- Email: [email protected]
Achieving breakthrough outcomes: Measurable ROI
Achieving Breakthrough Outcomes: Measurable ROI
Fredric I. Orkin, PE, and Sylvia Aruffo, PhD
Y
ou’re a case manager. Your boss is talking return on investment (ROI). Your patients don’t want to be numbers on a spreadsheet. What does it take to be a hero to both the boss and the patient? Case managers frequently try to argue that great gains in quality of life for the patient are so valuable that management ought to ease up on case managers when talking about budget and returns. An experienced quality professional might respond, “Good luck.”
You may hit a sympathetic boss now and then, but lobbying for outcomes without ROI is not a sustainable approach to justifying a case manager’s work. What does it take to achieve breakthrough improvements in outcomes while achieving measurable ROI? Other industries are way ahead of health care on this track. They have a proven and effective approach: quality assurance. TCM 50
September/October 2006
A History Lesson After the Second World War, Dr. Edward Deming went to Japan. Japanese industries had been bombed out, and their reputation was for cheap quality. Deming introduced process control with breakthrough results: many of us today are driving Japanese cars and using Japanese cameras, phones, and television sets. Deming defined quality in manufacturing. You may have been
unwittingly introduced to Deming in your case management training; he was the inventor of the “plan-do-study-act” system of total quality management. If you control the process, you have achieved quality. The problem for case managers is that Deming is now two generations behind. After Deming came Phil Crosby, who coined the phrase “zero
8020
Processes evolve: incremental improvements
Only a few projects will bring BREAKTHROUGH IMPROVEMENT
The
comes and dollars. The useful many quality-improvement projects look for change in limited portions of the process, not the final outcome. If you aren’t measuring your project with dollars, you’re probably not working with one of the vital few.
VITAL FEW vs. the USEFUL MANY
defects.” He pulled attention away from inspectors at the end of an assembly line and focused on initial specifications for products. Quality is meeting specifications. If you meet the specifications, you have achieved quality. Control the process, meet the specs, and you have quality. Adding the second idea to the first was another breakthrough, but both sets of ideas applied only to manufacturing. Joseph Juran is the father of modern quality. The top US quality award may have been named for the secretary of commerce, Malcolm Baldridge, but the standards for winning that award are Juran’s. He came forward to redefine the concept of quality as fitness for use. That is, fitness for customer use. Only if your product is fit for customer use do you have quality. That insight revolutionized the concept of quality. Quality relates not just to factories but also to customers and to the fitness of products to be used by those customers. Anyone who has customers should be concerned about fitness for use of the products. To emphasize quality as responsiveness to customers, he renamed quality control quality assurance. Control is something involving only manufacturing personnel. Assurance is something you give a customer. Other fields—even service industries—started to pick up the concept. Banks, accounting firms, and hospitals started to have quality-assurance staff and departments—all from redefining quality as fitness for use. Juran gave us a number of other new ideas. For an organization to move from lower quality to higher quality, of course they must change. Engineering recognizes evolutionary change and revolutionary change, incremental and break-
through. Once a basic production process is created, whether it produces goods or services, changes begin. Small improvements are almost inevitable: a tweak here, a tweak there, and things become a little faster, a little easier, a little better. Evolutionary steps. Juran challenged us, however, not to be satisfied with incremental change but to be actively developing change strategies to bring about revolutionary change and breakthrough improvements. How can you tell if a project you are working on will result in a small, incremental change or in a grand leap forward? Juran said we’ll measure it in dollars. Incremental change causes 15% or less improvement in ROI. If you can see that your project could bring more than 15% improvement, you’ve got a shot at breakthrough. If your organization doesn’t have projects that could create that much of an impact, you should get busy and design one that will. Juran wasn’t trying to say that the myriad incremental improvements going on all over an organization weren’t worth doing, although he made a misstep when he initially called those projects the “trivial many.” He quickly changed the label to the “useful many.” Juran challenged us to see beyond the useful many to the vital few. He pulled a concept from a 1930s thinker who was then relatively obscure, Wilfredo Pareto. It’s because of Juran that we refer to “the 80/20 rule.” It was Pareto’s principle, but it was Juran who taught it to us as 80/20, the useful many versus the vital few. The Juran Quality-Improvement Cycle So how do you identify those vital few projects that will bring breakthrough improvement in outcomes and ROI? As a first step, Juran tells us to make sure our project does in fact measure out-
The second step is to conduct quantitative research to find out where these dollars are today. Don’t be distracted by Juran’s using the word research. He is a professor, after all. Think “count” or “measure.” If you make friends with the bean counters, it can be pretty easy to get the numbers you need. Get the baseline. Know what the target number is to improve. This may seem obvious, but it’s not always well accepted in health care. A PhD nursing director at a major Midwestern cancer center was once asked to lead a quality-improvement project. She shrugged off the need to do a baseline measurement. When asked how she would be able to tell if the project had an impact, she answered, “Oh, I’ll just know.” Don’t be like this manager; get the baseline. Next, conduct qualitative research to come up with the functional requirements for your product or service. Functional requirements come from studying how customers use (or don’t use) products and services. In manufacturing, when they design a new product or modify an old one, they draw a flow diagram with boxes that show every interaction of the customer with the product. Then for each box you ask, “What are the requirements for the product when the customer uses it at that time and in that place?” That includes all aspects of the product. It might start with the packaging and then go to the type of power supply, how you turn it on, how it sits, on what platform, and so on, in excruciating detail. It should be clear that you can’t make this diagram if you don’t know much about how, where, and when your customers use your product. In every field, we make assumptions as to how customers use our products or respond to our services. When we learn first-hand, through qualitative research, what our customers actually do, think, and believe, we often are shocked. QualitaSeptember/October 2006
TCM 51
Figure 1.
Juran Quality Improvement Cycle
START HERE
CHOOSE THE VITAL FEW CHOOSE ROI PARAMETERS
CONDUCT QUANTITIVE RESEARCH RUN INTERVENTION (RE-MEASURE)
CONDUCT QUANTITATIVE RESEARCH GET BASELINE
CONDUCT QUALITATIVE RESEARCH
INSPECT TECHNICAL REGULATORY
DESIGN INTERVENTION
Figure 2.
Quality Improvement Projects Initial Hospitalizations Aspirin at Arrival for AMI Readmissions within 30 days HA1c Tests for Diabetes Inbound Calls for Repeat Information LVF Assessment for Heart Failure Antibiotic 1 hour before surgery After-Hours Calls for Rx refills Initial Antibiotic Timing for PNE
tive research on fitness for use in the customers’ hands exposes a good many of our assumptions as false, as roadblocks to better outcomes. At this point we need definitions with regard to quantitative and qualitative TCM 52
September/October 2006
How many? How many received; how long wait? How many? How many received? How many and how long? How many received? How many on time? How many? How long was the wait?
