From Waste to Value in Health Care

The United States ranks among the worst of industrialized countries for indicators of health such as infant mortality and life expectancy,¹ despite spending $2 trillion annually on health care,² more than any other nation per capita. However, higher health care spending does not correlate with higher quality of care or better patient outcomes.^{3 - 5} These sobering indicators suggest that an opportunity exists to close the value gap in the day-to-day delivery of health care by eliminating actions that impede optimal systematic performance, which result in less than perfect outcomes, extra work, or corrective work, otherwise described as waste.

Patient falls and decubitus ulcers represent waste in the form of “never events” that create more costs and result in systemic dissatisfaction. Waste is illegible and incomplete prescriptions that consume technician, nurse, and pharmacist time and, at worst, risk the life of the patient. Waste is acute care hospitalization of patients with diabetes who received inadequate preventive care. Waste is failing to adopt evidence-based care. Waste accounts for 30% to 50% of health care spending.^{6 - 7}

Over the last 20 years, quality has become a widely shared mantra in health care but with few efforts to systematically define the exact size and nature of the opportunity to improve value. This situation is somewhat analogous to when a physician determines that a patient is ill but does nothing more to diagnose or treat the patient. A better or more accurate approach to taking advantage of the opportunity would be to produce detailed problem statements that permit a locally driven but nationally connected set of interventions to close the value gap.

Creating a map of such opportunity requires combining original observation, synthesis of work already performed, and extrapolations of localized results to the national condition. The map would be characterized by the amount of different types of waste and the calculation of the potential cost associated with that waste. For example, one part of the map would show how many hospital-acquired infections occur annually alongside of the associated direct and indirect cost. This requires having enough validated data to ensure that results represent the entire continuum of care and to estimate indirect costs.

Defining the opportunity and identifying ways forward are key elements leading to and supporting quality improvement efforts. This and subsequent problem solving requires the focused efforts of the quality improvement research community in concert with the constructive engagement of information systems managers, educators of health professionals, payers who can align incentives, and everyone involved in health care delivery, including public health and community organizations to catalyze improvement.

Considerable effort has been expended to make medical systems safe, effective, patient-centered, timely, efficient, and equitable. Results of these efforts are reported in various venues but infrequently published in peer-reviewed journals. Consequently, accounts of these efforts reach limited audiences, and a lack of documentation interferes with their credibility and dissemination. Embedding rigorous analytical components in quality improvement activities would serve to (1) generate credible data as byproducts of care; (2) document and quantify the extent of the opportunity for improvements; (3) promote willingness to embrace transparency of data; (4) identify effective interventions and build an evidence base for improvement strategies; (5) create convincing arguments for broad dissemination; and (6) overcome barriers, such as reluctance to invest in the necessary expertise and infrastructure to conduct quality improvement research. A rationale for gathering and publishing evidence regarding improvement efforts has been articulated.^{8 - 9}

A broad spectrum of research approaches are required to document outcomes (process and health related) of quality improvement interventions and the contexts in which they are carried out. Randomized controlled trials should be complemented by a variety of research designs as the science of clinical practice draws more heavily on social science methods, in which qualitative, observational, and quasi-experimental research designs are widely accepted. The difficulty of drawing definitive interpretations from uncontrolled observations and the importance of identifying patterns are also well-recognized in social science. Increasingly, research designs introducing rigorously controlled comparisons will be desirable. Outcomes of quality improvement interventions must be replicated to validate observations in diverse, well-documented contexts to expand the applicability of findings to a variety of settings. Summaries and meta-analyses are particularly valuable approaches for identification of effective interventions.¹⁰

In many ways, present-day quality improvement science can be compared with clinical research conducted 50 to 60 years ago. Observational reports filled the literature and randomized controlled studies providing crisp answers to important clinical questions were infrequent. Currently, the medical literature is replete with reports of controlled trials. Methodological approaches to clinical research have advanced remarkably over the decades. Biological discovery has broadened the range of pathways targeted by molecular interventions, expanding the options for specific and more effective clinical interventions. Quality improvement research methods will likely expand and develop in a similar manner. Special attention is needed for methodological problems arising from the reflexive nature of introducing change in social and organizational settings in which the “dose” is difficult to standardize and the “drug” changes to fit the needs and abilities of the context. Quality improvement research must be undergirded by a discovery process requiring contributions from scientists from multiple disciplines, including clinical medicine, social and behavioral sciences, engineering, and health services research. This discovery process would generate new targets for quality improvement interventions for which outcomes must be rigorously documented—just as in clinical research.

