#MEQAPI – Tweetchat Jan 25-2018 3:00ET Perfection in Healthcare

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org

This is part 2 in the discussion of “perfection in healthcare”, in which we will continue down a practice-based QI journey. First we identify a few important parts of healthcare and ask what they would look like if they were perfect. This technique is also discussed in a recent Physician’s Weekly blog titled “Three Effective Ways to Pick Quality Improvement Targets“.

In this process, we will first chat about perfection, then in a future chat we will look for outliers (positive and negative), and then we will go through a root cause analysis on a few selected items to see if we can solve them to a degree.

In the previous blog on “Perfection in Healthcare”, I described a quality improvement method in which we reflect on a specific operation, and explore what it would look like if it were “perfect”. I defined what we would mean by “perfect”, thus:

QI poses a more practical, but still distant and largely unavailable level of perfection. This is the Theoretical Capacity, and is an expression of what a process could theoretically yield if everything was running at 100% performance and there were no defects. This is the level of perfection that will be the topic of the next few #MEQAPI chats.

Last time, we discussed the following elements:

  • Patients
  • Physicians
  • Nurses
  • Specialists
  • Environment

For this chat, we are going to run headlong through five components of the overall healthcare workflow:

  1. Training
  2. Diagnostics
  3. Scheduling
  4. Medication
  5. Emergency Care

For each of these, we are going to reflect of what it would look like if were perfect- what would the perfect patient be like, the perfect physician, the perfect nurse, etc. In future chats, we will take the input and explore more deeply.

Perfection 2

For example, is, does perfect training mean it must be timely, reflect real world needs, and not select students in a way that results in inequities?
What about medications would perfection reflect? – would they be safe, effective, affordable? Would reconciliation be an integral part?
How about emergency care? – Do we know when to head for the ED and when we can wait for the next available primary care appointment, do we know when to use an urgent care facility, when to call an ambulance, and when to DIY?




  1. What features, properties, or behavior does “Perfect Training” have
  2. What features, properties, or behavior does “Perfect Diagnostics” have
  3. What features, properties, or behavior does “Perfect Scheduling” have
  4. What features, properties, or behavior does “Perfect Medication” have
  5. What features, properties, or structure does “Perfect Emergency Care” have

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

    • Methods
      • Policies: office, organization, or national policies, including, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Quality Improvement Policies
      • Subsidies and funding
      • Facility Policies
      • Specialty Policies
      • Employment policies
      • National and State Laws
      • Training
      • Navigable processes and policies
      • Patient Centeredness
      • Evidence Based Medicine standards
      • Value-based Care
    • Machines (incl equipment, EHR)
      • Personal Safety Equipment
      • Real Time Locator Systems (RTLS)
      • Med Equipment
      • Test and scanning equipment
      • Equip Ergonomics
      • Interoperability
      • EHR/Software
      • TeleHealth
      • Home Equipment
      • Access Control
      • Office Equipment
      • Product tracking
      • Outcomes tracking
    • People
      • Staffing: sufficient and qualified staff
      • Patients – objectives, attitudes, ability to cope, beliefs, power-distance, health literacy
      • Subject Experts
      • Malpractice suits
      • Role Models, celebrity influence
      • Peer support/conflict
      • Training
      • Vendors
      • Friends/Family
      • Patient participation
      • Attitudes/Bullying
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc., and Access to Information
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • OTC and home remedies and drugs
      • Impurities and variances in product strength and effect
      • Internet sources and access
      • Checklists, SoPs
      • Uniforms, footwear, personal protective equipment
      • Costed consumables
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Adverse effects reporting and metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Gini Index
      • Incentives and rewards
      • Adverse Event reporting
      • Effectiveness of measurement
      • Productivity Metrics
      • Patient Goals
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Contamination and impurities
      • Temperature: too cold, too hot, too variable
      • Interruptions
      • Political climate
      • Social norms and group identity
      • Electrical Power
      • Climate and weather
      • Income inequality
      • Time
      • Direct marketing to patients

Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.


MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered. We expand this to include Affordability, STEEEPA.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.


The Author and Moderator: Matthew is a principal analyst for healthcare improvement at the Washington D.C. based firm of Whitney, Bradley, and Brown (WBB), and is a strategic adviser to the Blue Faery Liver Cancer Association. Matthew is a peer reviewer for the international journal of Knowledge Management Research and Practice, and writes on topics related to healthcare quality improvement and knowledge management.




Published by

Matthew Loxton

Healthcare Analyst using Lean Six Sigma, Knowledge Management, & Organizational Learning to improve healthcare http://linkedin.com/in/mloxton

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