• Applying the Science of Quality Improvement to the Ophthalmology Practice

    Concerns about health care quality and cost containment have moved to the forefront in political debates about health care and federal and state budget deficits. Despite the U.S. health system’s proven ability to treat complex, serious illnesses, studies have shown that patients are not receiving basic, cost-effective care known to reduce death and disability, such as cancer screenings and diabetic eye exams. The care that is delivered is prone to errors and often inefficient.

    • For example, it has been reported that up to 98,000 people die annually as a result of preventable medical errors and that the chances of dying from an avoidable error are 10,000 times higher in a hospital than in an airplane.
    • In one study, 22 percent of patients in the emergency room had to wait more than an hour before they saw a doctor.

    There is a growing consensus among health care leaders and policy experts that changes are needed to both improve the quality and reduce the financial burden of the health care delivery system.

    Rewarding Value

    As a result of these concerns, we are beginning to see payment reforms such as the Physician Quality Reporting System (PQRS) and those included within the Affordable Care Act.

    These reforms shift payment away from a system that rewards volume to one that rewards value, where value is defined as the health outcome divided by the cost to achieve that outcome.

    Other trends focusing attention on the value of health care are

    • The greater autonomy and knowledge of patients seeking health care,
    • Increased demand for health care services by an aging population,
    • Increased competition among care providers, and
    • Reporting on quality and cost-effectiveness by a variety of organizations.

    Providers will face challenges in transitioning to a system that rewards value rather than volume and one in which funding in general may be more limited. It is no longer a question of whether a health care organization should focus on quality and its costs to provide care, but rather of how it can do so to ensure its survival.

    Improving Quality

    Continuous Quality Improvement (CQI) offers one such approach to improving quality and containing costs. CQI has its roots in the theory of Total Quality Management (TQM) as applied to Japanese, American, and other industries around the world. Early proponents of this school of thought included Walter Shewhart, W. Edwards Deming, and Joseph Juran.

    A central principle of this school involves the recognition of variation within processes, an analysis of the causes of the variation, and attempts to reduce variation and continuously improve processes and outcomes. Projects employing the Plan-Do-Check-Act (PDCA) methodology are used to improve processes.

    Other important tenets of CQI include a focus on the customer, the use of interdisciplinary teams, strong leadership, and the avoidance of individual blame for poor outcomes.

    It has been argued that health care organizations’ traditional approaches to quality have been unsuccessful and have typically relied on quality assurance mechanisms that focus on identification of outliers and conformance to standards.

    Advocates of CQI argue that traditional methods result in one-time goal accomplishments instead of the continuous incremental improvement that is necessary to make long-term quality gains.

    Thinking Lean

    Another complementary approach to improving quality and reducing costs uses the perspective of lean management.

    The essence of lean thinking is the elimination of waste to create value for the customer.

    The assembly line instituted by Henry Ford was one of the earliest modern examples of lean management. Ford’s system worked very well initially but was unable to accommodate the public’s desire for variety and customization. In the 1930s and in the years after World War II the founders of Toyota built on Ford’s approach to create the Toyota Production System, the major precursor of lean management.

    Lean systems, which the Japanese industrial engineer Shigeo Shingo studied, taught, and wrote about, focus on the flow of products to their completion. These systems incorporate the following principles/steps:

    • Understanding value as defined by the customer;
    • Identifying those steps in the value stream (the steps necessary to produce the product) that create value for the customer;
    • Making sure the steps flow continuously;
    • Making sure that the next step in the sequence initiates product flow (referred to as “pull”); and
    • Evaluating the value stream, removing waste, and continuing to improve the cycle until a state of perfection is achieved.

    The eight wastes (non-value-added activities) that are targeted for elimination include defects, overproduction, waiting, non-value-added processing, transportation, inventory, motion, and employee underutilization.

    Applying the Principles to Health Care

    One might argue that the theories of CQI and lean management, which were originally described and applied in large industries, have little applicability to quality improvement efforts in ophthalmology practices.

    After all, ophthalmologists are not factory workers, and patients are not widgets.

    However, even a relatively small operation, such as a physician’s clinic, involves many processes that comprise patient care. These include:

    • Scheduling appointments and reducing missed appointments,
    • Patient check-in,
    • Examining the patient,
    • Performing ancillary studies,
    • Documenting the encounter,
    • Billing and collecting payment for care, and
    • Filling spectacle and contact lens corrections.

    Similarly, cataract surgery at an ambulatory surgery center involves numerous processes, from scheduling, registration, pre-surgical evaluation, the surgical procedure, post-surgical evaluation and checkout, documentation of the medical record, to coding and billing.

    Virtually all of these processes within a clinic or surgical center can be improved by simplification and reduction of waste and rework.

    A number of leading health care organizations have adopted the principles of CQI and lean management because those principles represent a way of thinking that is as applicable to the health care industry as it is to the manufacturing sector. Only the outcome differs: a healthier patient rather than production of an automobile at a lower cost.

    Asheville Eye Associates is a 17-doctor office (13 ophthalmologists and 4 optometrists) with 125 employees serving patients at eight locations in western North Carolina. The practice has been using the principles of CQI and lean management to improve quality for the past decade.

    More recently it has employed these principles as part of an overall program of performance excellence using the management infrastructure provided by the Baldrige health care criteria. The Baldrige program is a public-private partnership devoted to promoting an integrated approach for organizations to deliver value to their customers. Our organization has participated in evaluation using the Health Care Criteria for Performance Excellence through our state program, the N.C. Awards for Excellence. Managers in our organization have participated as examiners in this program. Our utilization of these principles and participation in this program have improved — and continue to improve — processes throughout the practice.

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    About the Author

    Robert Wiggins, MD, MHA specializes in pediatric and neuro-ophthalmology and is the physician administrator of Asheville Eye Associates. He is also on the AAOE Board of Trustees and co-chair of the AAOE EHR Committee.