Quality of Health Care in America
Grand Rounds Phillip M. Kibort, M.D., MBA
VPMA/CMO March 2010
“The journey of a thousand miles begins with a step”
Lao Tzu
Quality
All systems are perfectly designed to achieve the results they do.
Batalden
Quality
“The status quo is unacceptableunacceptable. Without serious commitment to change, health spending as a percentage of the gross domestic product will rise from 16% currently to 20% by 2017; and Americans without adequate insurance and access to essential services will continue to suffer affordable health consequences.
American resources and ingenuity are adequate for the challenge. What is required is national leadership and commitment to moving toward a high performance healthcare system.”
K. Davis
Status Quo
“There is nothing more difficult to plan,more doubtful of success, nor moredangerous to manage, than the creationof a new system. For the initiator hasthe enmity of all who would profit bythe preservation of the old institutionsand merely lukewarm defenders inthose who would gain by the new ones.”
MachiavelliThe Prince, 1518
Change
First, do no harm….
Quality: A Strategic NecessityBecause
Cost escalation Variation in practice Purchaser dominance Issues of public trust Integrated systems and
managed care New information systems
The Science&
Theories
“Quality”“Safety”
Performance Improvement
(Tools)The outcomesof our product
& services
Quality/Safety
A) Patient-Centered
B) Systems-Based
C) Evidence-Based
Quality
What is the Problem?
• If you don’t think something is broken, you won’t try to fix it.
• There may be a problem but not with my doctor or hospital.
… all hospitals are accountableto the public for their degree ofsuccess…If the initiative is not taken by themedical profession, it will be takenby the lay public.
1918 Am College Surg
Where did this begin?
Our Challenge
“Medicine used to be simple, ineffective and relatively safe.
“Now it is complex, effective, and potentially dangerous.”
Sir Cyril Chantler
Reality
The science of current western medicine is the best the world has ever seen;
(and continues to improve rapidly)
while the performance of American care delivery leaves much to be desired.
Chassin, MR, Glavin RW, and the National Roundtable on Health Care Quality.The urgent need to improve health care quality. JAMA 1998; 280(11):1000-1005.
Chassin, M. Is health care ready for six sigma quality? Milbank Quarterly 1998; 76(4):1-14.
A failure of execution
Quality Chasm
Uninformed Consumers
Spiraling Costs
We have a broken system
“Pimp My Ride”
The Battle for Quality:IOM versus “Pimp My Ride”
The IOM Vision of Quality:Charles Schwab meets Nordstrom meets the
Mayo Clinic
The Prevailing Vision ofQuality in American
Healthcare:“Pimp My Ride”
World’s Best Medical Care?
Editorial New York Times, August 12, 2007
Do we have
1.The WHO ranked 191 nations eight years ago regarding the overall quality of their healthcare, France and Italy took the top two spots and the United States was 37th.
2.The Common Wealth Fund compared the United States versus Australia, Canada, Germany, New Zealand, and the United Kingdom. The U.S. was last or next to last compared to these others.
3.All other major industrialized nations provide universal health coverage and most of them have comprehensive benefits with no cost sharing by the patients.
World’s Best Medical Care?
Top of the Line Care. Despite our poor showing in many international comparisons it is doubtful that many Americans faced with a life threatening illness would rather be treated elsewhere. Is this a realistic assessment or merely a cultural preference for the home team?
World’s Best Medical Care?
IOMAdd Injury to Insult
• 44,000-98,000 plus deaths from errors during hospitalizations
• 7,000 deaths from medication errors alone
• $17-29 billion in added costs
• Ambulatory care unknown
To Err Is Human 1999
Cadillac Prices,Yugo Quality…
Condition % Receiving Recommended Care*
Breast cancer 76%Heart attack & coronary artery disease 68%Immunizations 66%High blood pressure 65%Osteoarthritis 57%Asthma 53%Diabetes 45%Urinary tract infection 41%Sexually transmitted diseases 37%
*McGlynn, et. Al, New England Journal of Medicine, 2003
“Healthcare Quality for America’s ChildrenEven Worse Than for Adults, New Study Finds”
NEJM Mangione-Smith, et al 2007
But What About Pediatrics?
• Development• Differential• Demographics
Pediatric quality is different
What about Quality?
How good are we?
How hazardous is health care?
100,000
10,000
1,000
100
10
1 1 10 100 1,000 10,000 100,000 1,000,000
DANGEROUS REGULATED ULTRA-SAFE
HealthCare
Driving
Chartered Flights
Mountain Climbing
BungeeJumping
ChemicalManufacturing
Scheduled Airlines
EuropeanRailroads
Nuclear Power
Number of encounters for each fatality
Geography is Destiny!
