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