Intuitive-System Barriers to Quality Health Care

One of my teaching roles involves reviewing clinical quality improvement (QI) projects led by students in our Doctor of Nursing Practice (DNP) program. The classic QI method involves looking at regular reports from a clinic or hospital unit, graphing the data either monthly or weekly, and making changes with the hope of seeing a sharp improvement on the graph right around the time that the interventions were put into place. For example, a student might measure the percentage of hospitalized patients who have a fall after surgery (generally considered to be a preventable adverse event) on a weekly basis. If the rate is generally stable, but it goes down after the student initiates some provider training and a new procedure to screen patients for fall risk, and then the rate stabilizes at the new lower level going forward, it’s reasonable to assume that the student’s QI project caused the improvement. Regular measurement is the key: In the words of management consultant Peter Drucker (inventor of the idea of "SMART goals"), "once you have started to measure something, you have begun to improve it." In the course of reviewing literally hundreds of students' QI projects, I have seen many wonderful improvements in health care systems. Most of them also produce real-world benefits for patients in terms of better health outcomes, fewer negative events, or improved quality of life. As a whole, these student projects are saving lives. 

In the context of these many projects, though, I have also seen some dramatic changes in the wrong direction. Sometimes, the quality of health care becomes demonstrably worse. A lot of the time these negative changes go undocumented, but in many student projects we happened to see one of these just because a student was regularly measuring and reporting on some indicators of quality care. Negative changes weren't limited to one type of measurement: They were across-the-board drops in quality that showed up in process metrics like the percent of patients receiving follow-up calls after hospital discharge, adverse event metrics like the number of falls or pressure ulcers at a hospital, or patient-centered outcomes like the percentage of patients successfully treated for hypertension or depression. 

In almost all cases, when the quality indicators show a major movement in the wrong direction it reflects a systematic problem. The changes have nothing to do with health care professionals’ training or good intentions, but instead are created by the workings of the health care system itself. In Two Minds Theory terms, the health care system at these times experiences an "intention-behavior gap": People at the organization are actively working to improve some quality metric, but circumstances create a change in the wrong direction. This shows that health care providers are just like everyone else: Their Intuitive minds respond to environmental changes in ways that may be completely contrary to the intentions and preferences expressed by their Narrative minds.

Here are three major trends that often predict a significant drop in the quality of health care over time:

1. Staff Turnover. The most common timeframe for this type of problem is midsummer, specifically just after July 1. That's the date when most teaching hospitals start their new class of trainees, resulting in a large-scale replacement of more experienced providers with less experienced ones. (One moral of this story: Do everything you can to avoid needing hospital care around the Fourth of July). But other changes in staffing are less predictable. For instance, a group of staff members might resign in protest over some organizational policy or pay issue, or competition for providers within a particular metro area might result in frequent job changes. Staff turnover is a problem in any kind of business, resulting in excess time spent on activities like hiring, training, orientation paperwork, etc. Students leading QI initiatives often need to start from square one in training new staff about their quality initiatives, and it can be harder to engage new staff members' interest in these activities when they are still just learning the basics of their new job environment. More subtly, the less there is continuity within a team of health care providers, the harder it will be to achieve high-quality results because a great deal of improvement comes out of the group dynamic between people who get along well and know they can rely on each others' varied areas of expertise.

