Volume 189 - Issue 4
Health services under siege: the case for clinical process redesign
Authors: Caroline A Brand, Peter A Cameron, Peter B Greenberg and Ian A Scott
Med J Aust 2008; 189 (4): 238-240. || doi: 10.5694/j.1326-5377.2008.tb02008.x
Published online: 18 August 2008
Published online: 18 August 2008
To the Editor: In regard to your recent supplement dedicated to clinical process redesign in health care,1 we support the need to learn from other industries, but have concerns about an exclusive focus on process redesign to improve the quality and safety of health care for patients.
In industry, unlike in health care, outcomes surveillance is almost always feasible. Clinical practice reminds us of the fallibility of surrogate measures of benefit, which, like “processes”, require validation by “hard” outcomes.2 Industry knows when its services or products meet minimum quality standards and satisfy “customer” needs. By contrast, a “lean approach” in health care, while taking a patient-centred perspective of care processes, makes several assumptions.
The first is that better flow processes relate directly to improved outcomes. Process redesign focuses on measuring targets such as access block and elective surgery waiting lists, which are subject to confounding and manipulation.3,4 The impact on health care outcomes remains unclear. Furthermore, the studies cited in these supplement articles had no concurrent controls.3,4
The second assumption is the relative values of the process measures chosen. Is a relatively small reduction in time spent in the emergency department more important than use of an appropriate device for relieving pressure ulcers in an older woman with a fracture?5
The third assumption is that there are cause and effect links between process redesign and outcomes, such as fewer episodes of litigation at Flinders Medical Centre.6 Such links cannot be substantiated without a control group, as concurrent changes, such as open disclosure and guideline implementation, may have similar effects.
Other literature pertaining to the benefits of lean thinking in process redesign emphasises opportunities to reallocate resources to implementing best practice as a result of the efficiencies and cost savings achieved.7 This assumes that process redesign occurs quickly, and that all cost savings are reallocated. These claims appeal to managers and directors constrained by external demands for meeting efficiency targets. The inevitable consequence is that organisations are likely to focus on simple “fixable” problems rather than more fundamental system-based problems requiring more resources and longer timeframes. Also, it can be argued that the process redesign examples are “micro-reforms” within a “macro-system” that remains unchanged. The hospital sector needs broader redesign wherein existing models and systems of care, and not just internal processes, are subject to critical review and improvement.
Process redesign should be viewed as a useful tool, but the primary starting point must continue to be the delivery of evidence-based care, which is known to give patients the best chance of optimal outcomes.
References
- Health services under siege: the case for clinical process redesign. Med J Aust 2008; 188 (6 Suppl): S1-S40.
- Psaty BM, Lumley T. Surrogate end points and FDA approval: a tale of 2 lipid-altering drugs. JAMA 2008; 299: 1474-1476. 0_i1091855
- O’Connell TJ, Bassham JE, Bishop RO, et al. Clinical process redesign for unplanned arrivals in hospitals. Med J Aust 2008; 188 (6 Suppl): S18-S22. 0_i1091857
- MacLellan DG, Cregan PC, McCaughan BC, et al. Applying clinical process redesign methods to planned arrivals in New South Wales hospitals. Med J Aust 2008; 188 (6 Suppl): S23-S26. 0_i1091859
- Reddy, M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA 2006; 296: 974-984. 0_i1091861
- Ben-Tovim DI, Bassham JE, Bennett DM, et al. Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”. Med J Aust 2008; 188 (6 Suppl): S27-S31. 0_i1091865
- Going lean in health care. IHI Innovation Series white paper. Cambridge, Mass: Institute for Healthcare Improvement, 2005: 1-20. 0_i1091866