I recently spent four days understanding what lies at the heart of one of America’s greatest health care organisations, Intermountain Healthcare. During this time I observed one of the world's most prolific leaders in the field of health quality improvement, Dr Brent James, begin delivering the Advanced Training Programme (ATP). Participation in this programme is part of leadership development for clinicians at Intermountain; it aims to give them the understanding and tools needed to conduct quality improvement projects and internal quality improvement training.
So, what are the merits of the ATP? And how has it led to a shift in the culture of the organisation?
On one level the most striking insights come from some ‘simple’ truths. At the heart of the ATP is a motivation to deliver the best care for patients, but not by defining doctors as ‘good’ or ‘bad’. The approach to learning is based on the assumption that clinicians can change how they practise, something that was reinforced many times in the foundation module.
The volume of information that clinicians have to absorb grows every year and can become overwhelming. Alongside the ATP, Intermountain is committed to managing knowledge across the organisation but allowing it to be customised in a systematic way that enables clinicians to evolve their protocols for the purpose of quality improvement and share these changes. Variations are observed and the differences between theory and reality are challenged. Dr James was clear that ‘the best patient care does not reside in one individual, every doctor has something to learn and teach’. The ATP is part of acculturation at Intermountain.
This discipline, which I witnessed first-hand during a visit to the labour ward, focuses on the processes of care delivery that sit within every treatment pathway, and not on the clinicians who execute the processes. It seeks to promote a learning culture where ‘better has no limits’. Individual team members were able to describe the part they had to play in quality improvement because they had helped to define their roles at the start of the project. When teams are involved in this way they are more engaged with the process, leading to quality improvement projects that deliver sustainable culture change.
Quoting Winston Churchill, Dr James reminded the latest ATP cohort that ‘people like to change, they just don’t like to be changed.’
This culture is also present in Intermountain’s primary care work, for example in the development of clinical protocols for diabetes care. Here, frontline GPs, nurses and diabetologists review their core practice as an integrated team, share new research ideas and help to integrate new care models into the decision support system.
Much of the ATP is derived from Dr James’s interpretations of the quality theorist W Edwards Deming’s work on process management theory. For example, Dr James applies Deming’s principle that a dependence on inspection to achieve quality creates a culture in which excellence does not flourish. The ATP has enabled Intermountain to create a culture in which quality has been built into its core processes and can therefore be continually improved. Clinical quality based on clinical integration is the organisation's business strategy. It benefits from strong leadership from its CEO, visible, unswerving ‘thought leadership’ from Dr James, an investment in building organisational skills and an infrastructure to support performance.
Twenty years’ dedication to the principles of clinical integration have contributed to Intermountain’s undisputed lead in the low-cost (by US standards) high-quality provider league. Leaders in health and care in the UK could look to Intermountain as a model for balancing the need for quick management action with more strategic leadership to create a sustainable plan for achieving better quality care at lower cost.
Dr James’s words – ‘do Deming or die’ – still ring in my ears.
- Vijaya will be talking about Intermountain and Mayo Clinic and what the NHS could learn from their approaches to quality improvement at her masterclass on 23 September