2. Electronic Health Record Changes. The electronic health record (EHR) is a major aspect of most health care providers' daily work experience, even if it's invisible to patients. When I first entered practice, our Medical Records department was a large room filled with manila folders, staffed with people who would pull individual files and check out a stack of them corresponding to a provider's patient list for that day. Sometimes interviews were "performed without benefit of chart" (something that we would document in our progress notes). EHRs have overcome many of those limitations. They also provide a convenient way for QI specialists to deliver just-in-time "alerts" or reminders to providers, prompting them to ask questions, order labs, or offer preventive services that they otherwise might have forgotten. But EHRs also lead to "alert fatigue" among health care providers, who become adept at clicking quickly through screens they don't want to pay attention to. Over time, the EHR becomes just part of the background of providing health care -- sometimes a help, other times an annoyance, but in general something that providers interact with unthinkingly, navigating smoothly around with help from their Intuitive minds. A new EHR system significantly disrupts this smooth process: Information may be in a new location, might not appear when the provider expects it to, might come linked to a different set of alerts or practice tools, and in general might be harder to navigate just because of unfamiliarity. Hospitals or health care systems often select new EHRs for reasons of cost or convenience -- e.g., because they operate more smoothly across sites, or facilitate communication with a valued partner organization. But data from many student QI projects attest to the hidden cost of an EHR change, which is often associated with a 10-20% drop in quality improvement measures, a drop that can last for 3 to 6 months after the EHR change. 

3. Changes in Leadership, Finances, or Organizational Priorities. In the past year, most health care organizations made rapid changes due to the COVID-19 pandemic (e.g., a shift to telehealth). And many organizations experiences extreme financial stress due to the suspension of elective surgery for several months and the overall tendency for patients to delay any care that seemed optional to them. But in more normal times, the most common cause of changes in a health care organization's priorities had to do with mergers and acquisitions. Health care organizations are consolidating at a very fast rate, with free-standing clinics and hospitals being absorbed into much larger systems. This kind of organizational shake-up often leads to a new leadership structure, and potentially a different focus in terms of the organization's mission, values, and financial goals. Like EHR changes, this kind of transition can simply be distracting. It can also lead to an actual change in EHR systems to better integrate with the new parent organization. And it can result in simultaneous staffing changes if individual providers don't want to be part of the new system. But above and beyond those effects, a shift in priorities can result in a student's QI initiative being sidelined by other organizational projects and goals. If I'm trying to do a better job of treating my patients' depression, for example, and my clinic is acquired by a large organization with the philosophy of referring depression to a specialist at another location, the whole objective of my QI project needs to be reconsidered. I might still try to help patients with depression, but I will now need to go about it in a very different way. It might take some time for me to learn the new system and get my project rolling again; this can take so much time and effort that many QI projects simply don't survive the transition.

The Intuitive mind can be seen at work in all of these problems. Intuitive-level thinking relies on habit and training, which are often lacking in newly arrived health care team members. Success often depends on intuitive-level social perceptions that allow us to lean on our team members' expertise without thinking about it. Because the Intuitive mind operates so strongly based on habit, sudden changes like a new EHR can take up part of providers' limited attention, leaving fewer cognitive resources to deliver high-quality health care. Increased demands on providers' attention might even lead to glucose depletion, with providers experiencing worse mood, more craving for unhealthy foods, and poorer concentration as a result. (Speaking for myself, I would rather not be treated by an upset and distracted provider if I can help it!) Organizational changes such as an acquisition or a major financial shake-up can contribute to all of these problems. But they can also change a health system's focus or goals, which shape health care providers' behavior at the Intuitive level by way of behavioral barriers and incentives. Even providers who are aware of these problems and actively work to overcome may find themselves involuntarily distracted by changes in their environment.

What can we do about these problems? As patients, we can be alert to organizational changes like staff turnover, EHR changes, or recent mergers and acquisitions, and seek a second opinion if we think these things might be interfering with our health care providers' judgment. But if we want to prevent these problems from happening, we need to remove some of the distractions from health care providers' work lives. We can support more positive and human-centered work arrangements in order to minimize turnover (some providers, for instance, prefer telehealth work while others love their in-person patient visits; like any industry, health care needs flexible or hybrid work options rather than one-size-fits-all). And we can support models of health care that are less like a business and more like a public institution, whether that takes the form of public financing or simply greater regulation of private-sector health care. Those kinds of policy changes can reduce the amount of churn and wasted effort that occur when health care organizations are run like businesses with an excessive focus on the bottom line. And ultimately they can remove roadblocks that get in the way of providing high-quality care, saving lives.