My observation of the healthcare insurance reform debate and the war debate and the Tiger Woods debate and the economy debate and the obesity debate and the. . .is that there a lot of debates. There is little action towards an idea, centrally agreed upon that will move the U.S. and perhaps the world forward.
So, I came to the conclusion that all of us have become coffee table, computer desk, bar, stationary bike, recliner, barber shop statisticians as we are all engaged in Predictive Modeling. Let me briefly explain.
Predictive modeling is the process by which a model is created or chosen to try to best predict the probability of an outcome. (Geisser, Seymour (1993). Predictive Inference: An Introduction) In many cases the model is chosen on the basis of detection theory to try to guess the probability of a signal given a set amount of input data (Wikipedia).
The difference with us armchair statisticians in regard to predictive models for healthcare reform is that our models (for the most part) are not based on "detection theory" as described above. If so, that would mean that there was some level of understanding about how we discern potential outcomes. In most of the situations that we currently face including health insurance reform, the dynamics are completely without discernment.
In fact, most predictive modeling going on currently is based on one or a combination of: Self Interest, Fear, Preferred Media Outlet, and in the case of healthcare reform one's general depth (or lack thereof) of knowledge about healthcare.
Now, my biggest concern about the entire dynamic that we are facing is that given the circumstances (maybe given any circumstance at any time), speculation about what will happen in the future that is so highly unpredictable is a formula for failure and perhaps a formula for mass paranoia. It is not worth it.
What is the alternative? Well, I will stick to what I am most familiar with and what is the subject matter of this blog. . .Moving healthcare forward, in my opinion, will be much less dependent on reform of the system than it is on a paradigm shift in our organizations and individual consumers. The fundamental premise of healthcare is not cost, it's people, quality, and care in that order. I recognize that we have to make money to stay in business, those that know me will tell you I am far from naive in that regard.
However, the "money first" strategy has gotten us where we are in healthcare. The heuristic that emphasizes care is grossly compromised by financial considerations. In a model where people come first, efficiency is created through effective communication. Doing things well early in the process and setting the stage for effective self-care will inevitably save money.
Let's try this as a premise--1) focus on people/patients; 2) with this focus learn what effective communication is for each patient--make developing cultural competence central to effective communication; 3) resolve that effective communication for a year and the investment into it (not a highly expensive one) will impact quality/core measures more than anything else a healthcare organization can do.
Now, this premise is not going to quell the voracious appetites for the predictive tweeters and bloggers, ranting on about how the world is coming to a halt due to the actions of a single leader in one year. Nor will it make those demanding a public option without knowing enough about the pros and cons to do anything more than make an emotional plea.
What the premise above or any other premise you suggest can do is move us towards something we commonly agree on with the intent to use this heuristic to prove something or disprove something rather than speculate ourselves stagnant.
Make it a great day!
Showing posts with label quality affordable health care. Show all posts
Showing posts with label quality affordable health care. Show all posts
Thursday, December 17, 2009
Sunday, October 25, 2009
Go Beyond the Surface
It has been a minute since I had an entry. It has not been a break from the conversation, just one from my writing about the cultural competence and quality on our blogs.
This one will be short. It often occurs to me that we often think about health disparities purely from a deficit model. We approach the prevalence of adverse health outcomes with the notion that our opportunity lies solely in fixing what's wrong.
It is natural to try to repair the wrongs, especially when they are driving our intention. The issue with this is that it is a purely past-based approach that inherently leaves us with limits. We are limited in the sense that we begin to look for the root of problem and then spend countless hours and endless conversations about changing the root.
The problem is that the root is resistant to change just like we are. In fact, if I were to stretch a little, I would say that where health disparities (aka quality disparities) are concerned, trying to get at the root causes and change them won't work. Of course, I don't think change works all that well either.
When we enter into the conversation about health disparities, it is important to do a strengths inventory as well as understand the dynamics of disparate outcomes on the negative side. In example, is the "Chicana effect" with birth outcomes. This term has been used to indicate that interesting fact that low birth weight birth outcomes are similar to that of whites and in some instances have been found to be lower regardless of social-economic status. It has led researchers to conclude that there are things socially and culturally within Latino/Chicano culture that are protective in nature.
If research and/or anecdote via our experience gives us insight into a positive health outcome in a particular community, it is vital that we look at the dynamics involved within that outcome. They may be sociocultural, they be structural, they can be a number of things. And it is possible that they can be leveraged in our cultural competence and quality efforts.
