The Case for Local Management in Care of Frail Elders

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In 1980, American business discovered W. Edwards Deming and his quality improvement work in the Japanese automotive industry. In fact, that work helped to launch the application of Total Quality Management (TQM) strategies in the American healthcare system.In his final book, The New Economics, Deming outlined a way of seeing, a lens for looking at work and at life. He called this lens The System of Profound Knowledge (SoPK), and using it was to enable improvement in the quality of every facet of business life, including the quality of management, as well as the quality of our interactions with one another and with the environment.

To learn more about SoPK, one can find much detail on a website devoted to Deming’s life and work. And the video narrated by Ian Bradbury provides a good overview, too.

Deming considers the whole of a system. He wrote, “A system consists of components. Any company, any industry, consists of components that are different activities. All the components of the system must contribute to the system, not exist for their individual gains.”

Deming’s work has influenced more than twenty years of healthcare quality improvement efforts; healthcare system leaders have embraced an array of methods and techniques, including rapid-cycle quality improvement, Lean, and others. In general, successful quality improvement efforts require five essential elements:

  • Foster and sustain a culture of change and safety.
  • Develop and clarify an understanding of the problem.
  • Engage key stakeholders.
  • Test change strategies.
  • Conduct continuous monitoring of performance and reporting of findings to sustain the change.

These improvement essentials are a foundation upon which MediCaring communities can begin to improve care for frail elders, in part by addressing the very systems in which they live: Their communities. As Deming notes, systems are everything, in business and in communities. By focusing on local improvements in care for frail elders, MediCaring considers the environments in which frail elders live: in communities, tied to local norms, traditions, standards, resources, and so on. Indeed, frail elders are often tied to geography and local community: They get meals at senior centers or from Meals-on-Wheels, they do not have the resources or the reserves to travel far and search for something better.

Local leadership is able to respond to local needs, priorities, and preferences. It can assess what its residents need, what it can offer, and how to allocate resources. Local leadership in the form of a local board or authority can provide the five elements essential to improved quality in community care of frail elders. Such a board—an MediCaring Board, an ElderBoard—would provide the locus for assessing, monitoring, and managing services.

How might this begin to work? In a community of 50,000 people, it is reasonable to expect that about 500 frail elders need services at any point in time. Imagine how different frail elders’ lives would be if each one had a comprehensive, longitudinal care plan developed in concert with a multidisciplinary MediCaring team. That team would have ready access to those plans, and a commitment to ensuring that priorities were known and addressed. That team would also track outcomes, and shift course to correct gaps.

Such an approach would be a real advance in delivering reliability, quality, and efficiency in care. Those care plans could be used to evaluate a community’s overall services system, both in terms of quantity and quality. Planners and providers could readily see, for example, instances in which a particular service was oversupplied and overutilized, when a less costly service could have met the need. Consider, for instance, that our community has so many nursing home beds that it is simply routine and expedient to house people in those beds, and not in the community.

Aggregating care plans and using them in system planning would allow for ongoing monitoring that could in turn enable system managers to more readily address variations and anomalies that affect utilization and outcomes. For example, perhaps the 50 people who had a major fall with injury last year had widely varying response, ranging from some who received many tests and procedures followed by rapid institutionalization, to those who got short-term treatment, focused assessment including in-home evaluation, and modifications and supports in the home. If the more streamlined treatment group were found to have equal or better outcomes, and was in other ways similar to the other cohort, perhaps clinicians responsible would decide to change their practice patterns.

Taking a broader view, we could begin to plan for greater efficiencies. Consider another example. Let’s assume that a dozen people in one apartment building need home care aides. Rather than sending in a dozen workers for morning activities and another dozen for evening, with a 3-hour minimum work requirement for each, perhaps we could move a few around within a small area – say a few square blocks or miles — and cover all service needs with half as many aides, who would also know with greater certainty how many hours they would be working. It is also possible with a more efficient system to pay these workers higher wages, and concentrate their time on providing services, rather than driving or commuting between far-flung homes.

Periodic review of aggregated care plans would also make it possible to rapidly identify and investigate ineffective services that are being recommended. For example, many persons with a vertebral fracture do not need multiple scans and procedures. Likewise, an elder with attentive family in the area is unlikely to need grocery delivery.

However, there is no such planning, monitoring and rational management of the services for frail elders, or for other vulnerable populations. We are thoroughly inattentive to the per-person costs and quality of the care we provide across all relevant settings, combined with a magical belief that disparate service providers will somehow end up right-sizing their services and optimizing their quality. This is obviously implausible. Without a way to look across the care system for a community, hospitals maximize hospital revenues, nursing homes optimize nursing home investments, nutrition providers optimize grants and budgets for their services, and so on. There is no requirement that these myriad services somehow end up doing “just right” by the population, and it is not at all likely that they ever will.

MediCaring aims to change this status quo. And developing a local authority to start the change is a key step in the right direction.

References

W. Edwards Demming. Interview in Automobile Magazine, Ann Arbor, Michigan, June 1991

key words: MediCaring book, Joanne Lynn, Janice Lynch Schuster, frail elders

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