The (mis)application of management science in medicine: a flawed concept.

The business of medicine once again finds itself in the throes of rapidly escalating costs, concerns about quality of care, and demands for efficiency while simultaneously enhancing quality. Considerable effort has already been spent in trying to improve costs, quality, and patient satisfaction. The apparent failure to do so may be the result of a fundamental misunderstanding of the salient features of clinical practice and the misapplication of quality improvement techniques. This article explores some of the significant issues and offers potential new directions.

Operational conditions affecting the vaccination of older adults.

BACKGROUND: The content and context of the process of vaccinating older adults against influenza in outpatient settings has not been adequately described. Failure to appreciate the causal antecedents or precursors to the act of provider recommendation may explain why so many efficacious interventions identified by the U.S. Task Force on Community Preventive Services fail to be routinely implemented and why influenza immunization rates have remained static over the past decade. METHODS: This study used critical path analysis from data collected during standardized workflow observations of patients more than 50 years of age from a convenience sample of 16 ambulatory care settings in San Diego, California; Rochester, New York; and Albuquerque, New Mexico. Observations were made from October 23, 2001 to January 31, 2002. RESULTS: In this study, 62% (151/243) of patients observed during scheduled extended visits received influenza vaccinations. When operational, temporal, and clinical factors are examined altogether through critical path analysis, a model of seven critical organizational support, temporal, and clinical activities emerges that is able to predict 93% of the immunizations. Variation from the model predicts 73% of the missed opportunities. CONCLUSIONS: Vaccination of adults should not be seen as simply an incremental activity added to the general health encounter. Assuring a high rate of vaccination requires adequate time and operational support. Provider-patient discussion is more productively viewed as the culmination of the immunization process, not the beginning. Finally, this study indicates the potential need to identify and compare processes of care associated with other specific preventive services.

The price of prevention. cost of recommended activities to improve immunizations.

PURPOSE: To calculate the cost structure of a suite of immunization improvement interventions recommended by the Centers for Disease Control and Prevention (CDC). METHODS: A determination was made of the cost to clinics and agencies that implement a suite of CDC-recommended practice improvement interventions to fully immunize a child for diphtheria-tetanus-attenuated pertussis (DTaP), inactivated poliovirus (IPV), and measles-mumps-rubella (MMR) vaccines. Patient data were collected through chart analysis of 16-month-old children in clinics participating in this study's interventions between May 1997 and August 2000. The study began on October 1, 1996, and was funded for 5 years (until September 30, 2002). RESULTS: Study calculations suggest that an additional $0.013/per patient per month would be needed to cover these activities. CONCLUSIONS: Identifiable cost structures are associated with the practice improvement strategies recommended by the CDC. The method of implementation may be as important as the interventions themselves. Present compensation for immunization may not actually cover the cost of service provision, and it is unlikely to cover the costs of practice improvement, as described in this paper.

Can the doctor still see me? What happens when patients arrive late?

Demands to optimize productivity and quality require a patient scheduling system that can balance patient demand and clinic resources. The consequences of unscheduled and late patient arrivals on operational efficiencies have been documented. Less understood is the impact of unscheduled and late arrivals on the quality of service each receives. This article examines the impact of unscheduled and late patient arrivals on operational, clinical and administrative outcomes that affect quality of care of children potentially eligible for immunizations. An unexpected finding was the generally better and faster levels of service for late arrivals.

The cost of doing business: cost structure of electronic immunization registries.

OBJECTIVE: To predict the true cost of developing and maintaining an electronic immunization registry, and to set the framework for developing future cost-effective and cost-benefit analysis. DATA SOURCES/STUDY SETTING: Primary data collected at three immunization registries located in California, accounting for 90 percent of all immunization records in registries in the state during the study period. STUDY DESIGN: A parametric cost analysis compared registry development and maintenance expenditures to registry performance requirements. DATA COLLECTION/EXTRACTION METHODS: Data were collected at each registry through interviews, reviews of expenditure records, technical accomplishments development schedules, and immunization coverage rates. PRINCIPAL FINDINGS: The cost of building immunization registries is predictable and independent of the hardware/software combination employed. The effort requires four man-years of technical effort or approximately $250,000 in 1998 dollars. Costs for maintaining a registry were approximately $5,100 per end user per three-year period. CONCLUSIONS: There is a predictable cost structure for both developing and maintaining immunization registries. The cost structure can be used as a framework for examining the cost-effectiveness and cost-benefits of registries. The greatest factor effecting improvement in coverage rates was ongoing, user-based administrative investment.

Non-punctual patients: planning for variability in appointment arrival times.

Tighter competition and rationed resources place a premium on health clinic management of patient arrival times to maximize smooth workflow dynamics and consistency in patient processes. Early efforts to analyze patient arrival characteristics relied on assumptions that may have been too simplistic. For instance, it was assumed that a scheduled patient's arrival was likely to fit a bell-shaped curve in terms of being early, late, or on time and that any one patient's likelihood of being "on time" was purely a random event. However, our analysis of patient arrival times, obtained from detailed workflow observations in nine community clinics, indicates that the likelihood of a patient arriving early, late, or on time is neither entirely random nor does the pattern of arrivals fit a bell-shaped curve. Rather, patients tend to arrive in "clumps," possibly due to factors such as traffic patterns and parking availability. These findings are important with respect to 1) clinic practice management, 2) scheduling optimization strategies, and 3) computer simulation and analysis of clinic processes.

The forms that bind: multiple data forms result in internal disaggregation of immunization information.

To examine how forms encountered during routine clinical activities impact a provider's immunization activity, workflow analysis was performed in nine community clinics and small private practices. Data gathered included the number, source, and nature of forms. A total of 200 forms were used by the nine clinics just for children under 35 months of age. These represent a real labor cost as well as an opportunity cost. Use of a single summary sheet, yearly review of the forms, and coordination of agency documentation efforts are recommended.

Missed opportunities to immunize: psychosocial and practice correlates.

BACKGROUND: The goal of this pilot study was to correlate missed opportunities to immunize young children with providers' psychosocial characteristics and self-reported immunization practices. METHODS: In a population of children aged 0 to 36 months, missed opportunities to immunize were established for a sample of 28 providers, who also responded to a valid and reliable instrument measuring the aforementioned variables. RESULTS: Missed opportunities were significantly lower among providers with higher vested interest (r=-0.45, p=0.02) and tended to be lower among providers with more positive attitudes toward having all children properly immunized at every healthcare visit (r=-0.33, p =0.09). Neither knowledge nor perceived barriers correlated significantly with missed opportunities. Providers missed opportunities to immunize in over half of the visits studied (mean, 0.58), yet all of them reported always immunizing at preventive and follow-up visits, almost all (96.3%) at chronic illness visits, and a majority (78.6%) at acute care visits. As a result, none of the self-reported immunization practices was significantly correlated with missed opportunities. CONCLUSIONS: Missed opportunities appear to be best predicted by motivational psychosocial factors and not by knowledge or perceived barriers. Self-reported immunization practices do not correspond to actual immunization behavior.