Five Steps to Bad Healthcare

Jim Molpus, for HealthLeaders Magazine , January 13, 2009
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Gene H. Burke, MD, vice president and executive medical director of clinical effectiveness at Norfolk, VA-based Sentara Healthcare, says delivering a task without the context is a pitfall with a common-sense solution. "For example, you may tell them why it is important to make sure that vaccines are delivered. Do people really understand, for example, that there is an 80% protection rate in the adult population with a single immunization or influenza or pneumococcal vaccine?" Burke says.

3. C-suite funneling
One of the most misleading clichés in healthcare leadership may be to overstate the role of the C-suite in driving quality improvement. The proper role for the board and executive leadership is to provide the overall direction and goals for improving quality and patient safety, but anything else could clog up the pipeline.

"If you look at very successful improvement outside of healthcare like Toyota or the ISO-9000 organizations and Baldrige organizations, incremental improvement happens closest to where the work is done. That happens on the unit. It happens at the teams," he says.

What is worse is that managers are often overwhelmed by tasks from various uncoordinated leaders, Burke says. "Any leader may have five ideas, but the manager has the accumulation of five ideas from five leaders, so he has 25 things to do," Burke says. "Who is truly helping the managers understand how to do it, rather than just telling them to do it?"

4. Not improving the improvement skills
It sounds so simple as to be nonsensical, but healthcare somehow expects improvement from people with no training on how to improve.

"We have to dramatically improve our capabilities at improvement," Conway says. "We know how to deal with regulators. We know how to get through accreditation processes. But we haven’t as organizations made the commitment to grow the capabilities of the people we actually need to drive the improvement."

Improvement skills are not cheap, often requiring extensive training that may take busy managers offline. Many managers may have come through the unit as a nurse and demonstrated clinical skill, Burke says, but without some basic "change management" skills, they may struggle with getting other nurses and doctors to execute QI programs. "If our managers don’t have those skills, then how can we expect our front line troops to execute?" Burke says.

5. Blind attention to external groups
The Joint Commission, CMS, IHI, and other groups have created a chili pot of quality and patient safety measures that no one disputes have value of their own. But Conway says those measures are a poor platform for overall improvement and in fact may leave gaps that are the most crucial for protecting patients.

"We are seeing organizations that are unbelievably busy doing things, but their overall mortality is not changing or their overall patient experience is not changing," Conway says.

One area that may represent a gap is in OB/GYN care, where there are no real public measures, he says. If hospitals are only paying attention to the directions of external regulators without the context of internal observation, such gaps may become worse. One way to help is to develop whole system measures on big issues; mortality, infection rate, medication errors, and overall patient experience are among 10 or so whole system measures hospitals should examine.

Jim Molpus is editor-in-chief of HealthLeaders Media. He can be reached at




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