Quality improvement research, as a relatively new scientific discipline, is both undercapitalized and underfunded. Less than 0.1% of total health care expenditures is spent on health services research, not all of which focuses on quality improvement.¹¹ Institutions including medical colleges, hospitals, and specialty societies are just beginning to realize that quality improvement efforts and the ability to document the outcomes add value not only to clinical care but also to educational and research programs in the health care professions. Investments have been made, but not at the levels required for the field to soon advance with certainty. Funding agencies, such as Agency for Healthcare Research and Quality, were established to support health care services research and are very encouraging of quality improvement science but lack the dollars required. Public and private agencies that traditionally fund clinical research have been slower to respond. Recognition of the importance of quality improvement research by a broad array of funding agencies will be important, but adequate funding will only follow excellent science.

The numbers of individuals conducting quality improvement research must also expand. Formal training programs are few and far between and not yet attracting the numbers of trainees needed to advance the field.

Even with a clear statement of the opportunity to improve value in health care and strengthened quality improvement research, acceleration of the pace of quality improvement is not a foregone conclusion. Accelerated improvement requires rapid adoption of behaviors and practices to produce better outcomes and value. Such adoption is uncharacteristic of the current system and is not unique to health care. Few organizations truly act on the idea of continuous learning and improvement, for sustained change is exceedingly difficult.

Reasons not to engage in quality improvement are the same in most enterprises: too busy to do anything more, cannot afford it, different approach already in place, already in the top quartile or top 10%, need more and better people, and do not get paid for quality.

In health care, not engaging in quality improvement is compounded by reasons specific to the industry, including the following: quality improvement ideas cannot be applied to medicine because patients are heterogeneous; medical care is relational work requiring reflective professional practice; lack of knowledge about how to make changes in systems; medical center is a teaching hospital; medical center is not a teaching hospital; and if hospital administrators insist on strict adherence to quality improvement practices (eg, hand hygiene), independent contractors (physicians) will admit their patients to a different hospital.

These reasons are diverse, but all are a function of inconsistent leadership. Leadership should be distinguished from management, administration, and supervision. The critical work required of leadership is the creation of a blame-free culture in which every employee is expected to identify mistakes and participate in systemic change to prevent reoccurrence of the problem. Such a system requires curiosity, creativity, and transparency—the recognition of opportunities to improve, the constant pursuit of alternatives, and the open sharing of mistakes as near to real time as possible, with meticulous collection and analysis of data before and after the change. Leadership must also foster the integrated efforts of all contributors to the quality improvement effort.

Historically, programs of culture change are ineffective starting places. Mortality and morbidity conferences and periodic meetings of committees generally do not lead to systemic change. Successful, enduring quality systems ideally require the engagement of all who perform the work, identifying every problem as it occurs, followed by real time inquiry into the underlying causal networks and system redesign. These are not typical characteristics of current medical systems. Although this calls for radical change in the daily work habits of health care delivery, quality improvement research can only be impactful if individual institutions create the conditions necessary for rapid transfers of creatively designed, rigorously documented, and successful practice changes.

A credible opportunity map is needed to better direct future leadership. A focused nationwide effort should begin to create this map by documenting every process in a care setting to collect data that differentiate between processes that work correctly every time and processes that produce errors. In doing so, cost without value (eg, illegible or incomplete prescriptions) or cost with negative value (eg, improperly tended central lines producing nosocomial infections) would decrease. A similar networking approach to identifying, implementing, and demonstrating the benefits of the most promising improvement interventions should receive serious consideration.

Voluntary, independent networks of specialty registries can help clinicians see their work in a broader context and learn together. For example, the Cystic Fibrosis Foundation has set standards for practice at all funded care centers in the United States and tracks outcomes annually for each care center through its long-standing patient registry. Benchmarking and transparency across care sites has resulted in greater adoption of best practices and may have contributed to an impressive increase in survival nationwide.¹² The Vermont-Oxford Neonatal ICU Network has also used its registry to improve care for preterm infants.¹³ The pioneering work in Scandinavia, which has used population-based longitudinal databases for medical research since the early 1900s,¹⁴ also offers opportunities for learning. Going forward, there may be value in institutions creating their own networks, agreeing on efforts to accelerate change, and agreeing to rapid implementation of proven beneficial changes.

Now is the time to seize the opportunity to improve the value of health care in the United States. The value gap can be minimized with strategic, concerted efforts to reduce waste and improve health outcomes. These efforts will require leadership, long-term investment, and coordination among providers and researchers. Intrinsic to this activity is the need for all parties to support quality improvement research, generating an evidence base for effective improvements in health care delivery systems.