C-Sections
Coronary Bypasses
Back Surgery
Sunday, April 22, 2007New York Times
In turnabout, infant deaths climbin South
Race disparity persists
Poverty, Obesity and Lack of PrenatalCare Cited – a Visible Toll
…the IOM concluded that“(al)though myriad sourcescontribute to these disparities,some evidence suggests thatbias, prejudice, and stereotypingon the part of healthcare providersmay contribute to differences incare.”
Equitable Care
Three main ideas
1. Current American health care is very good, but… there is compelling evidence that health
outcomes could be much better.
2. Experience shows thatit is possible to close the quality gap.
3. The business case for quality:better patient results can produce significant cost savings.
Three Fundamental Assumptions:
1. A good physician takes quality personally. 2. A good physician wants to practice the best quality possible. 3. Physicians hate change as much as everyone else.
The public has replaced ourpaternalism with their consumerism
WHY DO THIS?
Payer fury is becoming stronger
WHY DO THIS?
Health Care Costs
80%C
os
ts
20%
70% of people 30% of people
PreventiveServices
Vaccines, healthylifestyle, blood
pressure management
Ambulatory Care
Physicianvisits
Emergency RoomCare
Diagnostic imaging,testing, ambulance
transportation
Chronic Diseasediabetes,
congestive heart
failure,pneumonia
Accident& Catastrophe
work injury,car accident
Cost:$400/person/yearSavings opportunity:
$0/person/year
Cost: $800Savings opportunity:
$400
Cost: $10,000Savings opportunity:
$2,000-$4,000
$300 billion dollars greater administrative costs than Canada.
Enough to support Medicare.
U. Reinhardt
Where do those dollars go?
Drivers of Health Care Costs
Population dynamics: an aging population with chronic diseases
Medical technology and treatment advances; genomics will fuel advances
Healthcare delivery model - failure of evidence-based care, medical errors, reactive interventions, lower threshold for interventions
Coverage mandates
Health professional shortages
Drivers of Health Care Costs (continued)
Consumer education, information, navigating the complex system
Unnecessary care; duplication of medical
services;
Protecting the medical commons: failure to “ration” care
Administrative costs: hospitals, insurers, medical practices
Physician and hospital compensation incentives
Medical malpractice
Historical trends in U.S. healthcare expense
15%
% GDP
4%Medicare
HMO’sDRG’s
ManagedCare
P4P
1965 1970s 1980s 1990s 2008
What have we tried?
“For most of its history, Medicare has been paying for services but not for results.”
Michael O. Levitt, Secretary of Health & Human Services
Reality
The best and worst providers receive the same payment
Is this crazy or what?
“While practice makes perfect”, in some situations physicians knowledge and performance may decline with the passage of time.
N.K. Choudhry, et alAnnals of Internal MedicineFeb. 15, 2005
Are we like wine?
During 2007, the U.S. National Library of Medicine
added more than 14,000 new articles per week
to its on-line archives.
That represented about 40% of all articles published,
world-wide, in biomedical and clinical journals.
National Library of Medicine: Fact Sheet MEDLINE. 2010.Http://www.nim.nig.gov/pubs/factsheets/medline.html
Is it possible to keep up?
3 to 4 years after board certification, internists - both generalists and subspecialists - begin to show significant declines in general medical knowledge…
14 to 15 years post-certification, ~68% of internists would not have passed the American Board of Internal Medicine certifying exam...
To maintain current knowledge, a pediatrician would need to read
> 20 articles per day, > 365 days of the year
an impossible task...
Shaneyfelt, TM. Building bridges to quality. JAMA 2001; 286(20):2600-2601 (Nov 28).
Exploding knowledge base
What is your definition of it?
Quality
Quality is like pornography – “we know it when we see it”
James Todd (AMA) 1986
Potter Stewart(Supreme Court) 1964
Quality
The Institute of Medicine’sDefinition of Quality
Quality of care is the degree to which healthservices for individuals and populations increase the likelihood of desired healthoutcomes and are consistent with currentprofessional knowledge.
Definition of Quality For Health Care
Quality Healthcare is: “Safe, effective, efficient, timely, patient-centered, and equitable”
Institute of MedicineCrossing the Quality Chasm
“no needless death, no needless pain, no unwanted waits, no helplessness, and no waste”
Don Berwick, MD 2003
What’s The Problem?