Make it a great day!
This one will be short. It often occurs to me that we often think about health disparities purely from a deficit model. We approach the prevalence of adverse health outcomes with the notion that our opportunity lies solely in fixing what's wrong.
It is natural to try to repair the wrongs, especially when they are driving our intention. The issue with this is that it is a purely past-based approach that inherently leaves us with limits. We are limited in the sense that we begin to look for the root of problem and then spend countless hours and endless conversations about changing the root.
The problem is that the root is resistant to change just like we are. In fact, if I were to stretch a little, I would say that where health disparities (aka quality disparities) are concerned, trying to get at the root causes and change them won't work. Of course, I don't think change works all that well either.
When we enter into the conversation about health disparities, it is important to do a strengths inventory as well as understand the dynamics of disparate outcomes on the negative side. In example, is the "Chicana effect" with birth outcomes. This term has been used to indicate that interesting fact that low birth weight birth outcomes are similar to that of whites and in some instances have been found to be lower regardless of social-economic status. It has led researchers to conclude that there are things socially and culturally within Latino/Chicano culture that are protective in nature.
If research and/or anecdote via our experience gives us insight into a positive health outcome in a particular community, it is vital that we look at the dynamics involved within that outcome. They may be sociocultural, they be structural, they can be a number of things. And it is possible that they can be leveraged in our cultural competence and quality efforts.
Make it a great day!
Wednesday, July 22, 2009
Cultural Competence is a Strategy II
I doubt that strategy and struggle have a common Latin root.
What I don't doubt is that they go hand in hand if success is desired.
With any change process, there is resistance. In many instances the resistance can even exist amongst those who want to actually see the change move forward. They may fundamentally believe in the idea of transforming the way their organization gets healthcare (or whatever their business is) done; nonetheless, something they cannot fully understand about their thinking or approach leaves them with results that are less than desired.
Why does this happen? It happens because CHANGE DOESN'T WORK.
Let me explain using a device that I found quite fascinating when I first came across the ad that read: "Drop 2-3 dress sizes in less than 10 minutes." When I first read it and then saw the pictures and read the testimonials on the postcard that was left on my car one day, I began to wonder how long this 2-3 size drop lasted. I was compelled to learn more because I have read about a lot of diets from The Zone to the Master Cleanser, and none of them promised results in such a short period of time.
As some of you who watch Oprah probably know (of course it was on Oprah!), this device is not actually a diet. It is in fact a very efficient body compression, girdle-type device that apparently allows one to wrap themselves up thus compressing 2-3 sizes worth of "love handles or other handles" that one has, leaving them visibly thinner under their clothing.
I am not discounting this device, it has its place. It creates change and from the outside, if you saw a person with one of these compression devices on, you would naturally perceive them to appear a certain way. They may appreciate your perception as their intention was to present themselves in a particular light.
Now, the person wearing this device changed, but how long did that change actually last? What will be required to sustain that change?
The answer: it cannot be sustained. It can be repeated and it can be replicated, but it cannot be sustained because CHANGE DOESN'T WORK. It doesn't fail because we are not sincere about our desire to see lasting results. It doesn't fail because the intention is not sincere or carefully considered. Change doesn't work because as long as it is viewed as change it will be resisted and it will be changed again. Change is a tactic. Some tactics have longer-term success than others but in and of themselves, they fall short of creating results that are sustainable.
So, change is like the love handle compression device shared above. It is a tactic that creates the appearance of a desired result, but it is not the desired result because its not possible for it to be sustained. 10 minutes to decrease 2-3 dress sizes is akin to doing a 2 hr, 4hr, or two-day "diversity" or "cultural competency" training and expecting that the learning will be sustained and put into practice. I am not saying that it doesn't have a positive effect and given that we deliver training as one of our services, I recommend it. However, I am very clear that it is a tactic in an overall strategy that takes more time and more struggle.
Cultural Competence is a Strategy--it is an organizational development strategy. If it is framed as such (and aligned with your overall organizational quality strategy) it can be a transformational strategy. Transformation is sustainable as it implies that the process leads to a place where what your organization is doing tactically transcends the moment of implementation and speaks to practices becoming part of what I call your "Organizational Being". This is in contrast to "Organizational Doing" which speaks to something temporary and consciously or unconsciously viewed as marginal to success.
A solid cultural competence strategy takes struggling with current mindsets, norms, and a variety of other conversations that we have become accustomed to that require a shift of perspective to create quality healthcare delivered in a patient-centered, culturally competent manner.