research, because many of us have assumptions that are holding us back from breakthroughs. Qualitative and quantitative are not alternative ways of measuring results. Only quantitative research tells you results, in numbers, of the impact of an intervention. But where
does the idea for the intervention come from? Does it just pop magically into someone’s head? Ideas for interventions come from qualitative research, exploring the customers’ world. What you discover about the end user tells you how to intervene. If we scorn qualitative research as simply a less rigorous or less reliable way to measure something, we will never be able to tap into its power. Qualitative research enables us to systematically improve quantitative outcomes. To begin the quality-improvement cycle (Figure 1), choose a project for which you measure outcomes in dollars. Get a baseline measurement. Then conduct qualitative research to find the requirements to make the product fit for the customers’ use. On the basis of those discoveries, design the intervention. Before you can implement, however, the intervention design must pass inspection. Every industry is burdened with demands from government or regulators. Juran called these nonfunctional requirements. They are absolute requirements, even though many are arbitrary. If you don’t meet them, you can’t go to the market. These are the guys with the checklists: labeling standards, packaging standards, engineering standards. You have to meet those standards, but they don’t tell you if your product actually works. The checklists are nonfunctional requirements. The only way you know if you have met the customers’ functional requirements is to run the intervention and measure the results. Then the cycle begins again: more qualitative research, another invention, a new inspection, and another measurement. This is continuous quality improvement. If you measure dollars and conduct qualitative research, you have a solid chance of breakthrough ROI—that is, better than 15% improvement—many times over. Applying Juran to Case Management The Centers for Medicare and Medicaid Web site has a list of measures that the government imposes on health care; each one implies quality-improvement projects. The shaded box in Figure 2 lists some areas. We’d like to think that the drafters of the list intended that if we all meet these standards, we will have
breakthrough improvement. Look closely at the items. Which ones are measured in dollars? None. But some of them are closer to dollars than are others. The initial hospitalization admissions we eliminate by good case management translates directly into dollars. Readmissions also convert easily into dollars. So does reducing inbound calls, taking into consideration the value of staff time in dollars. The ones on this list that translate quickly into dollars are the vital few. Others, like giving an aspirin on arrival at an emergency facility, are more distant from outcomes, and the dollar calculations more uncertain. Still others, such as ensuring that diabetic patients receive hemoglobin A1c tests, have no direct connection to a change in outcomes. The farther the measure is from outcomes, the more likely it is one of the useful many. Simply being on this list has dollar implications. If we give patients A1C tests, we get paid. An economist would call that a “market distortion.” Quality improvement does not directly create dollars (like a pool for rewards), but you get paid anyway. Getting paid for process rather than outcome clouds the picture of which projects truly bring breakthrough. Distortion keeps us ranking lesser projects in the same category with important ones. An even bigger problem with market distortion is that it can prevent us from achieving breakthrough. Say I’m getting my pay-per-performance for giving aspirin. A brilliant inventor comes along and says, “I have a new drug that is proven to work better, faster, smarter— it’ll even prevent repeat attacks!” I look at my list of pay-for-performance items and say to him, “Sorry, I get paid only for giving aspirin. I don’t get paid for outcomes. Goodbye.” We have just cut ourselves off from an innovation that could give us breakthrough. Another characteristic of vital few projects is that they allow maximum latitude for creative intervention. We have to be careful about quality-improvement projects that lock us in to today’s processes, even if those processes are today’s best evidence-based protocols. A few years ago, the dean’s welcome
Qualitative research is the source of ideas for innovation. Unfortunately, health care and especially service providers know very little about qualitative research. speech at Tufts Medical School warned the incoming students that “half of what we teach you today, by the time you graduate, will have been proven wrong. The trouble is, today, we don’t know which half.” Pay for performance, by locking in today’s processes, could make innovation much more difficult. Qualitative Research: The Unfamiliar Step in the Cycle Qualitative research is the source of ideas for innovation. Unfortunately, health care and especially service providers know very little about qualitative research. An old but still wonderful book, Through the Patient’s Eyes,1 calls for qualitative research: “We need to develop systematic, appropriate and effective ways to find out what patients need and experience.” The book also criticizes: “Providers are remarkably unsophisticated about methods of eliciting information from patients … not only a lack of familiarity with methods, but a fundamental and widespread resistance to researching the patients’ perspective.” That was 1993. There’s been progress since then but not a lot. Back to industry for some lessons: Maytag, Chrysler, Intel, and Procter & Gamble, for example, know an enormous amount about end users. Pepsi-Cola knows more details of customers’ context than we know about patients’ daily lives. They spend time and money collecting user insights. One major way they do that is with a set of techniques called ethnography. Few people in health care are familiar with it. Health care knows focus groups. You have probably been in some yourself. It may surprise you to learn that industry has largely left focus groups behind because they have pitfalls. In a
focus group, you pull people out of context. You are entirely dependent on what they are aware of back in their context, what they can remember during the meeting, and what they are willing to say in front of their peers and in front of you, an authority figure. Malcolm Gladwell, author of The Tipping Point,2 has said he would like to see a constitutional amendment against focus groups because they can be so misleading. In a focus group, the participants are all dressed up and on their best behavior. What we really need to know is what they say and do when you’re not there. We need observation in context. “Observation in context” is ethnography. Instead of bringing people in to the researcher, you send the researcher out to people’s homes, workplaces, communities, wherever they’re using your product or your service, and see how your input fits or doesn’t fit— use in context. Ethnography What does ethnography do for other industries? If you go to the Web site of the New Product Development and Marketing Association, you see “ethnography is the state of the art in new product development.” The consumer products division of Procter & Gamble writes, “Everyone knows what a powerful tool ethnography is.” Shane Wall, general manager of new product development at Intel, declares he wouldn’t consider starting on a new product without doing ethnography.3 Here are some quick examples of what ethnography can do. Sales for the Nissan Pathfinder had been completely flat for 10 years. The company decided to redesign the vehicle. But they didn’t do focus groups, asking users, “How should we redesign this van for you?” What would you say if someone asked you that? What Nissan did instead was to hire ethnographers. They sent researchers out to shopping mall parking lots to videotape the soccer moms coming out of the stores with shopping bags and kids and a coffee cup and stroller and Grandma waiting in the car and the dog bouncing around. The ethnographers went back to Nissan with this rich data set. The industrial designers analyzed in excruciating detail things like how far the door should open before it catches and holds, whether September/October 2006
TCM 53
it should slide or swing open, how much space it needs between the front seat and the back, and so on. The redesigned Nissan Pathfinder doubled sales. When Pepsi bought Gatorade, they hired a firm that does ethnography only for hand-held products. They took video cameras to sporting events and construction sites to watch people drinking. From the insights the researchers brought back, Pepsi designers made the top of the bottle oval so it fits the shape of your mouth. They re-engineered the hole so the flow rate of the fluid would be exactly right to accommodate swallowing while running—and so on. You might think that a mature brand such as Gatorade couldn’t make a dramatic leap forward in sales, but when the newly designed Gatorade bottle hit the shelves, sales went up 23%. How is health care doing on understanding the functional requirements in the context of patients’ use? In a product development meeting with a major health-care manufacturer, the top two marketing vice presidents said they had each worked for the company, marketing ostomy products, for over 10 years. So it was somewhat surprising when the two resisted viewing a photo of a stoma. The presenter stopped, puzzled. “Could I ask … have either of you ever actually watched a patient change an ostomy bag?” “No,” they replied, “but we’ve done focus groups.” It’s not likely this company will achieve breakthrough improvement in product design. Observation in context allows us to design interventions on the basis of evidence. We chose clinical protocols according to evidence-based medicine. We should design our quality improvement projects on the basis of evidence from the users’ context: evidence-based design. Here’s an example: as cited earlier, health care is beginning to use ethnography. Imagine a hospital that wanted continuous quality improvement in patient safety. They made some progress but wanted to launch a project in the cardiac cath lab. The clinicians there protested: “We’re doing everything we can already; everything we do is aimed at patient safety.” The quality-assurance (QA) people hired an ethnography firm to observe procedures in the lab. What they found was that there was only one person in TCM 54
September/October 2006
the lab who could interrupt or stop a procedure. All the clinicians did whatever this person wanted; it was the staff worker who prepared the documentation for risk management. At one point, the entire procedure was halted, the patient lying there on the table while the staff worker cleared a paper jam. When the ethnographers came back with their report, the QA department said, “Before we can move forward on patient safety, we’ve got to make the clinicians feel safer themselves. We’ll need new hardware and software for documentation.”4 Another new application of ethnography in health care can be found in Humana. The Wall Street Journal5 said Humana has hired ethnographers to generate insights for designing a consumer-directed health plan. The ethnographers, “experts at studying people in natural settings, shadowed people in their homes for 18 months to see how they make decisions about health care … ethnographers don’t ask questions; they watch and see what happens. They observe natural behavior and experience the context.” Whatever quality project you initiate, you will be on the fast track to improve your quantitative outcomes if you do qualitative research before designing your intervention. Observe the context of the people whose behavior you want to influence. Find out what you have to do to help them change. An Overlooked Area to Which to Apply the Juran Quality Cycle Juran’s principles apply to every quality initiative. If readers adopt the steps of the cycle for any project, this article will have served its purpose. But there is one area of health care where the steps of quality improvement have not yet been applied and to which most healthcare providers have not yet realized they could apply them. The one area that may produce the greatest ROI is engaging the patient in self-care. If we can accomplish this, our ROI will improve exponentially, because successful self-care achieves outcomes at no cost to the provider. Patient communications, by themselves, should be measured for their impact on outcomes: how many hospitalizations can
be eliminated by the use of materials with evidence-based design (as distinct from evidence-based clinical content)? How many fewer telephone calls can the call center make if patient education materials reflect the patients’ context? How much earlier might a patient be willing to leave the hospital if the materials were developed through all the steps of the Juran quality cycle? Let’s be very clear that approvals— whether from our local patient education committees, URAC, Joint Commission on Accreditation of Healthcare Organizations, or by a checklist for health literacy—are precisely what Juran calls nonfunctional requirements. All too often, providers write materials not for patients but for the approval bodies. This tends to be particularly true when writing letters that go to Medicare or Medicaid recipients: we write for government approvals and stop there. But those approvals don’t tell us anything about whether our writing actually inspires people to take the action we want. They don’t tell us whether our materials work. Health care has never measured whether the materials by themselves work. Do we have an impact when there is no professional involved (that is, a professional is neither present, nor on the telephone, nor at the other end of an in-home technology monitor)? We should get today a baseline on the impact of our materials. Then we should conduct qualitative research to find out how our materials are used—or not. The purpose of the intervention is to revise the materials on the basis of the findings. Of course they must meet standards, but as Juran said, “You can’t inspect in quality.” We have to press on to the last step in the cycle, to measure how much we have improved the patients’ outcomes with the new materials. If you’re like most case managers, you’ll be skeptical that materials by themselves can have an impact. Let me tell you the story of a patient with coronary artery disease. He said he asked his doctor, “What is cholesterol?” The doctor responded, “No problem, here’s a tear sheet from the American Heart Association.” The patient didn’t understand it. He thought, “My father has coronary artery disease, too. He
Figure 3. American Heart Association Handout What are High Blood Cholesterol and Triglycerides? (continued)
What are triglycerides?
