Physician leaders looking to improve both the financial bottom line and the clinical benchmarks of their medical groups can look for help in a seemingly odd place -- the manufacturing plants in their own communities, according to the chief medical officer of an Iowa multispecialty group.
In November 2003, the Physicians' Clinic of Iowa, based in Cedar Rapids, received certification to the International Organization for Standardization's 9001 quality-management system standards. An estimated 35,000 to 40,000 U.S. companies, many of them in manufacturing, have adopted an ISO quality-improvement regime, but fewer that 25 healthcare organizations are ISO-certified, according to Chief Medical Officer James Levett, M.D.
Levett advises any physician leader interested in exploring ISO certification to first pull together a reading list for some foundational education. "Then, I'd get a consultant to come in and talk to you, and talk to some industry people. Join the local chapter of the American Society for Quality," he said. "Any community will have that resource. They'll be very happy that you're interested."
Levett, a cardiac surgeon, first became interested in quality-improvement methodologies as chief of surgery at Lutheran General Hospital in Park Ridge, Ill., before moving back to his home state of Iowa and becoming medical director at the Physicians' Clinic in 2001. The clinic has 50 physicians, most of whom have surgical subspecialties, but also includes a few neurologists and rhumatologists.
Levett said he got a boost from a call he made to a major local employer, Rockwell-Collins, which already had an ISO quality-improvement program in place. Levett said the Rockwell-Collins gurus let him review their ISO-related manuals and procedures and also encouraged him to join their local ASQ chapter, which is affiliated with the University of Iowa just 25 miles up the road in Iowa City.
"I got some colleagues by doing that," Levett said. "I was absolutely convinced in reading their material that they knew things in industry and in the service industry that we needed in healthcare."
The ISO has deep roots in engineering and product standardization, but the ISO 9000 family of standards was created in 1987 to establish and promulgate state-of-the art methods of managing an organization's systems to produce quality in its products and services. To test their mettle, organizations that adopt ISO standards may seek certification by an outside certification organization, although external certification is not a requirement for using the ISO framework.
According to the ISO, the decision to seek certification is entirely a management prerogative, but one that could benefit an organization under several circumstances, including:
Levett said size is not a factor in ISO participation or certification. Of the 10 medical groups he believes are certified, Levett said his is by far the largest. A two-physician orthopedic group in upstate New York that is ISO-certified may be the smallest.Groups and hospitals achieve ISO certification and registration after passing an outside audit by an independent certification organization. Of about 70 certification organizations, about 10 have specialization in healthcare, Levett said. Each certification organization also keeps a registry of companies it has audited and certified.
Levett said achieving ISO certification and registration took about 2 1/2 years at Physicians' Clinic, in part because the group did not hire an outside consultant.
"I think the advantage we had is we were under no pressure to get it done and we got better buy-in because everybody was involved," Levett said. "We took interested employees to a special quality center run by our community college and gave them training in internal auditing. After we kind of got it and understood what was going on, people really loved it."
Levett said the program costs $108,000 to set up, including the $26,000 they've spent so far on ISO auditors for certification and registration. To achieve certification, ISO requires an audit once a year, but Levett said for its own benefit, the group has requested audits every six months.
Levett said Physicians' Clinic of Iowa has more than recovered its investment. "We reduced our days in accounts receivable and saved $72,000 over the first year," he said. "We found we had some underpayments from payers and found about $100,000 from that. I wouldn't say we saved it all because of ISO -- maybe half. We also saved about $45,000 for our workers' compensation insurance for 2004 because we redesigned some of our procedures and had a reduction in claims because of it."
The ISO process helped the group, which formed in 1997 from separate groups at five different sites, to develop a common culture, Levett said. As a requirement under ISO, an organization must develop a quality manual and a numbering system for documents. The group is working with the hospital on a surgical infection-monitoring program.
"We put together a wound-infection data sheet so we could monitor the surgical infections that come up in the offices," he said. "Most wound infections don't show up in the hospitals because the patient is usually out in a day or so."
This year, a key goal for the group is to use ISO methods to develop with its insurance carrier a risk-management program, he said.
Levett said his group has a grant application pending before the federal Agency for Healthcare Research and Quality to set up a community-wide clinic for patients taking anticoagulants developed around ISO principals.
"It not only gives your organization a framework to build and expand on, but it also gives a community a system to use for best practices and benchmarking," said Levett, who maintains an active surgical practice and estimates spending just 15% to 20% of his time on administrative duties. "You'll see more about ISO in healthcare, there is no question about that."