Next time I will speak briefly on leading your cultural competence efforts strategically.
Make it a great day!
What I don't doubt is that they go hand in hand if success is desired.
With any change process, there is resistance. In many instances the resistance can even exist amongst those who want to actually see the change move forward. They may fundamentally believe in the idea of transforming the way their organization gets healthcare (or whatever their business is) done; nonetheless, something they cannot fully understand about their thinking or approach leaves them with results that are less than desired.
Why does this happen? It happens because CHANGE DOESN'T WORK.
Let me explain using a device that I found quite fascinating when I first came across the ad that read: "Drop 2-3 dress sizes in less than 10 minutes." When I first read it and then saw the pictures and read the testimonials on the postcard that was left on my car one day, I began to wonder how long this 2-3 size drop lasted. I was compelled to learn more because I have read about a lot of diets from The Zone to the Master Cleanser, and none of them promised results in such a short period of time.
As some of you who watch Oprah probably know (of course it was on Oprah!), this device is not actually a diet. It is in fact a very efficient body compression, girdle-type device that apparently allows one to wrap themselves up thus compressing 2-3 sizes worth of "love handles or other handles" that one has, leaving them visibly thinner under their clothing.
I am not discounting this device, it has its place. It creates change and from the outside, if you saw a person with one of these compression devices on, you would naturally perceive them to appear a certain way. They may appreciate your perception as their intention was to present themselves in a particular light.
Now, the person wearing this device changed, but how long did that change actually last? What will be required to sustain that change?
The answer: it cannot be sustained. It can be repeated and it can be replicated, but it cannot be sustained because CHANGE DOESN'T WORK. It doesn't fail because we are not sincere about our desire to see lasting results. It doesn't fail because the intention is not sincere or carefully considered. Change doesn't work because as long as it is viewed as change it will be resisted and it will be changed again. Change is a tactic. Some tactics have longer-term success than others but in and of themselves, they fall short of creating results that are sustainable.
So, change is like the love handle compression device shared above. It is a tactic that creates the appearance of a desired result, but it is not the desired result because its not possible for it to be sustained. 10 minutes to decrease 2-3 dress sizes is akin to doing a 2 hr, 4hr, or two-day "diversity" or "cultural competency" training and expecting that the learning will be sustained and put into practice. I am not saying that it doesn't have a positive effect and given that we deliver training as one of our services, I recommend it. However, I am very clear that it is a tactic in an overall strategy that takes more time and more struggle.
Cultural Competence is a Strategy--it is an organizational development strategy. If it is framed as such (and aligned with your overall organizational quality strategy) it can be a transformational strategy. Transformation is sustainable as it implies that the process leads to a place where what your organization is doing tactically transcends the moment of implementation and speaks to practices becoming part of what I call your "Organizational Being". This is in contrast to "Organizational Doing" which speaks to something temporary and consciously or unconsciously viewed as marginal to success.
A solid cultural competence strategy takes struggling with current mindsets, norms, and a variety of other conversations that we have become accustomed to that require a shift of perspective to create quality healthcare delivered in a patient-centered, culturally competent manner.
Next time I will speak briefly on leading your cultural competence efforts strategically.
Make it a great day!
Saturday, July 4, 2009
Health Disparities are Quality Disparities
The 2008 National Healthcare Quality Report and the National Healthcare Disparities Report from the Agency for Health Research and Quality were and are generally published each year at the same time.
This is very much appropriate, but it is hard to know if people are making the connection between the two reports. If we have health and/or healthcare disparities, particularly in the sense that with most things equal (SES, access, etc.) there are still disparate outcomes or disparities, what does that speak to?
Well, there are few things that we can consider.
1) Genetics: While the data on genetic predisposition is emerging there are pros and cons to this variable. A 2005 editorial The Role of Race and Genetics in Health Disparities Research out of the American Journal of Public Health summarizes the potential role of the human genome mapping in our evaluating causes and approaches to health disparities quite succinctly.
My experience is that given the long history of disparate outcome by race coupled with the emerging understanding of disparities in the LGBT, Disabilities, and other communities, genetics may play a role but the role that they play will be at best complementary.