Title looks like a patient question but is not how patients talk
Triglycerides are the most common type of fat in your body. They’re also a major energy source. They come from food, and your body also makes them. High levels of blood
What are High Blood Cholesterol and Triglycerides? Cholesterol is a soft, fat-like substance found in the bloodstream and in all your body’s cells. Your body makes all the cholesterol it needs.
Picture elements are not labeled
The saturated fats, trans fats and cholesterol Definitions ofyour cholesterol you eat may raise blood cholesterol level. Having too much cholesterol in your blood and triglycerides are may lead to increased risk for heart disease vague and uncertain. and stroke. About half of American adults have levels that are too high (200 mg/dL or higher) and about 1 in 5 has a level in the high-risk zone (240 mg/dL or higher). The good news is that you can take steps to control your cholesterol.
lipoproteins
There are different kinds of fats in the foods we eat. Saturated fat is the kind that raises blood cholesterol, so it’s not good for you. Avoid animal fats like lard and meat fat, and some plant fats like coconut oil, palm oil and palm kernel oil. Trans fat comes from adding hydrogen to vegetable oils and tends to raise blood cholesterol. It’s used in commercial baked
oils and fish oils. These tend to lower blood cholesterol. Monounsaturated fats are found in olive, canola, peanut, sunflower and safflower oils. In a low-saturated-fat diet, they may lower blood cholesterol.
How can I learn more?
Cholesterol travels to the body’s cells through the bloodstream by way of lipoproteins.
Caption under the picture is ambiguous
What’s so bad about it? Cholesterol and other fats can’t dissolve in your blood. To travel to your cells, they use special carriers called lipoproteins. Lowdensity lipoprotein (LDL) cholesterol is often called “the bad kind.” When you have too much LDL cholesterol in your blood, it can join with fats and other substances to build up in the inner walls of your arteries. The arteries can become clogged and narrow, and blood flow is reduced. If a blood clot
Definition of triglycerides goods for cooking in most restaurants cannot beandmeaningfully and fast-food chains. It’s also in milk and distinguished from that beef. Polyunsaturated fats are found in vegetable of cholesterol.
What about fats?
No title on the picture cholesterol
What is high blood cholesterol?
triglycerides are often found in people who have high cholesterol levels, heart problems, are overweight or have diabetes.
forms and blocks the blood flow to your heart, it causes a heart attack. If a blood clot blocks an artery leading to or in the brain, a stroke results. A “good kind” of cholesterol, on the other hand, is called high-density lipoprotein (HDL). It carries harmful cholesterol away from the arteries and helps protect you from heart attack and stroke. It’s better to have a lot of HDL cholesterol in your blood.
1. Talk to your doctor, nurse or other healthcare professionals. If you have heart disease or have had a stroke, members of your family also may be at higher risk. It’s very important for them to make changes now to lower their risk. 2. Call 1-800-AHA-USA1 (1-800-242-8721), or visit americanheart.org to learn more about heart disease.
3. For more information on stroke, call 1-8884-STROKE (1-888-478-7653) or visit us online at StrokeAssociation.org. We have many other fact sheets and educational booklets to help you make healthier choices to reduce your risk, manage disease or care for a loved one. Knowledge is power, so Learn and Live!
What are the Warning Signs of Heart Attack? Warning Signs of Heart Attack: Some heart attacks are sudden and intense, but most of them start slowly with mild pain or discomfort with one or more of these symptoms:
• Shortness of breath with or without chest discomfort • Other signs including breaking out in a cold sweat, nausea or lightheadedness
• Chest discomfort • Discomfort in other areas of the upper body
Call 9-1-1… Get to a hospital immediately if you experience signs of a heart attack!
How can I lower the bad cholesterol in my blood?
Do you have questions or comments for your doctor or nurse?
• Cut down on foods high in saturated fat and cholesterol. These include fatty meats, butter, cheese, whole-milk dairy products, egg yolks, shellfish, other fish, organ meats, poultry and solid fats (foods from animals). • Enjoy at least 30 minutes of physical activities on most or all days of the week. • Eat more foods low in saturated fat and cholesterol, and high in fiber. These include
• Take a few minutes to write your own questions for the next time you see your healthcare provider. For example:
fruits and vegetables, whole grains and grain products, beans and peas, fat-free and low-fat milk products, lean meats and poultry without skin, fatty fish, and nuts and seeds in limited amounts. • Lose weight if you need to. • Ask your doctor about medicines that can reduce cholesterol (not recommended for all patients).
has a different doctor.” So he asked his father to ask his doctor the same question. The father asked his doctor, “What is cholesterol?” and the doctor said, “No problem. Here you go,” and tore off the same sheet for the father. He also did not understand the tear sheet. Why didn’t these men understand the handout? They were not limited in literacy. Both of them ran their own businesses. They just didn’t know what cholesterol was. We all know this handout. What does it say cholesterol is? “Cholesterol is a fat-like substance.” Then it says, “Triglycerides are fat in chemical terms.” What does this mean? Is cholesterol fat or is it not fat? I didn’t ask about triglycerides. How are they different from cholesterol? The handout does not say. Its title is a problem as well. It looks like a question a patient might ask, but what patient goes up to a doctor and asks, “Excuse me, doctor, but what are high blood cholesterol and triglycerides?” No human being would ever ask those words. If you are someone
Will I need cholesterol-lowering medicine? How does exercise affect my levels?
The statistics in this kit were up to date at publication. For the latest statistics, see the Heart Disease and Stroke Statistics Update at americanheart.org/statistics. ©1994, 2003, 2004, American Heart Association.
who doesn’t know what cholesterol is, you see at once that this handout does not talk your language. But let’s keep going and work hard at understanding the handout (Figure 3). It has a picture. What is the title? There is no title. If you don’t know what cholesterol is, you are not going to know what this picture is. Let’s keep working. The picture has some circles and some ovals. What is this big circle and what are these little ovals? There are no labels on the components. Well, at least there’s a sentence underneath the picture. “Cholesterol travels through the blood by way of lipoprotein.” What does that mean? Not long ago, I went to Richmond by way of Atlanta. Is “lipoprotein” a place? This handout from the American Heart Association is not fit for use. I have a friend who is an investment banker. He says, “In all my years investing in start-up ventures, I’ve learned one thing for sure: never let the engineers write the user instructions.” Unfortunately, there’s a parallel dictum: never let the clinicians write the patient instructions.
Saint Joseph Medical Center in Lexington, Kentucky, wanted to do something about this problem for heart failure patients. The administration hired ethnographers, who redesigned a whole set of materials according to ethnographic research and other principles of qualitative research and evidence-based design. Figure 4 shows the redesigned handout. First, it uses as the title patients’ language to ask the simple question, “What is cholesterol?” Before it tells about triglycerides, it answers the question: “Cholesterol is fat.” That’s all patients need to know. They are not going to be lab researchers splitting hairs on definitions of whole blood components. “Cholesterol is fat in your blood.” Once that’s established, we take a small step to the next thing we want them to know: there are actually “two kinds of fat in your blood, cholesterol and triglycerides.” In the overall layout of the page, you see two large words, Cholesterol and Triglycerides, with text under each. At a glance you know it’s going to explain both. You’ll notice pictures, but not cutaway diagrams September/October 2006
TCM 55
Figure 4. Saint Joseph Medical Center’s Redesigned Handout
Cholesterol is fat. Cholesterol is fat inside your blood. There are actually two kinds of fat in your blood: Cholesterol and Triglycerides.