A. Under use: Failure to provide a service where
benefit > risk
B. OveruseService provided when risk >benefit
C. MisuseRight services provided badly- wrong drug- wrong dose
Everyone Believes That They Have
• Great doctors• Great nurses• Great pharmacists• Great facilities• Great reputation
? Administrators
How Good A Physician/Clinician Are You?
• Opinion
• Referral Rates
• Anecdotes
No reason to measure excellent care
Who Among You Is Below Average?
• Available
• Affable
• Able
How do you evaluate?
What Do Patients Want?
1. competence2. communication3. cognizance4. caring5. contact6. coordination7. continuity
Americans’ Concerns
1) Will I be treated respectfully/access?
2) If I am sick will I get better?
3) Can I stay healthy through education, prevention?
4) If chronic problems can I maximize function
5) Help me cope with pain and suffering
1) Recognize patient
2) Acknowledge patient’s knowledge
3) Speak at eye level
4) Wash your “damn”hands
4 Main Things
Can you have better quality with less cost?
Quality
Value = QualityCost
x Volume
Value
x Service
Confusion?
Why is there so much
“Tower of Bable”
HQA CMS JCAHO
AHRQ NQF HEDIS
IHI AMA ANA
NCQA IOM AQA
CAPS Med Pac ICSI
Leap Frog CHCA NACHRI
PHIS QIO PPO
HMO IHA AHA
ACPE CDC CDHP
HRSA HSA
So how do we improve?
OK
What We Have to Change…
• Our values
Not Much Except…
• Our individual and collective behavior
• Our strategic focus: From Pimp my Ride to Primary Care and Prevention
• Our reimbursement system • Our delivery system
• Our expectations
1) Systematically adopt policies that:assess the comparative cost effectiveness of drugs, devices, national diagnostic tests, and treatment procedures with a national government task force
2) The adoption of information technology
3) Financing and organizing primary care
Three major things we can learn from international experience to control costs:
K. Davis
Variance Analysis and Intervention
The great majority of “outlying”physicians are GOOD physicianswho have developed a particularSTYLE of practice which can beMODIFIED
Unexplained variance is the
Essence of the Quality Improvement
Process !!
Bottom Line…….
• Success involves meeting the needs
of those served
• Most problems originate in processes
or systems, not in people
• Serial experimentation can be used to
achieve improvement
Improvement
The Process
• Honor the data
• Identify key variances
• Look for explainable causes
• “Peel the onion” to the next level
• Suggest process improvements
• Monitor and measure
“If you can’t describe what you are doing as a process, you don’t know what you’re doing.”
- W. Edwards Deming
You don’t get what you expect
You get what you inspect
Can we get better?
DonnabedianOld Quality Tripod
Structure Process Outcome
Outcomes MeasurementThe Quality Compass
CONVENTIONALCLINICAL INDICATORS
PATIENT SATISFACTION
FUNCTIONALSTATUS
COST-RELATEDMEASURES
The “Triple Aim”
PopulationHealth
Experience of Care
Per CapitaCost
11 Ways to Effect Change
• Continuing Medical Education• Individual/Small Group Education• Audit/Feedback/Profiling• Academic Detailing• Opinion Leaders• Clinical Decision Support/Reminders• Patient-Specific Decision Support• Patient-Centered Strategies• Clinical Process Redesign• Regulatory Strategies• Financial Incentives
1) Systems thinking2) Micro and macro orientation3) Patient-focused orientation4) Use of metrics, data, and information5) Recognition of multiple causes and co-producers6) Participation and empowerment of the work force7) Continuous individual and organizational development as a goal8) External and internal orientation
Philosophy of quality management
Crossing the Quality Chasm
Current Rules New Rules
1. “Do no harm” is an individual responsibility.
2. Secrecy is necessary.3. The system reacts to needs.4. Cost reduction is sought.5. Preference is given to
professional roles over the system.
1. Safety is a system property.2. Transparency is necessary.3. Needs are anticipated.4. Waste is continuously
decreased.5. Cooperation among clinicians
is a priority.
Traditional Improvementvs. Quality Management
Traditional Quality Management
• Focus on people
• Bad apples
• Try harder
• Opinion based
• Variation is normal
• Arbitrary goals
• Focus on processes
• Good apples
• Work smarter
• Data based
• Variation is bad
• Continuous improvement
From Old To New
• We don’t have time
• Quality costs money
• Use intuition and anecdote
• Defects come from people
• We don’t have time not to
• Quality saves money
• Collect and analyze date
• Defects come from defective processes
The enemy is disease
The enemy is error
The enemy is waste
Batalden
Remember Though
THANK YOU
Those are my principles.
If you don’t like them,I have others.
Groucho Marx