2) Social, Environmental, Behavioral Factors: Health behaviors differ from person to person. Some of these behaviors are influenced by cultural health models and beliefs, experiences and responses to the health system and healthcare providers, and environmental circumstances. Behavior has and will always have an influence on health outcomes and behaviors will always be influenced by the behaviors of healthcare providers. So, the dynamic is a two-way street. There is evidence that experiences of healthcare providers (of all ethnic backgrounds) influence how treatments and recommendations for treatment are allocated. One classic study of this is a New England Journal of Medicine Article by Schumann, et. al.: The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization.
While there were subsequent articles that questioned the authors' findings and the subsequent media attention that was generated, there was no denying the unequal treatment recommendations were prevalent and conclusive from the data collected in the study. This leads me to one last consideration (for now):
3) Quality Disparities: What do I mean by "quality disparities"? Let's move outside of healthcare for a minute and consider other industries where quality is vital (assume all industries believe it is).
For example, as the president of a company you have been delivering a high-quality product or service for quite sometime. Based on your evaluation and the responses of the customers, you are receiving feedback that what you are producing is consistently good amongst a majority of your customers. You are committed to quality because of your dedication to maintaining integrity but also due to the fact that your competition is fierce and while you are leading the pack, you never take your success for granted.
One day, it is brought to your attention that over 25% of your customers (by industry vertical, geography, or some other variable) are experiencing negative outcomes in the utilization of your product or service, yielding on average 2 times more problems than the other 75%.
What is your response? What do you think?
Well, one response is to say, "we have been delivering quality for so long, what is it with these 25%? We give everyone the same service consistently."
Another response is to say, "where is the breakdown?" Followed by, "is there something that we don't really understand about our customers that will help us serve them better?"
In an environment of stiff competition, you will do your research to understand who these 25% are, what exactly their challenges are and develop solutions to narrow the outcomes gap.
Or, you will decide that these 25% of customers are the problem and let them go, concluding that the 80/20 rule says that they are not necessarily benefiting you that much anyway. This may work or it may take you out of the #1 spot as the industry leader, especially if those segments are fast growing.
Back to healthcare. If 20% or more of our patients are experiencing worse health outcomes than the other 80%, obviously there are disparities there. More than likely, this is also what I would consider a quality issue even if we know that "we are treating everyone the same".
Why is this a quality issue? In fact, why are health disparities quality disparities? The answer lies not in the fact that hospitals are not delivering quality services. I believe that most facilities and individual practitioners are delivering very high quality services. I also think there are distinctions in what translates as quality.
Patient-centered care asks us to treat patients as individuals. It suggests that each patient is functioning and managing their health under a unique set of circumstances and if those circumstances are not understood to as great of an extent as possible, we may miss the mark on their needs short and long term and thus contribute to less than the best outcomes.
Missing the mark is reflective of the quality of services delivered for each person based on their unique needs that can sometimes be a result of archetypal dynamics of a particular group identity.
If over time, certain demographic segments are experiencing poor outcomes (just like a certain vertical or segment of a non-healthcare company) quality is being compromised. Your integrity is not compromised--you are doing all that you know how to do--but your outcomes are unequal and therefore certain groups are not getting what you intend for them to get and in some cases what you promise them based on previous experiences.
The response in healthcare has to be the first response described above for the hypothetical company--understand this population and develop solutions to address their problems. The second option of letting these customers go is not an option in healthcare. While there have been instances in which populations with greatest needs have been met with barriers to treatment because of the challenges they present, this is a response that given the times we are in and the realities of demography, we simply will not and cannot consider. We cannot do it morally nor can we shoulder it economically.
Aligning cultural competence with quality, affordable and accessible care is what the DHW Cultural Competence-Quality Framework for Healthcare Excellence is all about. Understanding that integrated efforts towards eliminating health and healthcare disparities (a core part of our CC-Q Framework) are a critical and central tenant in the quality care that all Americans desire is vital to assuring our success in reforming the healthcare system.
This post is a very short exploration of health disparities being considered as quality disparities. I would like to explore the idea of health disparities compromising our goal of quality affordable care in more detail. Please share your thoughts with me, the Diversity HealthWorks community and all those visiting our blogs.
Make it a great day!
This is very much appropriate, but it is hard to know if people are making the connection between the two reports. If we have health and/or healthcare disparities, particularly in the sense that with most things equal (SES, access, etc.) there are still disparate outcomes or disparities, what does that speak to?
Well, there are few things that we can consider.
1) Genetics: While the data on genetic predisposition is emerging there are pros and cons to this variable. A 2005 editorial The Role of Race and Genetics in Health Disparities Research out of the American Journal of Public Health summarizes the potential role of the human genome mapping in our evaluating causes and approaches to health disparities quite succinctly.