Your body makes some cholesterol naturally. When you eat animal fat, you add extra cholesterol. Animal fat turns into blobs of cholesterol in your blood. Some of those blobs stick to the walls of your arteries and clog up the channel. Your blood can’t flow through. Cholesterol that sticks is Low Density, LDL. Cholesterol that doesn’t stick is High Density, HDL. “Density” means how tightly packed something is. Low Density means L oose Pack. LDL sticks like Loose packing plastic bits.
LDL is LOW + LOOSE. It sticks. That’s BAD High Density means H ard Pack. HDL doesn’t stick, like Hard packing plastic. The same plastic bits, hard packed, don’t stick.
HDL is HIGH + HARD.It doesn’t stick. That’s GOOD Many people forget which cholesterol is good and which is bad. So take a moment right now to write your personal connection between something bad in your life and the letter “ L.” • Something low and loose that’s always bad, or • Someone you don’t like whose name starts with L. If you make a personal link, you’ll always remember.
When you eat carbohydrates and other kinds of food besides animal fat, if you don’t burn it all up right away with exercise, your body makes it into another kind of fat, triglycerides. Triglycerides are even more low and loose than LDL cholesterol. They may make everything stickier.
TCM 56
September/October 2006
For me,
L is BAD because...
write here
of body parts. Familiar images are depicted to make new concepts understandable. Finding familiar images that worked for a complex clinical concept is not easy, especially when we committed to not mixing metaphors. We would not say LDL is like one thing and HDL is like another. We searched for an image of a single, familiar substance that is just like cholesterol: sticky when loosely packed and not sticky when tightly compressed. We beat our heads on this until we came up with styrofoam. When it’s in loose little pieces, it sticks to your hands, shipping cartons, anything it touches. But when you compress styrofoam and make it hard, you can make all kinds of things out of it that don’t stick, like a coffee cup. Now we have an image that a person can remember and work with. You can teach effectively with it, or the person may be able to learn by extending the metaphor themselves. Why is hard-packed cholesterol good? If you take a piece of hard styrofoam and draw it through a pile of loose styrofoam bits, the bits will stick. You can draw them right out. That’s why hard cholesterol is good; it draws out loose, sticky cholesterol. When it comes to remembering that LDL is bad and HDL is good, even clinicians can have a little trouble sometimes. So this material takes a lesson from industry. Consumer product experts know how to make you remember. There is, in a recent film, a sad but hilarious sidewalk interview where everyone walking by the White House can sing the Big Mac song, but none of them knows any of the Bill of Rights. As health-care providers, let’s take the techniques of consumer-products advertising and make these health-care information points memorable, as intrinsically memorable as the Big Mac jingle. Ask the patient to think of something bad that starts with L, something or someone they don’t like that starts with L. We ask them to associate something bad with L and not something good with H, because human nature always brings shock and humor along with bad. Shock and humor will lodge the association in our memory. If you are using this material to teach, and your learner comes up with an L that is obviously bad and works for them, fine. Move on with your teaching. But if they can’t think of a bad L, start giving
hints: “There is one thing we all know that when it’s low and loose, it’s not very desirable, but when it’s high and hard— well, you want just about as much of that as you can get.” Shock, humor, and I guarantee you will never forget it again.
Interventions like that of Saint Joseph’s suggest that if we give patients materials they can understand, they will spontaneously comply. Patients are not resistant; they have received materials that are not fit for use.
Now we get to the last point: triglycerides. What are they? We were unable to find on the Web any patient-directed site that tells what triglycerides actually are. Only when we dug into nursing textbooks could we find a professional description. It turns out that whereas cholesterol comes from animal fat, triglycerides come from other kinds of food. So we have a neat, tight framework for understanding the difference in their origins. Next, the textbooks said triglycerides are even lower and looser than LDL. They make everything more sticky. I was very gratified when the medical director of one of the largest health plans in the country said, “That’s the best explanation of cholesterol I’ve ever seen.”
Sometimes people ask if Saint Joseph’s outcomes were successful as a result of the materials. Members of the hospital staff were doing other things, after all. When we examine the time line of the project, we see that the rate of readmission was dropping month by month after the materials distribution began. Then in June they shot back up again. Only one case manager had been responsible for passing out the materials. He went on vacation, and no one else passed out the materials. This nurse, Alan Howard, reports, “Nothing else we were doing made any difference when we took away the materials that enabled the patients to act independently.” After the materials were reinstated, the rate of readmission dropped again and remained around 4% for the remainder of the year. This represents a true breakthrough.
All of this may be entertaining, but it would have no value if it didn’t make a difference in patient outcomes. What happened in Lexington? This cholesterol handout was one of a set that was redesigned in similar ways for a heart failure program. The hospital administration measured readmission, length of stay (LOS), and LOS on readmission. The redesigned materials were delivered at discharge. A DME person familiar with the handouts came to the house and evaluated patients’ oxygen needs, but no other follow-up was provided. The hospital QA department collected the statistics. Saint Joseph was already doing well with outcomes before they started this program. Their readmission rate for heart failure was 8.6%, which was about half the national average at the time. They were 1 day over the Medicare limit on LOS. For those who were readmitted, the second stay was almost 6 days of unreimbursed costs. With each month of using the materials, the readmission rate dropped steadily until it reached 2%. The initial LOS went to 4.4 days. The readmission LOS shrank by half, to 2.8 days. In discussions of compliance, providers seldom discuss the quality of their handouts but often blame patients for being resistant.
We don’t realize the magnitude of patients misunderstanding what we write for them. Rush Medical Center in Chicago decided to measure whether patients understood their postsurgical instructions for changing a dressing. For 3 months, they followed their normal procedure of distributing gauze and tape to patients after abdominal and orthopedic surgery. They also distributed instructions that had been written by the nurses and approved by the Patient Education Committee. One week after discharge, they called the patients at home. Knowing that everyone will say yes to a focusgroup kind of question, they did not simply ask, “Did you understand?” Instead they asked, “Were you able to manage without calling for repeat instructions or asking anyone for help?” Some of the patients answered, “Yes, I was able to follow the instructions.” What percentage do you think answered yes? People often guess about half, thinking of health literacy statistics: at least a third of patients at Rush would probably be “limited literacy.” But the number who answered yes was only 4%; a full 96% could not change their dressing independently. Even if you take out the limited-literacy population, September/October 2006
TCM 57
that leaves 63% who could read and still couldn’t follow the instructions. In no other industry would it be tolerable to have a 96% failure rate. In health care, we’re not even measuring whether our patient-education products work. We write them, we get nonfunctional approvals, and we don’t realize that when the product reaches the context of use, it does not function. Breakthrough in Both Patient Outcomes and ROI Whether we apply the principles to patient education, Medicare pay-for-performance areas, or other quality-improvement projects, the Juran Quality Improvement Cycle will earn breakthrough ROI for our case management departments. First, find the projects that are the vital few, by checking if you can measure outcomes and not simply process improvements. Next, get a
TCM 58
September/October 2006
baseline on today’s performance. Then conduct qualitative research to learn what the functional requirements are for use in context. From those findings, design an intervention. If we measure outcomes, we have maximum freedom to consider all types of innovations. Make sure the intervention passes all nonfunctional requirements, then measure the impact on outcomes. If quality is fitness for use in the context of the end user, then we have no trade-offs between ROI and patient-centered care. We can achieve breakthrough in both. ❑
3. Epstein, E. The human touch. ITworld [serial online] May 29, 2000. Available from: www.itworld.com/Tech/2425/IW000529hnhuman/pfindex.html. Accessed July 5, 2006. 4. Wilcox S, Reese WJ. Ethnographic methods for new product development. Medical Device and Diagnostic Industry [serial online] September 2001. Available from: http://www.devicelink.com/mddi/archive/01/09/0 01.html. Accessed June 27, 2006. 5. Fuhrmans V. An insurer tries a new strategy: listen to patients. Wall Street J April 11, 2006; p. A1.
References
Fredric I. Orkin, PE, is president of CzarnekOrkin Laboratories, Inc., in Highland Park, Illinois, and a contributing author of the Juran Quality Handbook. Sylvia Aruffo, PhD, is president of Communication Science, Inc., in Buffalo Grove, Illinois.
1. Edgman-Levitan S, Gerteis M, eds. Through the patient’s eyes. San Francisco: JosseyBass; 1993. 2. Gladwell M. The tipping point. Boston: Little, Brown; 2000.
