To have a meaningful discussion on improving health care delivery, one must first understand both how the individual components of health care systems function and how they interrelate. In my view, too much of health care today is still a “black box.” Things go in, things come out, but there is little or no visibility into that system. This is why I argue that for real improvement to occur, there must be clear visibility across the entire enterprise. The Department of Veterans Affairs (VA) has made and continues to make significant strides in achieving such visibility.
Well-meaning efforts at improving health care delivery can easily miss their mark. The corporate re-engineering movement that began in the early 1990s, including seminal work by Michael Hammer and James Champy, makes the point that one of the worst things that can happen to a system is to re-engineer an unneeded process. Why? Because what you end up with is a really well-engineered, unneeded process, and in doing so you consume time and precious resources.
In health care, we must focus on rethinking everything we do, and then, using the principles of systems engineering, make health care systems function better and more reliably. However, we should not expend effort and resources to redo things that do not need to be done in the first place. The current health care environment is focused on “find it faster, fix it better,” and while necessary in certain areas, this is not sufficient to engender real health care reform; and where we do this, the efficiencies garnered from such efforts need to be reinvested in prevention and wellness.
Even in very chaotic environments, the key to success is well-prescribed team-based care delivered in well-engineered systems.
What can health plans and provider organizations learn from the Veterans Health Administration (VHA) about improving health care delivery? Our experience points, to three key principles: building healthy health care systems; leveraging the interdependence across organizations; and shifting toward sustained provider-patient relationships rather than just encounters.
1. To ensure healthy patients, you must have healthy health care systems. In other words, to deliver true evidence-based care, evidence-based management is necessary to support it. Information, of course, is the key. If information is important enough that it is needed to manage the patient or the system, then it must be acquired as part of the workflow process; we call that transactional quality and management. Real-time data is required for true systems improvement in health care, and in the end, better information will lead to better decisions and, in turn, to better health.
Success in health care delivery is predicated on very principled processes. For instance, why is cardiopulmonary resuscitation successful? Because it is highly codified, taught with high consistency, team-based, and everybody knows their roles — in this way it is similar to space flight. Sometimes the greatest threat to proper procedure in a cardiac arrest is the temptation for fellows and residents to defer to authority when an attending arrives rather than to rely on the role-based processes they have been rigorously taught.
Even in very chaotic environments, the key to success is well-prescribed team-based care delivered in well-engineered systems.
A driving principle in health care reform is the recognition that systems should be built around patients, rather than continuing to have patients adapting to the system. To give a personal example of what needs to change: A family member went to the emergency department on the advice of her primary care physician, whom she consulted by telephone, and was admitted to the hospital. About a month after discharge, when seeing that doctor for a follow-up visit, she was asked, “So whatever happened a while back when you called me?” This dissociation between the inpatient and outpatient environments is but one of the disconnects we commonly see in health care today. There is little true continuity of care because there is so little coherence and sharing of health information. A truly patient-centered system would ensure optimal health through alignment of both patient needs and the health data that supports informed decision making.
As I see it, one of the goals of the accountable care organization envisioned in health care reform is to create a focus of responsibility to ensure true continuity. The ability to provide that level of continuity is one of the reasons the VA system is as good as it is, and this is directly attributable to the very robust electronic health record (EHR) called VistA.
Case in point: there is a resurgence in emergency medicine in the VA. Despite an initial concern that it would be difficult to hire board-certified emergency medicine specialists, it turns out that the two things emergency department doctors dread are that they don’t know what type of emergency is coming in, and they don’t know where the patient is going when he leaves. As a result of both the availability and breadth of information through VistA and the continuity of care it enables, in VA emergency departments we know almost everything about our patients coming in, and we know where they are going for follow-up. If a patient needs to be seen tomorrow, he or she can be seen tomorrow. That is a very important consideration for any clinician working in urgent and emergent care. For primary care providers, the coherence of health data through VistA is seamless and allows visibility into all the care received within the VHA system.
2. Interdependence must take precedence over the fragmentation of “silos.” As part of VHA’s current reorganization, we are taking apart entrenched silo structures and rebuilding them as logical associations. For example, we have long been a very data-rich organization, but we had multiple data systems, in addition to VistA, across the organization. As a result, if you were to ask the same question of different parts of the organization, you could get different answers. Bringing all the data and analytical capability together became crucial in ensuring both consistency and the capability to transform data into effective information. We have made great strides in that direction; more importantly, the ability to put that information to productive use is the foundation of our transformation to a knowledge-driven learning health care organization.
