Written by Beth Keolanui and Darcy Craig
Think for a moment about your last experience receiving healthcare. Were you at a doctor’s office? A hospital? Was it easy to get to the provider’s office? When you entered the building, how easy was it finding your doctor’s office? Was there any staff to help you? If English is not your primary language, was there anyone who asked you if you preferred to have an interpreter during your visit? How long did you wait in the provider’s office? Who were you seen by? Did you have to repeat any information to various healthcare providers during the visit? Did you feel that your visit answered all your questions? Were you appropriately sent for lab tests or were you given prescriptions that could be easily filled at the pharmacy? How would you rate this experience? Did you feel that you received the best quality of care?
In one healthcare visit, providers and hospitals are asking these very questions that get to a root piece of providing healthcare: the patient experience. Long gone is the simple rhetoric of increasing quality of care for patients. The Affordable Care Act (ACA) requires healthcare stakeholders such as doctors and hospitals to be held accountable for care that is provided to you.
Understanding how healthcare stakeholders are tracking quality improvement measures requires a bit of “Quality Measure 101.” Here is a high-level snapshot. Avedis Donabedian created the first rationale for measuring quality of healthcare in 1978. Since then, many institutions, organizations, and programs have developed quality measurements off Donabedian’s early principles that quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Organizations such as the National Quality Forum (NQF) reviews, endorses, and recommends quality measures that are recognized as the “gold standard” by government agencies such as the Centers for Medicare and Medicaid (CMS) and other commercial entities adopting quality improvement projects. Other commercial projects such as the California based Integrated Healthcare Association (IHA) develops measures to standardize quality measure reporting in its highly recognized Pay for Performance (P4P) program and Value Based P4P program. IHA P4P defines measures loosely into four domains: Clinical Quality, Meaningful Use of Health IT, Resource Use, and Patient Experience.
So what? Do these measures actually improve quality of care, and more importantly, patient experience? Some examples have been adopted that are proving to be promising. The Toyota Production System’s LEAN manufacturing practices are being adopted by healthcare delivery systems to reduce waste and improve healthcare value. Ultimately, revisiting and revamping healthcare process means better healthcare to the patient—to you. Safety net hospitals such as San Francisco General Hospital (SFGH) are proving that the LEAN method can work—even with limited resources in comparison to other healthcare systems that have a higher volume of commercial patients (e.g. which generally means more money flowing through the hospital). Specifically referred to as Kaizen, a specific LEAN management tool that requires about a week long improvement workshop, SFGH has been using Kaizen methodologies to focus on improving value stream processes over the last two-years. The Kaizen approach has helped improve SFGH quality of care.
Looking deeper into the Kaizen process, brings up some interesting word choices. Kaizen means “good change” or “improvement” in Japanese and refers to the philosophy of continually improving processes. The process focuses on standardizing an operation, measuring the operation, gauging measurements, innovating processes to increase productivity, standardizing the new process, and continuing the cycle. Throughout the process, words like seiri (tidiness), seiton (orderliness), seiso (cleanliness), seiketsu (standardized clean-up), and shitsuke (discipline) are used. The Kaizen method is thought of as a way of life philosophy and that every part of our life may have continuous incremental improvements. Looking at health improvement in this way begs the question: are quality measurements and delivery systems capturing the improvement on an individual’s total health?
One important piece of the puzzle that is missing when looking at improving quality of care is that healthcare is only one driver of people’s overall health. When looking at people’s health, we need to consider other factors such as environmental and social factors, personal behaviors, and family history and genetics. McGinnis et al spoke of these drivers of health and that medical care makes up about 10-15 percent of the picture. In thinking of bold concepts, perhaps there could be a focus to use Kaizen principles that link to patient values to improve the total individual. Many patients and providers believe holistic health care is one ideology to treat the total individual in that it manages and can often prevent long term health conditions while simultaneously encouraging a connection to cultural and personal beliefs.
Kaiser Permanent’s Center for Complimentary Medicine (CCM) is a holistic health care approach promoting “harmony” through preventative care. Complimentary and preventative medicine is alive and well in the United States and continuing to gain momentum as bigger health care organizations such as Kaiser integrate and promote this level of care. At Kaiser Permanente, the Center for Complimentary Medicine (CCM) provides support to their members (and non-members) working to meet the needs of their patients, not just when they are sick, but by treating the “whole person”. The provided support encourages patients to maintain health lifestyle choices and increase their overall health and wellness. CCM’s mission is to provide personalized complementary care with an emphasis on preventive measures, pain reduction and patient education. Many people are incorporating complementary care into their lives as a way to connect to cultural and personal beliefs and manage or even prevent health conditions.
Offerings from the Center for Complimentary Medicine include:
- Chiropractic Services
- Therapeutic Massage
- Complementary Kitchen Demo: hands on preparation of simple, health recipes and understanding food choices
- Cancer Fighting Food Classes
- Wellness Coaching
- Mind Body Classes: (mindfulness based stress reduction, senior yoga, Qigong, Core Strength for Women)
CCM recently introduced Integrative Medicine in 2012. Integrative Medicine is a combination of conventional Western medicine with complementary and alternative medicine treatments, personalized for effectively treating the individual patient, not just the symptoms or the disease. Patients receive a 1 hour consult with an Integrative Medical Physician, a 1 hour consult with a Nutritionist, a 30 minute follow up with Nutritionist and Demo Kitchen Cooking Classes. Many patients are referred to CCM through provider referrals because providers believe the preventative care model encourages healthier lifestyles, improving the health of their patients and reducing the amount of chronic disease providers treat outside of the Center for Complementary Medicine.
There is a need to re-focus and integrate care that treats the “whole person.” One method we believe could capture this is treating the individual with Kaizen methodologies in an environment such as the Kaiser Center for Complimentary Medicine. Current quality measures to improve patient experience do not necessarily target these delivery systems and metrics may not be able to truly capture the good work coming out of these centers. However, incorporating patient’s individual culture and beliefs to encourage life changes may have the biggest impact on improving people’s health. The topic of complimentary medicine as a way to improve total health and the patient experience relates directly back to the discussion about quality improvement. There is the proverbial saying that if you give a man a fish, you feed him for a day. If you teach him how to fish, you feed him for a lifetime. This concept should be the next focus in revitalizing the healthcare industry: let’s incorporate medicine that harnesses people’s values and changes people’s lives.
 Brien, S. E., E. Dixon, and W. A. Ghali. 2009. Measuring and reporting on quality in health care: A framework and road map for improving care. Journal of Surgical Oncology 99 (8) (Jun 15): 462-6.
 McGinnis, J. M., P. Williams-Russo, and J. R. Knickman. 2002. The case for more active policy attention to health promotion. Health Affairs (Project Hope) 21 (2) (Mar-Apr): 78-93.