Reprint orders: E-mail [email protected] or phone (toll-free) 888-834-7287; reprint no. YMCM 414 doi:10.1016/j.casemgr.2006.06.003
Fredric I. Orkin, PE, and Sylvia Aruffo, PhD
Y
ou’re a case manager. Your boss is talking return on investment (ROI). Your patients don’t want to be numbers on a spreadsheet. What does it take to be a hero to both the boss and the patient? Case managers frequently try to argue that great gains in quality of life for the patient are so valuable that management ought to ease up on case managers when talking about budget and returns. An experienced quality professional might respond, “Good luck.”
You may hit a sympathetic boss now and then, but lobbying for outcomes without ROI is not a sustainable approach to justifying a case manager’s work. What does it take to achieve breakthrough improvements in outcomes while achieving measurable ROI? Other industries are way ahead of health care on this track. They have a proven and effective approach: quality assurance. TCM 50
September/October 2006
A History Lesson After the Second World War, Dr. Edward Deming went to Japan. Japanese industries had been bombed out, and their reputation was for cheap quality. Deming introduced process control with breakthrough results: many of us today are driving Japanese cars and using Japanese cameras, phones, and television sets. Deming defined quality in manufacturing. You may have been
unwittingly introduced to Deming in your case management training; he was the inventor of the “plan-do-study-act” system of total quality management. If you control the process, you have achieved quality. The problem for case managers is that Deming is now two generations behind. After Deming came Phil Crosby, who coined the phrase “zero
8020
Processes evolve: incremental improvements
Only a few projects will bring BREAKTHROUGH IMPROVEMENT
The
comes and dollars. The useful many quality-improvement projects look for change in limited portions of the process, not the final outcome. If you aren’t measuring your project with dollars, you’re probably not working with one of the vital few.
VITAL FEW vs. the USEFUL MANY
defects.” He pulled attention away from inspectors at the end of an assembly line and focused on initial specifications for products. Quality is meeting specifications. If you meet the specifications, you have achieved quality. Control the process, meet the specs, and you have quality. Adding the second idea to the first was another breakthrough, but both sets of ideas applied only to manufacturing. Joseph Juran is the father of modern quality. The top US quality award may have been named for the secretary of commerce, Malcolm Baldridge, but the standards for winning that award are Juran’s. He came forward to redefine the concept of quality as fitness for use. That is, fitness for customer use. Only if your product is fit for customer use do you have quality. That insight revolutionized the concept of quality. Quality relates not just to factories but also to customers and to the fitness of products to be used by those customers. Anyone who has customers should be concerned about fitness for use of the products. To emphasize quality as responsiveness to customers, he renamed quality control quality assurance. Control is something involving only manufacturing personnel. Assurance is something you give a customer. Other fields—even service industries—started to pick up the concept. Banks, accounting firms, and hospitals started to have quality-assurance staff and departments—all from redefining quality as fitness for use. Juran gave us a number of other new ideas. For an organization to move from lower quality to higher quality, of course they must change. Engineering recognizes evolutionary change and revolutionary change, incremental and break-
through. Once a basic production process is created, whether it produces goods or services, changes begin. Small improvements are almost inevitable: a tweak here, a tweak there, and things become a little faster, a little easier, a little better. Evolutionary steps. Juran challenged us, however, not to be satisfied with incremental change but to be actively developing change strategies to bring about revolutionary change and breakthrough improvements. How can you tell if a project you are working on will result in a small, incremental change or in a grand leap forward? Juran said we’ll measure it in dollars. Incremental change causes 15% or less improvement in ROI. If you can see that your project could bring more than 15% improvement, you’ve got a shot at breakthrough. If your organization doesn’t have projects that could create that much of an impact, you should get busy and design one that will. Juran wasn’t trying to say that the myriad incremental improvements going on all over an organization weren’t worth doing, although he made a misstep when he initially called those projects the “trivial many.” He quickly changed the label to the “useful many.” Juran challenged us to see beyond the useful many to the vital few. He pulled a concept from a 1930s thinker who was then relatively obscure, Wilfredo Pareto. It’s because of Juran that we refer to “the 80/20 rule.” It was Pareto’s principle, but it was Juran who taught it to us as 80/20, the useful many versus the vital few. The Juran Quality-Improvement Cycle So how do you identify those vital few projects that will bring breakthrough improvement in outcomes and ROI? As a first step, Juran tells us to make sure our project does in fact measure out-
The second step is to conduct quantitative research to find out where these dollars are today. Don’t be distracted by Juran’s using the word research. He is a professor, after all. Think “count” or “measure.” If you make friends with the bean counters, it can be pretty easy to get the numbers you need. Get the baseline. Know what the target number is to improve. This may seem obvious, but it’s not always well accepted in health care. A PhD nursing director at a major Midwestern cancer center was once asked to lead a quality-improvement project. She shrugged off the need to do a baseline measurement. When asked how she would be able to tell if the project had an impact, she answered, “Oh, I’ll just know.” Don’t be like this manager; get the baseline. Next, conduct qualitative research to come up with the functional requirements for your product or service. Functional requirements come from studying how customers use (or don’t use) products and services. In manufacturing, when they design a new product or modify an old one, they draw a flow diagram with boxes that show every interaction of the customer with the product. Then for each box you ask, “What are the requirements for the product when the customer uses it at that time and in that place?” That includes all aspects of the product. It might start with the packaging and then go to the type of power supply, how you turn it on, how it sits, on what platform, and so on, in excruciating detail. It should be clear that you can’t make this diagram if you don’t know much about how, where, and when your customers use your product. In every field, we make assumptions as to how customers use our products or respond to our services. When we learn first-hand, through qualitative research, what our customers actually do, think, and believe, we often are shocked. QualitaSeptember/October 2006
TCM 51
Figure 1.
Juran Quality Improvement Cycle
START HERE
CHOOSE THE VITAL FEW CHOOSE ROI PARAMETERS
CONDUCT QUANTITIVE RESEARCH RUN INTERVENTION (RE-MEASURE)
CONDUCT QUANTITATIVE RESEARCH GET BASELINE
CONDUCT QUALITATIVE RESEARCH
INSPECT TECHNICAL REGULATORY
DESIGN INTERVENTION
Figure 2.
Quality Improvement Projects Initial Hospitalizations Aspirin at Arrival for AMI Readmissions within 30 days HA1c Tests for Diabetes Inbound Calls for Repeat Information LVF Assessment for Heart Failure Antibiotic 1 hour before surgery After-Hours Calls for Rx refills Initial Antibiotic Timing for PNE
tive research on fitness for use in the customers’ hands exposes a good many of our assumptions as false, as roadblocks to better outcomes. At this point we need definitions with regard to quantitative and qualitative TCM 52
September/October 2006
How many? How many received; how long wait? How many? How many received? How many and how long? How many received? How many on time? How many? How long was the wait?
