© 2014 health catalyst proprietary and confidential © 2014 health catalyst proprietary and...

© 2014 Health Catalystwww.healthcatalyst.comProprietary and Confidential


John L. Haughom, MDMarch 2014

Healthcare’s Challenging Trio: Quality, Safety and Complexity


Healthcare: The Way It Should Be

Section One – Forces Driving Transformation

• Chapter One – Forces Defining and Shaping the Current State of U.S. Healthcare

• Chapter Two – Present and Future Challenges Facing U.S. Healthcare

Section Two – Laying the Foundation for Improvement and Sustainable Change

• What will it take to successfully ride the transformational wave?

Section Three – Looking into the Future


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Seminal IOM Publications

3

November 1, 1999:

The Institute of Medicine

Committee on Quality of Health Care in America

announces its first report:

To Err is Human:Building a Safer Health System

Health care in the United States is not as safe as it should be and can be.

44,000 to 98,000 deaths annually! “


Patient Safety: A known problem…

4

Prevalence of adverse events is a known problem… Given the existence of undesired circumstances, there is no insulation against error!

• 1964 – Schimmel et. al. (Ann. Int. Med.)

– 20% of University Hospital admissions result in injury with 20% fatality rate

• 1981 – Steel et. al. (NEJM)

– 36% of Teaching Hospital admissions result in injury with 25% of such injuries being serious

• 1989 – Gopher et. al. (Proc. Human Factors Society)

– 1.7 errors/day/patient with 29% that are potentially serious

• See Table for more studies…


Reaching the Public’s AttentionError Institution Year Impact

A 18 year old woman, Libby Zion, daughter of a prominent reporter, dies of a medical mistake, partly due to lax resident supervision

Cornell’s New York Hospital

1984 Public discussion regarding resident training, supervision, and work hours. Led to New York law regarding supervision and work hours, ultimately culminating in ACGME duty hour regulations.

Betty Lehman, a Boston Globe healthcare reporter, dies of a chemotherapy overdose

Harvard’s Dana Farber Cancer Institute

1994 New focus on medication errors, role of ambiguity in prescriptions and possible role of computerized prescribing and decision support.

Willie King, a 51 year old diabetic, has the wrong leg amputated

University Community Hospital, Tampa, Florida

1995 New focus on wrong-side surgery, ultimately leading to Joint Commission’s Universal Protocol, and later the surgical checklist, to prevent these errors.

18 year old Josie King dies of dehydration

Johns Hopkins Hospital 2001 Josie’s parents form an alliance with Johns Hopkins’ leadership (leading to the Josie King Foundation and catalyzing Hopkins’ safety initiatives), demonstrating the power of institutional and patient collaboration.

Jessica Santillan, a 17 year old girl from Mexico, dies after receiving a heart-lung transplant of the wrong blood type

Duke University Medical Center

2003 New focus on errors in transplantation and on enforcing strict, high reliability protocols for communication of crucial data.

The twin newborns of actor Dennis Quaid are nearly killed by a heparin overdose

Cedars-Sinai Medical Center

2007 Renewed focus on medication errors and the potential value of bar coding to prevent prescribing errors.

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Adverse Events: Lethal & Expensive

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• Adverse events are the 8th leading cause of death

• Total cost of preventable adverse events = $19-29 billion annually

• Cost of preventable medication errors = $16.4 billion annually

• Cost of preventable readmissions = $17 billion annually

Medical Errors estimate is midrange of IOM figures of 44,000-98,000

Medical errors are costly in terms of human suffering and in real dollar terms


And the Problem Extends to the Outpatient World…

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For Every:

• 1000 patients coming in for outpatient care1

• 1000 patients who are taking a prescription drug2

• 1000 prescriptions written3

• 1000 women with a marginally abnormal mammogram4

• 1000 referrals5

• 1000 patients who qualified for secondary prevention of high cholesterol6

There Appear to Be:

•14 patients with life-threatening or serious ADEs

•90 who seek medical attention because of drug complications

•40 with significant medical errors

•360 who will not receive appropriate follow-up care

•250 referring physicians who have not received follow-up information in 4 weeks

•380 will not have a LDL-C, within 3 years, on record

(1) Gandhi T et al. Adverse drug events in primary care, under review, NEJM. (2) Gandhi T et al. Drug complications in outpatient settings J Gen Int Med 2000. (3) Gandhi TK et al. Adverse drug events in primary care, under review, NEJM. (4) Poon E, et. al. Failure to follow mammographers recommendations on marginally abnormal mammograms: determination of associated factors [abstract]. J Gen Intern Med 2001. (5) Gandhi T et. al. Communication breakdown in the outpatient referral process J Gen Intern Med 2000. (6) Maviglia SM, et.al. Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines J Gen Intern Med 2001


Seminal IOM Publications

8

March 1, 2001:

The Institute of Medicine

Committee on Quality of Health Care in America

announces its second report:

Crossing the Quality Chasm:A New Health System for the 21st Century

Between the health care we have and the care we could have lies not just a gap, but a chasm.“


How Good is American Healthcare?