My experience is that given the long history of disparate outcome by race coupled with the emerging understanding of disparities in the LGBT, Disabilities, and other communities, genetics may play a role but the role that they play will be at best complementary.
2) Social, Environmental, Behavioral Factors: Health behaviors differ from person to person. Some of these behaviors are influenced by cultural health models and beliefs, experiences and responses to the health system and healthcare providers, and environmental circumstances. Behavior has and will always have an influence on health outcomes and behaviors will always be influenced by the behaviors of healthcare providers. So, the dynamic is a two-way street. There is evidence that experiences of healthcare providers (of all ethnic backgrounds) influence how treatments and recommendations for treatment are allocated. One classic study of this is a New England Journal of Medicine Article by Schumann, et. al.: The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization.
While there were subsequent articles that questioned the authors' findings and the subsequent media attention that was generated, there was no denying the unequal treatment recommendations were prevalent and conclusive from the data collected in the study. This leads me to one last consideration (for now):
3) Quality Disparities: What do I mean by "quality disparities"? Let's move outside of healthcare for a minute and consider other industries where quality is vital (assume all industries believe it is).
For example, as the president of a company you have been delivering a high-quality product or service for quite sometime. Based on your evaluation and the responses of the customers, you are receiving feedback that what you are producing is consistently good amongst a majority of your customers. You are committed to quality because of your dedication to maintaining integrity but also due to the fact that your competition is fierce and while you are leading the pack, you never take your success for granted.
One day, it is brought to your attention that over 25% of your customers (by industry vertical, geography, or some other variable) are experiencing negative outcomes in the utilization of your product or service, yielding on average 2 times more problems than the other 75%.
What is your response? What do you think?
Well, one response is to say, "we have been delivering quality for so long, what is it with these 25%? We give everyone the same service consistently."
Another response is to say, "where is the breakdown?" Followed by, "is there something that we don't really understand about our customers that will help us serve them better?"
In an environment of stiff competition, you will do your research to understand who these 25% are, what exactly their challenges are and develop solutions to narrow the outcomes gap.
Or, you will decide that these 25% of customers are the problem and let them go, concluding that the 80/20 rule says that they are not necessarily benefiting you that much anyway. This may work or it may take you out of the #1 spot as the industry leader, especially if those segments are fast growing.
Back to healthcare. If 20% or more of our patients are experiencing worse health outcomes than the other 80%, obviously there are disparities there. More than likely, this is also what I would consider a quality issue even if we know that "we are treating everyone the same".
Why is this a quality issue? In fact, why are health disparities quality disparities? The answer lies not in the fact that hospitals are not delivering quality services. I believe that most facilities and individual practitioners are delivering very high quality services. I also think there are distinctions in what translates as quality.
Patient-centered care asks us to treat patients as individuals. It suggests that each patient is functioning and managing their health under a unique set of circumstances and if those circumstances are not understood to as great of an extent as possible, we may miss the mark on their needs short and long term and thus contribute to less than the best outcomes.
Missing the mark is reflective of the quality of services delivered for each person based on their unique needs that can sometimes be a result of archetypal dynamics of a particular group identity.
If over time, certain demographic segments are experiencing poor outcomes (just like a certain vertical or segment of a non-healthcare company) quality is being compromised. Your integrity is not compromised--you are doing all that you know how to do--but your outcomes are unequal and therefore certain groups are not getting what you intend for them to get and in some cases what you promise them based on previous experiences.
The response in healthcare has to be the first response described above for the hypothetical company--understand this population and develop solutions to address their problems. The second option of letting these customers go is not an option in healthcare. While there have been instances in which populations with greatest needs have been met with barriers to treatment because of the challenges they present, this is a response that given the times we are in and the realities of demography, we simply will not and cannot consider. We cannot do it morally nor can we shoulder it economically.
Aligning cultural competence with quality, affordable and accessible care is what the DHW Cultural Competence-Quality Framework for Healthcare Excellence is all about. Understanding that integrated efforts towards eliminating health and healthcare disparities (a core part of our CC-Q Framework) are a critical and central tenant in the quality care that all Americans desire is vital to assuring our success in reforming the healthcare system.
This post is a very short exploration of health disparities being considered as quality disparities. I would like to explore the idea of health disparities compromising our goal of quality affordable care in more detail. Please share your thoughts with me, the Diversity HealthWorks community and all those visiting our blogs.
Make it a great day!
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