research, because many of us have assumptions that are holding us back from breakthroughs. Qualitative and quantitative are not alternative ways of measuring results. Only quantitative research tells you results, in numbers, of the impact of an intervention. But where
does the idea for the intervention come from? Does it just pop magically into someone’s head? Ideas for interventions come from qualitative research, exploring the customers’ world. What you discover about the end user tells you how to intervene. If we scorn qualitative research as simply a less rigorous or less reliable way to measure something, we will never be able to tap into its power. Qualitative research enables us to systematically improve quantitative outcomes. To begin the quality-improvement cycle (Figure 1), choose a project for which you measure outcomes in dollars. Get a baseline measurement. Then conduct qualitative research to find the requirements to make the product fit for the customers’ use. On the basis of those discoveries, design the intervention. Before you can implement, however, the intervention design must pass inspection. Every industry is burdened with demands from government or regulators. Juran called these nonfunctional requirements. They are absolute requirements, even though many are arbitrary. If you don’t meet them, you can’t go to the market. These are the guys with the checklists: labeling standards, packaging standards, engineering standards. You have to meet those standards, but they don’t tell you if your product actually works. The checklists are nonfunctional requirements. The only way you know if you have met the customers’ functional requirements is to run the intervention and measure the results. Then the cycle begins again: more qualitative research, another invention, a new inspection, and another measurement. This is continuous quality improvement. If you measure dollars and conduct qualitative research, you have a solid chance of breakthrough ROI—that is, better than 15% improvement—many times over. Applying Juran to Case Management The Centers for Medicare and Medicaid Web site has a list of measures that the government imposes on health care; each one implies quality-improvement projects. The shaded box in Figure 2 lists some areas. We’d like to think that the drafters of the list intended that if we all meet these standards, we will have
breakthrough improvement. Look closely at the items. Which ones are measured in dollars? None. But some of them are closer to dollars than are others. The initial hospitalization admissions we eliminate by good case management translates directly into dollars. Readmissions also convert easily into dollars. So does reducing inbound calls, taking into consideration the value of staff time in dollars. The ones on this list that translate quickly into dollars are the vital few. Others, like giving an aspirin on arrival at an emergency facility, are more distant from outcomes, and the dollar calculations more uncertain. Still others, such as ensuring that diabetic patients receive hemoglobin A1c tests, have no direct connection to a change in outcomes. The farther the measure is from outcomes, the more likely it is one of the useful many. Simply being on this list has dollar implications. If we give patients A1C tests, we get paid. An economist would call that a “market distortion.” Quality improvement does not directly create dollars (like a pool for rewards), but you get paid anyway. Getting paid for process rather than outcome clouds the picture of which projects truly bring breakthrough. Distortion keeps us ranking lesser projects in the same category with important ones. An even bigger problem with market distortion is that it can prevent us from achieving breakthrough. Say I’m getting my pay-per-performance for giving aspirin. A brilliant inventor comes along and says, “I have a new drug that is proven to work better, faster, smarter— it’ll even prevent repeat attacks!” I look at my list of pay-for-performance items and say to him, “Sorry, I get paid only for giving aspirin. I don’t get paid for outcomes. Goodbye.” We have just cut ourselves off from an innovation that could give us breakthrough. Another characteristic of vital few projects is that they allow maximum latitude for creative intervention. We have to be careful about quality-improvement projects that lock us in to today’s processes, even if those processes are today’s best evidence-based protocols. A few years ago, the dean’s welcome
Qualitative research is the source of ideas for innovation. Unfortunately, health care and especially service providers know very little about qualitative research. speech at Tufts Medical School warned the incoming students that “half of what we teach you today, by the time you graduate, will have been proven wrong. The trouble is, today, we don’t know which half.” Pay for performance, by locking in today’s processes, could make innovation much more difficult. Qualitative Research: The Unfamiliar Step in the Cycle Qualitative research is the source of ideas for innovation. Unfortunately, health care and especially service providers know very little about qualitative research. An old but still wonderful book, Through the Patient’s Eyes,1 calls for qualitative research: “We need to develop systematic, appropriate and effective ways to find out what patients need and experience.” The book also criticizes: “Providers are remarkably unsophisticated about methods of eliciting information from patients … not only a lack of familiarity with methods, but a fundamental and widespread resistance to researching the patients’ perspective.” That was 1993. There’s been progress since then but not a lot. Back to industry for some lessons: Maytag, Chrysler, Intel, and Procter & Gamble, for example, know an enormous amount about end users. Pepsi-Cola knows more details of customers’ context than we know about patients’ daily lives. They spend time and money collecting user insights. One major way they do that is with a set of techniques called ethnography. Few people in health care are familiar with it. Health care knows focus groups. You have probably been in some yourself. It may surprise you to learn that industry has largely left focus groups behind because they have pitfalls. In a
focus group, you pull people out of context. You are entirely dependent on what they are aware of back in their context, what they can remember during the meeting, and what they are willing to say in front of their peers and in front of you, an authority figure. Malcolm Gladwell, author of The Tipping Point,2 has said he would like to see a constitutional amendment against focus groups because they can be so misleading. In a focus group, the participants are all dressed up and on their best behavior. What we really need to know is what they say and do when you’re not there. We need observation in context. “Observation in context” is ethnography. Instead of bringing people in to the researcher, you send the researcher out to people’s homes, workplaces, communities, wherever they’re using your product or your service, and see how your input fits or doesn’t fit— use in context. Ethnography What does ethnography do for other industries? If you go to the Web site of the New Product Development and Marketing Association, you see “ethnography is the state of the art in new product development.” The consumer products division of Procter & Gamble writes, “Everyone knows what a powerful tool ethnography is.” Shane Wall, general manager of new product development at Intel, declares he wouldn’t consider starting on a new product without doing ethnography.3 Here are some quick examples of what ethnography can do. Sales for the Nissan Pathfinder had been completely flat for 10 years. The company decided to redesign the vehicle. But they didn’t do focus groups, asking users, “How should we redesign this van for you?” What would you say if someone asked you that? What Nissan did instead was to hire ethnographers. They sent researchers out to shopping mall parking lots to videotape the soccer moms coming out of the stores with shopping bags and kids and a coffee cup and stroller and Grandma waiting in the car and the dog bouncing around. The ethnographers went back to Nissan with this rich data set. The industrial designers analyzed in excruciating detail things like how far the door should open before it catches and holds, whether September/October 2006
TCM 53
it should slide or swing open, how much space it needs between the front seat and the back, and so on. The redesigned Nissan Pathfinder doubled sales. When Pepsi bought Gatorade, they hired a firm that does ethnography only for hand-held products. They took video cameras to sporting events and construction sites to watch people drinking. From the insights the researchers brought back, Pepsi designers made the top of the bottle oval so it fits the shape of your mouth. They re-engineered the hole so the flow rate of the fluid would be exactly right to accommodate swallowing while running—and so on. You might think that a mature brand such as Gatorade couldn’t make a dramatic leap forward in sales, but when the newly designed Gatorade bottle hit the shelves, sales went up 23%. How is health care doing on understanding the functional requirements in the context of patients’ use? In a product development meeting with a major health-care manufacturer, the top two marketing vice presidents said they had each worked for the company, marketing ostomy products, for over 10 years. So it was somewhat surprising when the two resisted viewing a photo of a stoma. The presenter stopped, puzzled. “Could I ask … have either of you ever actually watched a patient change an ostomy bag?” “No,” they replied, “but we’ve done focus groups.” It’s not likely this company will achieve breakthrough improvement in product design. Observation in context allows us to design interventions on the basis of evidence. We chose clinical protocols according to evidence-based medicine. We should design our quality improvement projects on the basis of evidence from the users’ context: evidence-based design. Here’s an example: as cited earlier, health care is beginning to use ethnography. Imagine a hospital that wanted continuous quality improvement in patient safety. They made some progress but wanted to launch a project in the cardiac cath lab. The clinicians there protested: “We’re doing everything we can already; everything we do is aimed at patient safety.” The quality-assurance (QA) people hired an ethnography firm to observe procedures in the lab. What they found was that there was only one person in TCM 54
September/October 2006
the lab who could interrupt or stop a procedure. All the clinicians did whatever this person wanted; it was the staff worker who prepared the documentation for risk management. At one point, the entire procedure was halted, the patient lying there on the table while the staff worker cleared a paper jam. When the ethnographers came back with their report, the QA department said, “Before we can move forward on patient safety, we’ve got to make the clinicians feel safer themselves. We’ll need new hardware and software for documentation.”4 Another new application of ethnography in health care can be found in Humana. The Wall Street Journal5 said Humana has hired ethnographers to generate insights for designing a consumer-directed health plan. The ethnographers, “experts at studying people in natural settings, shadowed people in their homes for 18 months to see how they make decisions about health care … ethnographers don’t ask questions; they watch and see what happens. They observe natural behavior and experience the context.” Whatever quality project you initiate, you will be on the fast track to improve your quantitative outcomes if you do qualitative research before designing your intervention. Observe the context of the people whose behavior you want to influence. Find out what you have to do to help them change. An Overlooked Area to Which to Apply the Juran Quality Cycle Juran’s principles apply to every quality initiative. If readers adopt the steps of the cycle for any project, this article will have served its purpose. But there is one area of health care where the steps of quality improvement have not yet been applied and to which most healthcare providers have not yet realized they could apply them. The one area that may produce the greatest ROI is engaging the patient in self-care. If we can accomplish this, our ROI will improve exponentially, because successful self-care achieves outcomes at no cost to the provider. Patient communications, by themselves, should be measured for their impact on outcomes: how many hospitalizations can
be eliminated by the use of materials with evidence-based design (as distinct from evidence-based clinical content)? How many fewer telephone calls can the call center make if patient education materials reflect the patients’ context? How much earlier might a patient be willing to leave the hospital if the materials were developed through all the steps of the Juran quality cycle? Let’s be very clear that approvals— whether from our local patient education committees, URAC, Joint Commission on Accreditation of Healthcare Organizations, or by a checklist for health literacy—are precisely what Juran calls nonfunctional requirements. All too often, providers write materials not for patients but for the approval bodies. This tends to be particularly true when writing letters that go to Medicare or Medicaid recipients: we write for government approvals and stop there. But those approvals don’t tell us anything about whether our writing actually inspires people to take the action we want. They don’t tell us whether our materials work. Health care has never measured whether the materials by themselves work. Do we have an impact when there is no professional involved (that is, a professional is neither present, nor on the telephone, nor at the other end of an in-home technology monitor)? We should get today a baseline on the impact of our materials. Then we should conduct qualitative research to find out how our materials are used—or not. The purpose of the intervention is to revise the materials on the basis of the findings. Of course they must meet standards, but as Juran said, “You can’t inspect in quality.” We have to press on to the last step in the cycle, to measure how much we have improved the patients’ outcomes with the new materials. If you’re like most case managers, you’ll be skeptical that materials by themselves can have an impact. Let me tell you the story of a patient with coronary artery disease. He said he asked his doctor, “What is cholesterol?” The doctor responded, “No problem, here’s a tear sheet from the American Heart Association.” The patient didn’t understand it. He thought, “My father has coronary artery disease, too. He
Figure 3. American Heart Association Handout What are High Blood Cholesterol and Triglycerides? (continued)
What are triglycerides?