When looking at organizational design, we tend to focus on the “org chart.” When reorganizing a system, it can be quite uncomfortable for some staff when their box on the chart gets moved. But it is important to remember that work does not get done in a box — the box just delineates the structural hierarchy (e.g., who pays the salary). The real work gets done outside the box.
With the reorganization, our mantra has been to “get out of the box and work in the white space.”
Interestingly, there is now the capability to actually map these interactions across organizations, evaluating individual and team effectiveness by identifying who connects with whom and at what frequency. These capabilities have become so sophisticated that they can actually determine the hubs — positive hubs of production and negative hubs of obstruction.
I find it fascinating that the most positive hubs are not necessarily in senior leadership positions. This has very powerful implications for organizational productivity, and especially for how improvement is driven in organizations.
As I mentioned earlier, we need to build health care systems that are centered on the patient. How do we put the focus back on the patient? One thing we are doing at the VA is restructuring our quality programs. We were concerned that quality had stopped being about the unique patient and had become instead a statistical function. Quality should inform the system, but from the perspective of patients, their loved ones, and caregivers, quality is about only one patient. The focus on each and every patient has resulted in a big shift toward a focus on safety, which is fundamentally driven by the prevention of harm. This gives us a huge opportunity to have a positive effect on how we organize systems and on operational matters.
Rather than dealing with the notion of quality as a statistic, this shift forces us to build “mindful” organizations strongly focused on patient-centered outcomes. We need to operate on the same principles of high reliability that high-risk organizations demand. When we do that, my best guess is that about 85 percent of this thing we call health care is really driven by ensuring that the systems operate with high reliability. When that happens, the time that we spend directly with a patient becomes of immense value; unfortunately, the opportunity is lost when we squander that precious time apologizing or compensating for systems that are inefficient or ineffective. Only when health care systems work with high reliability will the art of medicine truly flourish.
3. Health care must change from being about the encounter to being about a sustained relationship. This is a fundamental goal in transforming the VA health care system. When we achieve this, we will have built a foundation of prevention and wellness for the trusted supporting relationship that is crucial when people become ill or are injured.
We presume that a relationship-based model is correct, as it is the basis for the historical principle of continuity of care. Health care training in this country today — our medical schools, our residency programs, our fellowship programs and every educational encounter we facilitate — is built around the construct of the provider as the focus for continuity of care. But is continuity of care a provider function, an informatics function, or a personal responsibility? While I do not know the answer, I do think that continuity of care solely as a provider function is not necessarily a very patient-centered construct.
In the personal example I used previously, there was little continuity among providers because there was no continuity in the flow of crucial health information across the system (in this case from inpatient to outpatient). That responsibility defaulted to the patient because the system failed to provide it. I believe that as health information becomes more accessible, people will increasingly take it upon themselves to manage their health information, and the health care world will change very quickly. Continuity of care will become fundamentally an informatics function that will be controlled by the patient or a surrogate, and the relationship with health care providers will shift from one of dependency to one where we, the providers, are invited participants into a patient’s care.
The primacy of the face-to-face office visit — which is very time-intensive and thus costly for the provider, staff, and patient — will also change. Often patients have just a single question they want answered. For this reason, secure messaging has immense potential, especially when time to convey information is more important than scheduling face-to-face access. When patients get their labs done, they do not want to wait until the next visit six months later to learn the results — they want to know the next day. If patients can access their data in a way that is understandable and also provides a secure vehicle for returning and asking questions of their providers, that becomes a very enriching transaction.
So much goes on in a patient’s life outside of the visibility of the health care system that having access to some of that information could inform health care decision making. Improving access is not just about scheduling face-to-face visits; it is about using those face-to-face visits well — and the time between them, too. Regardless of the modality used (home tele-health, e-health, mobile applications, secure messaging, etc.), the ability for the patient to be engaged with the health care system — to have a sustained relationship that supports health and well-being — is most important. I believe the future of health care will be defined by connected health and its ability to improve information, decisions, and health.
The Veterans Health Administration is strongly committed to leveraging all the capabilities available to transform health care into a model that is personalized, proactive, and patient-driven. Managing the system through the sound principles of systems engineering and improvement science will allow us to deliver evidence-based care with high reliability, which in turn will allow the art of medicine to flourish. This, along with incredible opportunities coming through connected health, will foster patient engagement and empowerment, and will lead to better health and well-being.