NOTE:  This blog post was taken from Need to Know: How to Arm Yourself and Survive on the Healthcare Battlefield (2018) by Darwin Hale, COL (RET), USAR, the Founder & CEO of Advocate Health Advisors. Darwin is a respected entrepreneur, author and decorated military officer with more than 30 years’ experience in the corporate world to include serving in the United States Army and Army Reserve (USAR).

It is widely agreed that the American health care system needs serious reform. Opinion polls from respected organizations like Gallup and Pew consistently place health care at or near the top of issues most Americans want to see addressed. There is good reason. In 2019, Americans spent 3.8 trillion dollars on health care, an amount larger than the GDPs of entire nations like the U.K. and Canada! This amounts to $11,582 per person, by far the highest per capita spending in the world. At the same time, nations like Japan, Switzerland, Israel and Korea spend far less per person and have longer life expectancies. Something is not right!

Most Americans have firsthand experience dealing with the failings and the inefficiencies of the health care system. Simply getting a copy of your medical records, scheduling the right appointments in the correct sequence or shopping for needed services may take enormous effort, if you are able to do it at all.

Every person has some special interest, their “thing,” a subject that is intensely interesting to them. From my younger days, my “thing” has been the subject of efficiency. Efficiency is a primary driver behind what I do. By making things simpler and more efficient, people can live better lives. Given this attitude, you can imagine how much the health care system irritates me.

The health care system is just so massive, touching the life of every American. Where would you even start fixing a structure that is so important and so immense?

Certainly, I do not have all the answers, but while I was working at IBM, I learned about a management process that can serve as a blueprint for improving the health care industry. IBM had retained a knowledge-management consultant named Lawrence Prusak. Mr. Prusak is an influential leader in the field of managing knowledge and information, a subject at the heart of health care.

Total Quality Management as a model for improving health care

Prusak maintained that you could not directly change the culture of an organization like IBM or a system like American health care. However, you can change a process, and that could lead to cultural change. This process is taken from my notes, made when I first learned about Total Quality Management or TQM. It has worked well at several large companies, including McCaw Cellular, which later became AT&T.

The simple objective of TQM is “Do the right things, do them right the first time, and right every time.” TQM was originally applied only to manufacturing operations, but it is now becoming recognized as a general management tool. TQM is certainly applicable in service and public sector organizations like health care.  Applying the principles of TQM, here are some steps that would go a long way towards improving health care.

  1. Identify improvement opportunities. Here we decide on the measures which most need our attention. We focus on opportunities for disease prevention and how to reduce costs. We listen to health care consumers to find out what they like and don’t like, what works and what does not work. Then, we set priorities based on these opportunities.

    Here is a simple example- Many patients find it irritating to have to fill out their entire medical history on a clipboard every time they go for care. The Elite Health organization is a great example of a company that’s working to fix what’s broken: the doctor enters the room at the same time you do, and your electronic medical records are displayed on a wall monitor for you and the physician to view together.
  • Identify inputs and outputs. All stakeholders, including individual patients, providers, health care plans, governments, and insurance agents, must identify key customers and suppliers. I use the terms “customers” and “suppliers” on purpose. Each stakeholder has a role here and can gain efficiency by defining the inputs and outputs they need. Patients need inputs like prompt attention to medical problems. Their outputs, like compliance with sound medical advice, are also essential.

    All stakeholders must ask, “Who gets my output and whose input do I need?” In turn, they must ask how they can improve delivery of their medical service, lab results or insurance coverage, their outputs. That’s where new value can come, making the medical system better, faster and less expensive.

  • Establish agreed-upon requirements. Exactly what does each participant in the health care system need and how should it be delivered? Answers to these questions are needed so that we can establish standards against which performance can be measured. For example, if a cancer center needs to know specific details about a melanoma, the pathology lab should provide a level of detail that enables selection of an appropriate course of action without delay. The agreed-upon requirement is this: provide us with exact details so the precise treatment can be prescribed.

  • Identify gaps. Based on available data, we identify the gaps between what customers need and what existing work process supply. There are plenty of these to choose from. Gaps are everywhere, and we need to identify and fix them. End-of-life issues are a common example. There is a huge gap between how people want to die, how they spend their final days and how the system treats them. There is a need for serious talk about end-of-life issues. How can we provide proper medical care while respecting a patient’s very human needs as life ends?

  • Describe and analyze the current process. Does the current process consistently meet patient or customer requirements or not? This step may involve flow charting, looking at bottlenecks, and engaging in root-cause analysis. Why do breakdowns happen and how can they be avoided?

    Consider the hospital admission process. Each of the hospital departments can do a great job of admitting and providing the appropriate services in a timely manner, yet, the overall customer wait time was eight hours. Why? It is because the departments operated independently, and the overall efforts were not coordinated. In isolation, the independent departments get high marks, but that does not reflect the overall customer experience. There’s room for improvement here.
  • Develop and execute solutions. Whenever a current process does not work satisfactorily, you must find an alternative. In short, FIX IT! Do something about it, and if it still doesn’t meet requirements, you may need to develop a completely new process. Data and analytics are making it easier to recognize problems, but execution is often a challenge. It is not enough to simply recognize the problem, you must develop a plan to overcome it.

    This can be tricky, because the various participants in a system may have different needs. The pathology department in a hospital cannot tell the insurance/admissions people how to go about their business. Still, the objective is to shorten the admissions process. Perhaps a position of “admissions expediter” could be established to oversee the process. When the insurance is processed, the expediter could inform the lab so that needed tests can begin immediately.
  • Measure and monitor. In this process, we identify leading and lagging indicators of success, set performance benchmarks, create a feedback system and start to document the results. All of this must be transparent, so people can know what the results are, compare and shop. Allowing the consumer to shop for value will fundamentally change the way the health care industry operates today.

    There are already a few measures in place to do this. The Centers for Medicare and Medicaid Services (the CMS) has implemented a program that tracks the performance of Medicare Advantage plans. Its “Star Rating System” provides a quality score to Medicare Advantage Organizations, rating them on a 5-star scale, 5 being the best performers.  Ratings are based on the plan’s performance on selected criteria.

    These defined criteria include member experiences, customer service (how well the plan handles member appeals), plan performance (how often Medicare found problems with the plan), staying healthy (did the patients get preventive measures to help them maintain good health) and managing chronic conditions. The five-star rating system makes it easy to understand which plans are providing good value.

    The government is making strides through this publicly available Star Rating System. It’s a good start, but we need more systems like this in place.


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