Title looks like a patient question but is not how patients talk
Triglycerides are the most common type of fat in your body. They’re also a major energy source. They come from food, and your body also makes them. High levels of blood
What are High Blood Cholesterol and Triglycerides? Cholesterol is a soft, fat-like substance found in the bloodstream and in all your body’s cells. Your body makes all the cholesterol it needs.
Picture elements are not labeled
The saturated fats, trans fats and cholesterol Definitions ofyour cholesterol you eat may raise blood cholesterol level. Having too much cholesterol in your blood and triglycerides are may lead to increased risk for heart disease vague and uncertain. and stroke. About half of American adults have levels that are too high (200 mg/dL or higher) and about 1 in 5 has a level in the high-risk zone (240 mg/dL or higher). The good news is that you can take steps to control your cholesterol.
lipoproteins
There are different kinds of fats in the foods we eat. Saturated fat is the kind that raises blood cholesterol, so it’s not good for you. Avoid animal fats like lard and meat fat, and some plant fats like coconut oil, palm oil and palm kernel oil. Trans fat comes from adding hydrogen to vegetable oils and tends to raise blood cholesterol. It’s used in commercial baked
oils and fish oils. These tend to lower blood cholesterol. Monounsaturated fats are found in olive, canola, peanut, sunflower and safflower oils. In a low-saturated-fat diet, they may lower blood cholesterol.
How can I learn more?
Cholesterol travels to the body’s cells through the bloodstream by way of lipoproteins.
Caption under the picture is ambiguous
What’s so bad about it? Cholesterol and other fats can’t dissolve in your blood. To travel to your cells, they use special carriers called lipoproteins. Lowdensity lipoprotein (LDL) cholesterol is often called “the bad kind.” When you have too much LDL cholesterol in your blood, it can join with fats and other substances to build up in the inner walls of your arteries. The arteries can become clogged and narrow, and blood flow is reduced. If a blood clot
Definition of triglycerides goods for cooking in most restaurants cannot beandmeaningfully and fast-food chains. It’s also in milk and distinguished from that beef. Polyunsaturated fats are found in vegetable of cholesterol.
What about fats?
No title on the picture cholesterol
What is high blood cholesterol?
triglycerides are often found in people who have high cholesterol levels, heart problems, are overweight or have diabetes.
forms and blocks the blood flow to your heart, it causes a heart attack. If a blood clot blocks an artery leading to or in the brain, a stroke results. A “good kind” of cholesterol, on the other hand, is called high-density lipoprotein (HDL). It carries harmful cholesterol away from the arteries and helps protect you from heart attack and stroke. It’s better to have a lot of HDL cholesterol in your blood.
1. Talk to your doctor, nurse or other healthcare professionals. If you have heart disease or have had a stroke, members of your family also may be at higher risk. It’s very important for them to make changes now to lower their risk. 2. Call 1-800-AHA-USA1 (1-800-242-8721), or visit americanheart.org to learn more about heart disease.
3. For more information on stroke, call 1-8884-STROKE (1-888-478-7653) or visit us online at StrokeAssociation.org. We have many other fact sheets and educational booklets to help you make healthier choices to reduce your risk, manage disease or care for a loved one. Knowledge is power, so Learn and Live!
What are the Warning Signs of Heart Attack? Warning Signs of Heart Attack: Some heart attacks are sudden and intense, but most of them start slowly with mild pain or discomfort with one or more of these symptoms:
• Shortness of breath with or without chest discomfort • Other signs including breaking out in a cold sweat, nausea or lightheadedness
• Chest discomfort • Discomfort in other areas of the upper body
Call 9-1-1… Get to a hospital immediately if you experience signs of a heart attack!
How can I lower the bad cholesterol in my blood?
Do you have questions or comments for your doctor or nurse?
• Cut down on foods high in saturated fat and cholesterol. These include fatty meats, butter, cheese, whole-milk dairy products, egg yolks, shellfish, other fish, organ meats, poultry and solid fats (foods from animals). • Enjoy at least 30 minutes of physical activities on most or all days of the week. • Eat more foods low in saturated fat and cholesterol, and high in fiber. These include
• Take a few minutes to write your own questions for the next time you see your healthcare provider. For example:
fruits and vegetables, whole grains and grain products, beans and peas, fat-free and low-fat milk products, lean meats and poultry without skin, fatty fish, and nuts and seeds in limited amounts. • Lose weight if you need to. • Ask your doctor about medicines that can reduce cholesterol (not recommended for all patients).
has a different doctor.” So he asked his father to ask his doctor the same question. The father asked his doctor, “What is cholesterol?” and the doctor said, “No problem. Here you go,” and tore off the same sheet for the father. He also did not understand the tear sheet. Why didn’t these men understand the handout? They were not limited in literacy. Both of them ran their own businesses. They just didn’t know what cholesterol was. We all know this handout. What does it say cholesterol is? “Cholesterol is a fat-like substance.” Then it says, “Triglycerides are fat in chemical terms.” What does this mean? Is cholesterol fat or is it not fat? I didn’t ask about triglycerides. How are they different from cholesterol? The handout does not say. Its title is a problem as well. It looks like a question a patient might ask, but what patient goes up to a doctor and asks, “Excuse me, doctor, but what are high blood cholesterol and triglycerides?” No human being would ever ask those words. If you are someone
Will I need cholesterol-lowering medicine? How does exercise affect my levels?
The statistics in this kit were up to date at publication. For the latest statistics, see the Heart Disease and Stroke Statistics Update at americanheart.org/statistics. ©1994, 2003, 2004, American Heart Association.
who doesn’t know what cholesterol is, you see at once that this handout does not talk your language. But let’s keep going and work hard at understanding the handout (Figure 3). It has a picture. What is the title? There is no title. If you don’t know what cholesterol is, you are not going to know what this picture is. Let’s keep working. The picture has some circles and some ovals. What is this big circle and what are these little ovals? There are no labels on the components. Well, at least there’s a sentence underneath the picture. “Cholesterol travels through the blood by way of lipoprotein.” What does that mean? Not long ago, I went to Richmond by way of Atlanta. Is “lipoprotein” a place? This handout from the American Heart Association is not fit for use. I have a friend who is an investment banker. He says, “In all my years investing in start-up ventures, I’ve learned one thing for sure: never let the engineers write the user instructions.” Unfortunately, there’s a parallel dictum: never let the clinicians write the patient instructions.
Saint Joseph Medical Center in Lexington, Kentucky, wanted to do something about this problem for heart failure patients. The administration hired ethnographers, who redesigned a whole set of materials according to ethnographic research and other principles of qualitative research and evidence-based design. Figure 4 shows the redesigned handout. First, it uses as the title patients’ language to ask the simple question, “What is cholesterol?” Before it tells about triglycerides, it answers the question: “Cholesterol is fat.” That’s all patients need to know. They are not going to be lab researchers splitting hairs on definitions of whole blood components. “Cholesterol is fat in your blood.” Once that’s established, we take a small step to the next thing we want them to know: there are actually “two kinds of fat in your blood, cholesterol and triglycerides.” In the overall layout of the page, you see two large words, Cholesterol and Triglycerides, with text under each. At a glance you know it’s going to explain both. You’ll notice pictures, but not cutaway diagrams September/October 2006
TCM 55
Figure 4. Saint Joseph Medical Center’s Redesigned Handout
Cholesterol is fat. Cholesterol is fat inside your blood. There are actually two kinds of fat in your blood: Cholesterol and Triglycerides.
