Discovering the Cause and Cure for
America’s Health Care Crisis
A physician’s memoir
CQI Applied to the American Health Care System
I became a W. Edwards Deming disciple during the late 1980s training and experience with his Continuous Quality Improvement (CQI) management method, fourteen points and seven deadly diseases of American business. Out of the Crisis, by Dr. Deming is a very difficult read requiring deep knowledge of business. Mary Walton, in collaboration with Dr. Deming, wrote The Deming Management Method. This book presents Dr. Deming’s business management concepts in a way easily understood by the lay person. Dr. Deming’s book was reprinted in 2000.
I realized many of his concepts had direct application to our health care system. With profound knowledge of CQI came my epiphany, and CQI became one pillar of the foundation for my vision. My contacts with Dr. L. L. Weed, the father of the Problem Oriented Electronic Medical Record (POEMR), and his concepts about medical education and decision making, became another pillar. My experience in private practice and administrative medicine formed the third pillar. The blend of my education, training, life experience and contacts with these two intellectual giants resulted in the formulation of my vision of the future American health care system.
Deming’s Fourteen Points and Seven Deadly Sins, focused on improving the quality of manufactured goods and services through improving the work flow processes and following production with statistical analysis. He believed that most errors were directly related to the process rather than a special cause resulting from an individual worker’s mistake. Flawed work flow processes produce predictable error rates. Dr. Deming understood quality improvement depended on improving the process.
Dr. L. L. Weed determined medical errors were the result of the physician’s flawed decision making process. In effect, the physician is at the center of both the flawed process and delivery of the service. His focus was on the problems in medical education, medical records and medical decision making. Decisions made using global subjective memory based intuition rather than evidence based on standards of clinical epidemiology produce and error rate approaching 50 percent.
His early book, Medical records, medical education, and patient care; the problem-oriented record as a basic tool, proposed a radical change from source oriented to problem oriented medical records and from incident based charting entries to S.O.A.P. (subjective, objective, appraisal, plans) notes. Each patient problem required a structured plan consisting of:
1) Goal of treatment;
2) Basis for the problem statement;
3) Status of the problem;
4)Disability from the problem;
5) Parameters to follow [both symptomatic and objective] and the treatments;
6) Investigate further—to rule out what diagnoses and by what means;
7) Complications to watch for.
Dr. Weed developed personal computerized patient medical records and medical decision support to shift the basis of physician decision making from memory based to clinical evidence based. His computer programs supported his new medical records model. Dr. Weed understood the difference between doing the “right thing” and doing the “thing right.” He wrote Knowledge Coupling: New Premises and New Tools for Medical Care and Education, a book about computers in health care, in 1991.
My vision combines most of Dr. Deming’s quality improvement methods with most of Dr. Weed’s philosophy of and approach to the provider side of our health care system. I am a disciple of both men. However, my basic nature to question authority and skeptically view experts makes me a disciple in the “Doubting Thomas” mold. With this understanding, my modifications and explanations for adaptation of Dr. Deming’s concepts with Dr. Weed’s influence to our medical-industrial complex follows:
Transformation of Health Care Through Application of the Fourteen Points
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