Only 50% of Americans receive recommended preventive care

Patients with acute illness:• 70% received recommended treatments• 30% received contraindicated treatments

Patients with chronic illness:• 60% received recommended treatments• 20% received contraindicated treatments

9

Schuster MA, McGlynn EA, Brook RH. How good is the quality of healthcare in the United States? Millbank Quarterly.


Types of Quality Problems

Several types of quality problems in healthcare have been documented by the IOM:

•Variation in services

•Underuse of services

•Overuse of services

•Misuse of services

•Disparities in quality

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How Good is American Health Care?

Aspirin ACE inhibitors Beta-blockers Reperfusion

Medication

0

10

20

30

40

50

60

70

80

90

100

% "

idea

l p

atie

nts

" re

ceiv

ing

Major teaching Minor teaching Nonteaching

Allison JJ et al. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI. JAMA 2000; 284(10):1256-62 (Sep 13)

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Practice Variation in the U.S.

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The Dartmouth Atlas of Healthcare is available at: http://www.dartmouthatlas.org


Practice Variation in the U.S.

13

0.0

20.0

40.0

60.0

80.0

100.0

% R

ecei

vin

g B

eta

Blo

cke

rs

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

55.0

% A

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d t

o IC

U

Red Dots Indicate HRRs Served by U.S. News 50 Best Hospitals for Geriatric Care

Red Dots Indicate HRRs Served by U.S. News 50 Best Hospitals for Cardiovascular Care

The Dartmouth Atlas of Healthcare is available at: http://www.dartmouthatlas.org


Unwarranted & Warranted Sources of Practice Variation

• Clinical differences among patients

• Variable risk attitudes • Variable preferences

among health outcomes• Variable willingness to

make time trade-offs• Variable tolerance for

decision responsibility• Variable coping styles

Warranted

Patient-Centered

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• Variable access to resources and expertise

• Insufficient research• Unfounded enthusiasm• Parochial perspectives• Faulty interpretation• Poor information flow • Poor communication• Role confusion

Unwarranted

Knowledge-Based

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Extensive research has made it

very clear…

…inappropriate variation…

…harms patients,

leads to poor quality,

and results in waste…


Reasons for Practice Variation

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Inadequate levels of safety and inconsistent quality result from clinical uncertainty which in turn results from:

• An increasingly complex healthcare environment

• Rapidly exploding medical knowledge

• Lack of valid clinical knowledge (poor evidence)

• Over reliance on subjective judgment


Human Limitations

Miller, G.A.

The magic number is seven, plus or minus two:

limits on our capacity for processing information.

Psychological Review 1956; 63(2):81-97

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Medical Progress Over Half a Century

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Care circa 1960… Care circa 2011…

The complexity of modern American medicine exceeds the capacity of the unaided human mind.

- David Eddy, MD, PhD“


The Evidence Base is Expanding

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1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1966

1967

1968

1969

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

12000

10000

8000

6000

4000

2000

12000

10000

8000

6000

4000

2000

00

Year

Nu

mb

er o

f R

CT

s

First RCT published: 1952

First five years (66-70): 1% of all RCTs published from 1966 to 1995

Last five years (91-95): 49% of all RCTs published from 1966-1995


Rapidly Exploding Medical Knowledge

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In 2004, the U.S. National Library of Medicine addedalmost 11,000 new articles per week to its on-line archives

That represented about 40% of all articles published, world-wide, in biomedical and clinical journals.

(1,500 – 3,500 completed references per day, 5 days a week)

To maintain current knowledge, a general internist would need to read:

– 20 articles per day, – 365 days of the year

This is an impossible task…

Current estimates are this has grown to 1 article every 1.29 minutes in 2009!


The Science of Medicine

Of what we do in routine medical practice, what proportion has a basis (for best practice) in published scientific research?

• Williamson (1979): < 10%

• OTA (1985): 10- 20%

• OMAR (1990): < 20%

The rest is opinion• That doesn't mean that it's wrong – much of it probably

works

• But, it may not represent the best patient care

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Williamson et al. Medical Practice Information Demonstration Project: Final Report. Office of the Asst. Secretary of Health, DHEW, Contract #282-77-0068GS. Baltimore, MD: Policy Research Inc., 1979).

