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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.
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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.
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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.