Without question, people are at the heart of quality healthcare, but computerized systems are needed to monitor their performance, measure improvement, and provide them with immediate feedback to keep them motivated and on track. Moreover, computer technology is needed to translate performance into useful information for consumers. Yet the role of electronic data in healthcare quality continues to be undervalued. As Chip Caldwell says, "Those who have chronicled the modern quality movement have failed to highlight the vital role of technology."¹

Caldwell continues, "Even when huge investments are made in technology, little attention is paid to the productivity gain." Likewise, little notice is made of how the use of technology directly contributes to, and is a conveyance for, quality. Previous articles in this series have detailed proven, standardized methods of monitoring and measuring quality; however, this article underscores the technology imperative. Technology, as a critical component of quality, propels the entire process to a strategic business initiative.

Quality is Strategic

In a business context a strategic plan is one that will be executed over a three to five year horizon with the target being specific, measurable outcomes. A strategic plan is one important enough to justify total commitment by leadership and financial commitment by the organization, with other significant resources allocated to it. Strategic decisions are driven by and toward the organization’s vision, mission, and goals. Therefore, authentic commitment to quality must be strategic.

Technology is the most consistently overlooked resource associated with quality performance. Because technology, with its attendant costs, is critical to achieving quality, a case must be made for the financial benefit of technology-supported quality performance. Does quality performance warrant allocation of sufficient resources necessary to achieve the goal? Does technology, with its associated costs, create a positive cost-benefit balance that justifies its inclusion in the strategic initiative? Only with cost-benefit analysis information in hand is management able to form a strategic decision regarding quality, thereby structuring and allocating affiliated costs and other necessary resources, including technology, to achieve the goal.

People are certainly at the heart of healthcare quality, but people are also the greatest cost in the quality equation. They are the perpetrators of errors, omissions, and redundancies, the most frequent causes of quality variance. Similarly, people are the greatest deterrent to exploiting the benefits of technology that would otherwise contribute to quality. Business and clinical processes have not been adjusted to incorporate adequate electronic documentation. The essential reason is that value is not attached to human effort applied to technology.

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Cost of Effort

Effort applied to electronic documentation is best evidenced by the time and focus dedicated to computer technology, regardless of the application. Only when management values technology output as much as other task-oriented activities will technology effort be consistently applied. Thus, the necessity for committed management leadership in achieving quality goals is essential. Employees do what their managers expect and reward them to do.

One way management can clearly demonstrate the high value of technology is to offer and require repeated training in system use. Staff well trained in the use of a system, with understanding about how the data are applied (beyond billing) is far more likely to embrace the technology with its necessary data entry effort. Furthermore, staff that are provided immediate feedback in the form of performance reports will recognize technology effort is part of the performance evaluation.

The cost of effort cannot be ignored, but it can be logically allocated and balanced against benefits. When a business rationale exists for measuring and monitoring specific quality variables, including assigned data entry accountabilities, the attendant costs for staff time can be applied and balanced against quality benefits gained.

Misperceived Cost

Besides effort, costs associated with technology are typically awarded to hardware and software purchase and maintenance. But twenty-five years of decreasing costs for PC technology render this a misrepresentation of the issue. Technology is now an expected and standard cost of doing business, similar to the cost of telephone service or insurance. What is not standard is understanding how to optimize available technology to gain its subordinate benefits that define and contribute to quality.

Benefits of Technology

Amazingly, many people still do not get it. Productivity opportunities inherent in software systems are overlooked as rationale for technology acquisition, upgrades, data integration, expansion and continued training. Productivity gains are consistently ignored when justifying additional staff training in the use of current systems. Marketing and competitive advantage opportunities go unnoticed when existing data could be re-portrayed and exploited for that purpose.

To be honest, 20 years ago productivity gains from technology were minimal. The notion of electronic recording was too new, too untried, and required too much effort. Results were inconsistent. Old manual methods were more familiar and reliable so people resisted change. But systems have improved exponentially and people are generally more fluent with them. Yet, attitudes toward computers and software have changed little, leaving unmined pockets of information opportunity.

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Looking for Quality in Data

Technology can be leveraged for budget justification. More interestingly, it can be used to harvest measures of productivity and quality, thereby realizing several advantages. Think of technology solutions to:

• remove operational redundancies;
• standardize processes;
• automate failure alerts;
• provide immediate feedback;
• measure improvement; and
• translate findings into meaningful information.

Remove operational redundancies: When new systems are implemented, redundant operational processes invariably surface. In a manual or non-comprehensive process, redundancy is expected, even necessary, while carrying a high error rate. Each time a process is repeated, a new opportunity for error emerges. But in electronically supported processes, redundancies can and should be eliminated, thereby improving accuracy and efficiency. For instance, patient and client satisfaction is increased when medical history questions are not repeated. The data are automatically summarized and available to caregivers within the system.

Not only are errors increased each time a process is repeated, the likelihood of offending patients and other constituents also increases, while efficiency and productivity suffers. A bonus benefit is that when redundancies are removed, staff formerly required to produce them can be reassigned to more productive (and satisfying) activities such as improving processes. Another way to decrease errors and increase efficiency is to standardize processes.

Standardize processes: Using software systems to standardize processes is legitimate. Standard processes are more efficient and lead to greater accuracy. Formerly, prevailing thought regarding software systems was that the work process should be adapted to the purchased system, but this is no longer true. Now systems are flexible and can be manipulated to mirror an efficient work process. No operation is completely standard across providers, but subtleties of detail and flow can be infused into the systems that add user-supported flexibility while significantly enhancing efficiency, accuracy and results. A process that requires even two minutes less time but is repeated twenty times a day saves forty minutes per day, an obvious but usually ignored fact.

Automate failure alerts: Yet another way to gain quality through technology is to add failure and error alerts to systems. Amazingly, the only requirement may be designing and infusing new variance reports and running them at key times during the day. Used as an accuracy check, variance reports look for data entered through normal processes that describe performance and service combinations that have been pre-identified as possibly leading to undesirable results. The focus may be clinical or simply identifying those that cause rework or apologetic damage control with clients.

Automated alerts can also be designed to activate immediately to prevent error by warning the user on the screen before an action is executed. Alerts on the screen or newly designed reports will both require special programming, but costs for either approach is minimal while the quality gains and risk management prospects may be extraordinary.

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Provide immediate feedback: The previous article in this series² points to the fact that sharing current performance results with staff will improve performance. Using reports that provide immediate feedback, individuals can self-monitor their performance, thereby initiating positive momentum toward improvement. To achieve this end, the information should be presented in an objective, rather than punitive manner by means of specially designed reports, and should be available regularly or on demand. Staff will anticipate the next report to review and adjust their performance, thereby influencing future feedback. The result is attention to quality and continued improvement.

Measure improvement: Information can be mined for improvement trends on a concurrent, short and long term basis, thereby creating performance information for user feedback and also competitive marketing. Using data as the basis for claiming service excellence is palatable to clients because it contains objective and measurable rationale for the alleged best practice. Moreover, when data are compared (benchmarked) to others by a third party, demonstrated quality is irrefutable.

Translate findings into meaningful information: Whether quality performance information is intended for staff, clients or other constituents, its vehicle must be designed for quick reading and easy comprehension. People respond to summarized, simple portrayals of data, rather than those that are lengthy and complex. Graphical reports portraying trends are especially powerful because they are visually absorbed instantly.

Footnotes