Institute of Medicine. Assessing Medical Technologies. Washington, D.C.: National Academy Press, 1985:5.Ferguson JH. Forward. Research on the delivery of medical care using hospital firms. Proceedings of a workshop. April 30

and May 1, 1990, Bethesda, Maryland. Med Care 1991; 29(7 Suppl):JS1-2 (July).


Variation in Expert Opinion

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Experts’ estimates of the chance of a spontaneous rupture of a silicone breast implant

0% 0.2% 0.5% 1% 1% 1% 1.5% 1.5% 2% 3%

3% 4% 5% 5% 5% 5% 5% 5% 5% 6% 6%

6% 8% 10% 10% 10% 10% 13% 13% 15%

15% 18% 20% 20% 20% 25% 25% 25% 30%

30% 40% 50% 50% 50% 62% 70% 73% 75%

75% 75% 75% 80% 80% 80% 80% 80% 80%

100% Courtesy of David Eddy, MD, PhD


Variation in Expert Opinion

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Eddy. A Manual for Assessing Health Practices & Designing Practice Policies: The Explicit Approach. Philadelphia, PA: The American College of Physicians, 1992; pg. 14.

The practitioners, all experts in the field, were then asked to write down their beliefs about the probability of the outcome ... "that would largely determine his or her belief about the proper use of the health practice, and the consequent recommendation to a patient."

0 20 40 60 80 100

“

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You can find a physician who honestly believes (and will testify in court to) anything you want.

- David Eddy, MD“


Complexity Science

• Complexity science is the study of complex adaptive systems, the relationships within them, how they are sustained, how they self-organize, and how outcomes result.

• Complexity science is made up of a variety of theories and concepts.

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• It is a multidisciplinary field involving many different disciplines including biologists, mathematicians, anthropologists, economists, sociologists, management theorists, computer scientists, and many others.


Viewing Healthcare as a Complex Adaptive System

• Complexity science is the study of complex adaptive systems, the relationships within them, how they are sustained, how they self-organize, and how outcomes result.

• Complexity science is made up of a variety of theories and concepts. • It is a multidisciplinary field involving many different disciplines

including biologists, mathematicians, anthropologists, economists, sociologists, management theorists, computer scientists, and many others.

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In complex situations,

A + B ≠ C


Characteristics of Complex Adaptive Systems

Comparison of Organizational System Characteristics

Complex Adaptive Systems Traditional Systems

Are living organisms Are machines

Are unpredictable Are controlling and predictable

Are adaptive, flexible, creative Are rigid, self-preserving

Tap creativity Control behavior

Embrace complexity Find comfort in control

Evolve continuously Recycle

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Comparison of Leadership Styles

Comparison of Leadership Styles

Complex Adaptive Systems Traditional Systems

Are open, responsive, catalytic Are controlling, mechanistic

Offer alternatives Repeat the past

Are collaborative, co-participating Are in charge

Are connected Are autonomous

Are adaptable Are self-preserving

Acknowledge paradoxes Resist change, bury contradictions

Are engaged, continuously emerging Are disengaged, nothing ever changes

Value persons Value position, structures

Are shifting as processes unfold Hold formal position

Prune rules Set rules

Help others Make decisions

Are listeners Are knowers

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The Need for a Better System

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Every system is perfectly designed to produce the results that it does achieve.

– Paul Bataldan, MD

Insanity is doing the same thing over and over again and expecting a different result.

– Albert Einstein““


In Summary…

• The levels of quality and harm in modern clinical care are not acceptable

• Inadequate levels of safety and inconsistent quality result largely from clinical uncertainty

• Clinical uncertainty results from an increasingly complex healthcare environment, a rapidly expanding healthcare knowledge base, a lack of valid clinical knowledge for much of what we do, and an over reliance on expert opinion

• Extensive research has made it very clear that inappropriate variation harms patients, leads to poor quality, and results in high levels of waste

• Healthcare can be viewed as a complex adaptive system, and going forward complexity science will play an increasingly large role in the design of new care delivery systems and new care models

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Healthcare: The Way It Should Be

Section One – Forces Driving Transformation

• Chapter One – Forces Defining and Shaping the Current State of U.S. Healthcare

• Chapter Two – Present and Future Challenges Facing U.S. Healthcare

Section Two – Laying the Foundation for Improvement and Sustainable Change


Section Three – Looking into the Future


31


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Questions, discussion, etc…

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