Series: Costs Down, Quality Up
Historically, initiatives to improve quality have also meant added cost—smaller class sizes, more faculty who conduct research, etc.—but this is no longer a sustainable model for all institutions. What are the innovations that can actually drive the cost to educate a student lower while driving critical outcomes like student success and completion higher? This series offers provocative questions that challenge the cost-quality paradigm and the old ways of managing institutional strategy and growth.
Also in this series:
- Why Good is Still the Enemy of Great for Most Colleges and Universities by Cid Seidelman
- Rethinking General Education: Too Many Options? by Bob Dickeson
3 Ways to Address the Cost/Quality Challenge Facing Higher Ed: Lessons from the Healthcare Sector
In a previous article in this series, I noted that many colleges and universities are trapped in the thinking that quality can only be increased if costs are increased. This is a paradigm we have to challenge if we are to find a sustainable business model for our colleges and universities. At the end of that article, I issued this call to action: “Let’s empower our colleges and universities to learn from the success of other organizations and other industries.”
Healthcare, for example, has a number of success stories where unnecessary procedures have been eliminated, clinical outcomes have improved, patient engagement has increased, and costs have been reduced or eliminated. This is what tackling the cost-quality paradigm looks like.
Healthcare is a powerful analogue for higher education, because while there are certainly distinct differences between the delivery of education and the delivery of healthcare, these two industries do share much in common:
- A history of high price inflation
- Long reliance on the cost-quality paradigm
- Rampant price discrimination
- Attempts to standardize delivery to maintain quality and reduce cost
- A dis-empowering hierarchy of stakeholders: faculty and physicians, professional staff, and students and patients
- Students and patients that have different propensities for learning or healing
- External calls for more accountability
Because these sectors share similar challenges some higher education institutions may benefit from looking at innovative new experiments underway in the delivery of healthcare. Can these innovations in healthcare inform and guide academe toward a more effective and sustainable future? There are a number of prominent healthcare organizations and systems experimenting with a new paradigm of healthcare delivery. The models they have begun to employ include strategic, game-changing initiatives that redefine best practice and clinical excellence, improve operational process, and also raise stakeholder engagement and satisfaction. There are three themes driving much of this innovation:
- Moving from expert-based to evidence-based medicine
- Creating a culture focused on error reduction
- Aligning incentives and resources strategically
In this article, I’ll take a close look at how the healthcare sector has pursued these three objectives; there will be important clues for higher-ed leaders to note.
1. Moving from Expert-Based to Evidence-Based Medicine to Inform Best Practices
In higher education, we are predisposed to assume that much of the student experience is unmeasurable. We need to challenge this assumption. Healthcare already has; referencing the changes in the healthcare sector, Ricardo Azziz, a physician and educator, published a 2015 Huffington Post article challenging higher-ed leaders to “measure the unmeasurable,” and to “emulate the success of healthcare in using evidence to improve outcomes.” In the healthcare sector, shifting to evidence-based medicine has allowed hospitals to more effectively use data to inform best practices, eliminate unnecessary or ineffective procedures, and increase efficiency both clinically and operationally. “There is unassailable evidence,” Azziz summarizes, “that many of these measures (not all, of course) have helped to rapidly improve outcomes, including reducing medical errors.”
Such emphasis on measurement is the first step in breaking the cost-quality paradigm. We need to do more to collect the most relevant data and evidence on what actually contributes the most to student learning, student engagement and satisfaction, and retention and graduation rates. This will help us invest in doing more of what the evidence tells us is working best, and doing less of those efforts that add little real impact. For examples of this, look to the academic productivity studies sponsored by the National Center for Academic Transformation (NCAT). These include over 80 successful projects focused on course redesign, experimenting with new models and pedagogies that improve quality (learning outcomes and student engagement) while expending fewer resources.
2. Creating a Culture Focused on Error Reduction
Fostering a culture of error reduction is the next step in addressing the cost/quality paradigm. In the medical sector, the transition to evidence-based medicine has facilitated a cultural shift to greater accountability, as transparency exposes the best and worst of procedure, process, and performance. Healthcare organizations committed to continuous improvement recognize how important the right organizational culture is to the achievement of high performance.
Innovators in healthcare are now adopting error prevention strategies such as Zero-Harm to reduce errors and safety events where patients experience preventable harm, or ineffective or inefficient care. Error prevention sets a cultural context where patient safety is the top institutional priority, more open communication is encouraged, (all stakeholders are encouraged to voice any reasonable concern related to a patient’s clinical status and safety without fear of retaliation), and well-defined procedural checks informed by evidence, significantly reduce the chance of human error.
What do we consider to be an error in higher education? Obviously these are negatives that retard or prevent the institution from achieving its goals that we wish to reduce or eliminate. For higher education, here are examples of what a high-reliability institution might look like:
- Indisputable evidence of student learning and student achievement of learning goals.
- A close to zero failure rate in retaining and graduating students.
- A business model that is sustainable over the long run.
- A campus environment that is very safe, respectful, and committed to learning.
- Extremely high student satisfaction and engagement scores.
- An abundance of happy and satisfied alumni who continue to support the institution.
Colleges and universities, no less than clinics and hospitals, can become high-reliability organizations by measuring the unmeasurable, using evidence to inform strategies for improvement, making a commitment to reduce errors, and building the right cultural context for transformational change.
3. Aligning Incentives and Resources Strategically
The third way we need to break the cost-quality paradigm is examining our incentives. Some healthcare organizations are working to realign incentives, transitioning from a fee-for-service model that compensates doctors and hospitals based on number of procedures completed, to a model that incentivizes arriving at the best clinical outcome given evidence and the needs of the patient. The intent is to provide greater quality of care at lower cost: provide the more care.
Similarly, it is realistic and practical for colleges to use productivity measures to assess outcomes (student learning) and to compare the cost of what they are currently doing to the cost of new models for course design and delivery. Efforts to increase academic productivity need to be informed by evidence so that faculty, like doctors, can see whether new program designs that use new technologies and change how professors are deployed actually do lead to improved outcomes and lower costs. As William F. Massey points out, in “Creative Paths to Boosting Academic Productivity,” breaking down the barriers to productivity improvement requires:
- A conceptual structure for productivity that professors can buy into – evidence driven.
- A workload planning schema that allows time for productivity improvement work.
- A reward system that values such improvement, or at least does not undermine it.
A good place to start is to highlight the course-redesign experiments of NCAT and to pilot similar on-campus experiments. Incentivize faculty to test whether new learning designs can address the cost-quality paradigm.
If higher education and especially high-risk institutions measure the unmeasurable, develop a high-reliability culture, and align resources and incentives strategically, progress can be made in tackling the cost-quality paradigm. The innovators in healthcare provide a roadmap that our sector can learn from, and NCAT’s experiments provide evidence of that similar efforts can yield similar results in higher education. As noted by one very innovative healthcare system, “we can’t envision any future in which higher-quality care provided as affordably as possible will not be a successful strategy.”