Your body makes some cholesterol naturally. When you eat animal fat, you add extra cholesterol. Animal fat turns into blobs of cholesterol in your blood. Some of those blobs stick to the walls of your arteries and clog up the channel. Your blood can’t flow through. Cholesterol that sticks is Low Density, LDL. Cholesterol that doesn’t stick is High Density, HDL. “Density” means how tightly packed something is. Low Density means L oose Pack. LDL sticks like Loose packing plastic bits.
LDL is LOW + LOOSE. It sticks. That’s BAD High Density means H ard Pack. HDL doesn’t stick, like Hard packing plastic. The same plastic bits, hard packed, don’t stick.
HDL is HIGH + HARD.It doesn’t stick. That’s GOOD Many people forget which cholesterol is good and which is bad. So take a moment right now to write your personal connection between something bad in your life and the letter “ L.” • Something low and loose that’s always bad, or • Someone you don’t like whose name starts with L. If you make a personal link, you’ll always remember.
When you eat carbohydrates and other kinds of food besides animal fat, if you don’t burn it all up right away with exercise, your body makes it into another kind of fat, triglycerides. Triglycerides are even more low and loose than LDL cholesterol. They may make everything stickier.
TCM 56
September/October 2006
For me,
L is BAD because...
write here
of body parts. Familiar images are depicted to make new concepts understandable. Finding familiar images that worked for a complex clinical concept is not easy, especially when we committed to not mixing metaphors. We would not say LDL is like one thing and HDL is like another. We searched for an image of a single, familiar substance that is just like cholesterol: sticky when loosely packed and not sticky when tightly compressed. We beat our heads on this until we came up with styrofoam. When it’s in loose little pieces, it sticks to your hands, shipping cartons, anything it touches. But when you compress styrofoam and make it hard, you can make all kinds of things out of it that don’t stick, like a coffee cup. Now we have an image that a person can remember and work with. You can teach effectively with it, or the person may be able to learn by extending the metaphor themselves. Why is hard-packed cholesterol good? If you take a piece of hard styrofoam and draw it through a pile of loose styrofoam bits, the bits will stick. You can draw them right out. That’s why hard cholesterol is good; it draws out loose, sticky cholesterol. When it comes to remembering that LDL is bad and HDL is good, even clinicians can have a little trouble sometimes. So this material takes a lesson from industry. Consumer product experts know how to make you remember. There is, in a recent film, a sad but hilarious sidewalk interview where everyone walking by the White House can sing the Big Mac song, but none of them knows any of the Bill of Rights. As health-care providers, let’s take the techniques of consumer-products advertising and make these health-care information points memorable, as intrinsically memorable as the Big Mac jingle. Ask the patient to think of something bad that starts with L, something or someone they don’t like that starts with L. We ask them to associate something bad with L and not something good with H, because human nature always brings shock and humor along with bad. Shock and humor will lodge the association in our memory. If you are using this material to teach, and your learner comes up with an L that is obviously bad and works for them, fine. Move on with your teaching. But if they can’t think of a bad L, start giving
hints: “There is one thing we all know that when it’s low and loose, it’s not very desirable, but when it’s high and hard— well, you want just about as much of that as you can get.” Shock, humor, and I guarantee you will never forget it again.
Interventions like that of Saint Joseph’s suggest that if we give patients materials they can understand, they will spontaneously comply. Patients are not resistant; they have received materials that are not fit for use.
Now we get to the last point: triglycerides. What are they? We were unable to find on the Web any patient-directed site that tells what triglycerides actually are. Only when we dug into nursing textbooks could we find a professional description. It turns out that whereas cholesterol comes from animal fat, triglycerides come from other kinds of food. So we have a neat, tight framework for understanding the difference in their origins. Next, the textbooks said triglycerides are even lower and looser than LDL. They make everything more sticky. I was very gratified when the medical director of one of the largest health plans in the country said, “That’s the best explanation of cholesterol I’ve ever seen.”
Sometimes people ask if Saint Joseph’s outcomes were successful as a result of the materials. Members of the hospital staff were doing other things, after all. When we examine the time line of the project, we see that the rate of readmission was dropping month by month after the materials distribution began. Then in June they shot back up again. Only one case manager had been responsible for passing out the materials. He went on vacation, and no one else passed out the materials. This nurse, Alan Howard, reports, “Nothing else we were doing made any difference when we took away the materials that enabled the patients to act independently.” After the materials were reinstated, the rate of readmission dropped again and remained around 4% for the remainder of the year. This represents a true breakthrough.
All of this may be entertaining, but it would have no value if it didn’t make a difference in patient outcomes. What happened in Lexington? This cholesterol handout was one of a set that was redesigned in similar ways for a heart failure program. The hospital administration measured readmission, length of stay (LOS), and LOS on readmission. The redesigned materials were delivered at discharge. A DME person familiar with the handouts came to the house and evaluated patients’ oxygen needs, but no other follow-up was provided. The hospital QA department collected the statistics. Saint Joseph was already doing well with outcomes before they started this program. Their readmission rate for heart failure was 8.6%, which was about half the national average at the time. They were 1 day over the Medicare limit on LOS. For those who were readmitted, the second stay was almost 6 days of unreimbursed costs. With each month of using the materials, the readmission rate dropped steadily until it reached 2%. The initial LOS went to 4.4 days. The readmission LOS shrank by half, to 2.8 days. In discussions of compliance, providers seldom discuss the quality of their handouts but often blame patients for being resistant.
We don’t realize the magnitude of patients misunderstanding what we write for them. Rush Medical Center in Chicago decided to measure whether patients understood their postsurgical instructions for changing a dressing. For 3 months, they followed their normal procedure of distributing gauze and tape to patients after abdominal and orthopedic surgery. They also distributed instructions that had been written by the nurses and approved by the Patient Education Committee. One week after discharge, they called the patients at home. Knowing that everyone will say yes to a focusgroup kind of question, they did not simply ask, “Did you understand?” Instead they asked, “Were you able to manage without calling for repeat instructions or asking anyone for help?” Some of the patients answered, “Yes, I was able to follow the instructions.” What percentage do you think answered yes? People often guess about half, thinking of health literacy statistics: at least a third of patients at Rush would probably be “limited literacy.” But the number who answered yes was only 4%; a full 96% could not change their dressing independently. Even if you take out the limited-literacy population, September/October 2006
TCM 57
that leaves 63% who could read and still couldn’t follow the instructions. In no other industry would it be tolerable to have a 96% failure rate. In health care, we’re not even measuring whether our patient-education products work. We write them, we get nonfunctional approvals, and we don’t realize that when the product reaches the context of use, it does not function. Breakthrough in Both Patient Outcomes and ROI Whether we apply the principles to patient education, Medicare pay-for-performance areas, or other quality-improvement projects, the Juran Quality Improvement Cycle will earn breakthrough ROI for our case management departments. First, find the projects that are the vital few, by checking if you can measure outcomes and not simply process improvements. Next, get a
TCM 58
September/October 2006
baseline on today’s performance. Then conduct qualitative research to learn what the functional requirements are for use in context. From those findings, design an intervention. If we measure outcomes, we have maximum freedom to consider all types of innovations. Make sure the intervention passes all nonfunctional requirements, then measure the impact on outcomes. If quality is fitness for use in the context of the end user, then we have no trade-offs between ROI and patient-centered care. We can achieve breakthrough in both. ❑
3. Epstein, E. The human touch. ITworld [serial online] May 29, 2000. Available from: www.itworld.com/Tech/2425/IW000529hnhuman/pfindex.html. Accessed July 5, 2006. 4. Wilcox S, Reese WJ. Ethnographic methods for new product development. Medical Device and Diagnostic Industry [serial online] September 2001. Available from: http://www.devicelink.com/mddi/archive/01/09/0 01.html. Accessed June 27, 2006. 5. Fuhrmans V. An insurer tries a new strategy: listen to patients. Wall Street J April 11, 2006; p. A1.
References
Fredric I. Orkin, PE, is president of CzarnekOrkin Laboratories, Inc., in Highland Park, Illinois, and a contributing author of the Juran Quality Handbook. Sylvia Aruffo, PhD, is president of Communication Science, Inc., in Buffalo Grove, Illinois.
1. Edgman-Levitan S, Gerteis M, eds. Through the patient’s eyes. San Francisco: JosseyBass; 1993. 2. Gladwell M. The tipping point. Boston: Little, Brown; 2000.
Reprint orders: E-mail [email protected] or phone (toll-free) 888-834-7287; reprint no. YMCM 414 doi:10.1016/j.casemgr.2006.06.003