.png)
Up until the 1980’s and 90’s,American manufacturing operated based on a system of identifying defects that fell outside of preset quality limits. After manufacture, measurement enabled inspectors to sort the defects (scrap) from quality production.
A company that successfully identified “defects” resulting in piles of scrap was applauded for excellence in manufacturing. If you wanted to improve quality, add more inspectors.
The system, however, was flawed. Within the preset quality limits there was still a great deal of variability. When the parts manufactured under this system were assembled into the final product, the fit was not optimal. When a car door was closed, there was often a clank versus the distinct sound of a perfectly fitting door. Perhaps more importantly, the waste associated with piles of scrap and rework added cost to the product.
The sad reality is that this contributed to the myth still widely held today that high quality equals high cost when in fact the opposite is true.
Enter Japanese manufacturers who had been known for the worst quality products in the world.
Post World War II, American statistician W. Edwards Deming and others taught Japanese industry leaders a system of management that included continuous measurement over time. The focus was on reducing variation around the desired target rather than sorting scrap that fell outside of predetermined defect limits.
Eliminating waste was an obsession and smart business decision. Not only were the products of higher quality—the unique sound when a car door is closed—but they cost less. Higher quality equals lower costs.
In June 1980, NBC News presented the NBC White Paper, “If Japan Can, Why Can’t We”, and over the next several years US manufacturers began to take seriously the teaching of Deming and others. The quality of American manufacturing began to improve and over time has become competitive on a global basis.
Twice I had the opportunity to participate in Deming’s four-day seminar and one of our consultants at Executive Learning, the firm I led at the time, was an RN who traveled the world with Deming as an assistant—he was in his 90’s and still doing his standard four-day seminar.
At Executive Learning we had been working with manufacturing and literally walked off the manufacturing floor into a very large healthcare provider organization to support the introduction of this system in healthcare. We were privileged to work with Dr. Paul Batalden, who was head of the Quality Resource Group at HCA, and Dr. Don Berwick, who was leading the National Demonstration Project on Quality Improvement in Health Care that became the Institute for Healthcare Improvement as this new management system was adopted in hospitals and healthcare system across the country.
While continuous improvement is now applied extensively, our healthcare system is still primarily a fee for service, sick care system. The argument has been that healthcare is different. The unique payment system and complex regulatory environment insulate healthcare from external forces, and to some extent that is true. It remains a system marked by unacceptable defect rates, high costs, and low margins.
Transformation is required. While improvements have been made, improvement of a fundamentally flawed system is still a fundamentally flawed system.
As we emerge from the public health emergency, perhaps a fresh look at measurement in the context of what Deming taught us, but now informed by new insights learned during the pandemic from remote patient monitoring, will help us finally transform the system.
One gift from the pandemic was the validation of the value of remote patient monitoring. Monitoring and measurement are not new in healthcare. There is of course continuous monitoring when a person is hospitalized. Consumer products that enable monitoring have been on the market for health conscious and tech savvy individuals for sometime. And remote patient monitoring by healthcare organizations has been on a slow adoption curve.
Rather than being seen in a clinic or admitted to a hospital, telehealth visits and remote monitoring ofCOVID patients became an important part of the response to the public health emergency. It brought attention to this form of measurement and has served to bring it to the forefront of the new and emerging models of care delivery.
This validation of how monitoring and measurement can be used offers promise for the fundamental transformation of healthcare—a transformation of the payment system and movement from sick care to health.
Today most measurement in healthcare is more like pre-Deming measurement for the purpose of inspection in manufacturing than measurement for continuous improvement. For most of us, measurement only occurs when we are sick or when we go in for our annual physical. The objective is to identify defects (scrap), not continuous improvement of health.
When I open my healthcare provider’s online portal and look at the results of my last comprehensive metabolic panel (inspection results), I am happy to report that only one value is outside of the “standard range” and only slightly. Of course, several, like the parts manufactured under an inspection system, are bumping up against the predetermined limits.
Our sick care model of healthcare is driven by episodic measurement to identify illness or defects. This identification of defects leads to clinical encounters to address the defects.These encounters are generally paid for on a fee for service basis.
The validation of remote patient monitoring offers the opportunity to move to a system focused on health driven by continuous measurement. Like manufacturing, the purpose is not to see if values lie outside of preset limits but to reduce variation around health targets. The goal is to continually improve health paid for on a value basis.
While remote patient monitoring can be a driver of transformation, the name itself reflects the paradigm shift we must embrace. The term “remote” implies that collecting health data is normally done in a doctor’s office, clinic, or hospital. And “patient” implies we collect the data only when a person is sick. Perhaps we will soon find a better term like simply “health monitoring”.
The pandemic changed a lot of paradigms forever. Many argue that fee for service reimbursement is the driver of our sick care system. Lessons learned years ago in manufacturing and more recently insights from remote patient monitoring suggest that we should take afresh look at measurement.
While healthcare leaders and patients should be alarmed that healthcare still operates under a system abandoned by manufacturing years ago, we now have a unique opportunity to transform the monitoring and measurement system and transform healthcare.