K, Baltalden P B and Nelson E C, Designing an instrument panel to monitor and improve coronary artery bypass grafting. Journal of Clinical Outcomes Management 1995; 1: 57-64. 3. McEachern J E, Schiff L and Coganm O, How to start a direct patient care team. Quality Review Bulletin 1994; 18: 191-200. 4. Headrick L, Neuhauser D and Melnikow J, Asthma health status: Ongoing measurement in the context of continuous quality improvement. Medical Care 1992; 31: MS97-MS105. 5. Burkman R T, Ward R E, Balchandani K and Kini S, A continuous quality improvement project to improve the quality of cervical papanicolaou smears. Obstetrics & Gynecology 1993; 84: 470-475. 6. Neuhauser D, McEachern J E and Headrick L (Eds.), Clinical CQI: A book of readings. Oakbrook Terrace, IL: the Joint Commission on Accreditation of Healthcare Organizations, 1995. 7. Kennedy M, How to accelerate and replicate improvement. The Quality Letter for Healthcare Leaders 1994; 8: 2-11. 8. Jencks S F and Wilensky G R, The health care quality improvement initiative: A new approach to quality assurance in Medicare. JAMA 1996; 268: 900-903. 9. EUerbeck E F, Jencks S F and Radford M G, Quality of care for Mediacare patients with acute myocardial infarction: A four-state pilot study from Cooperative Cardiology Project. JAMA 1992; 273: 15091514. Downloaded from by guest on November 10, 2014 Dr. Stern is concerned that CQI will be "...stigmatized as essentially concerned with organizational and administrative functions, since the method has not yet been applied to the sphere of clinical medicine as such". This concern is misplaced because the premise is not true, at least in the United States. CQI has been applied frequently to clinical issues, in a large number of organizations, with noticeable success. Indeed, one of the strongest features of CQI is its ability to transcend the unique concerns of specific departments or types of work in the health care organization, and become a "common culture" and "common language" that knits those diverse parts together. The format of this commentary does not allow a detailed review of examples of application of CQI in clinical medicine, but I would suggest an examination of the work at Dartmouth-Hitchcock Medical Center in Lebanon, NH [2], at West Paces Ferry Hospital in Atlanta [3], at University Hospitals in Cleveland [4], and at the Henry Ford Health System in Detroit [5], as well as others too numerous to list here [6]. I would also suggest an examination of some of the voluntary organizations that have developed for purposes of sharing information about CQI and process improvement among physicians and other clinicians. The example I am most familiar with is the Group Practice Improvement Network (GPIN), a voluntary organization of some 60 multispecialty group practices which meets periodically, produces newsletters and reports, and otherwise shares information about clinical process improvements [7]. One might also examine work by Peer Review Organizations (PROs) to act as catalysts for clinical process improvement activities among hospitals in their states [8,9]. In both cases, I think one can find a rich set of examples of not only activity but success and continued improvement in clinical care processes. concern about "stigmatization" of CQI is irrelevent to situations where CQI is the natural way of addressing both clinical and administrative support processes. I share his concerns about the long-term outlook for CQI in the "pilot project" environments he is describing. I am much more sanguine about the long-term value of CQI in organizations that have been able to make a broader and deeper commitment He is right that CQI will require an ongoing commitment from administrators and clinicians. In this, though, I don't believe that CQI is different from service excellence, patient satisfaction, community relations, financial success, or any other desirable organizational feature that requires ongoing management attention. Organizations that have made the full commitment to CQI have decided that quality improvement belongs on the list of issues that should receive ongoing attention and energy, perhaps even occupying a spot at the head of the list. The time to worry about CQI is when it is a "distraction" or a "special project" for management rather than one of the routine priorities.
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