Quality of Health Care in America
Grand Rounds
Phillip M. Kibort, M.D., MBA
VPMA/CMO
March 2010
Quality
“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
Status Quo
“The status quo is unacceptable. 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
Change
“There is nothing more difficult to plan,
more doubtful of success, nor more
dangerous to manage, than the creation
of a new system. For the initiator has
the enmity of all who would profit by
the preservation of the old institutions
and merely lukewarm defenders in
those who would gain by the new ones.”
Machiavelli
The Prince, 1518
First, do no harm….
Quality: A Strategic Necessity
Because





Cost escalation
Variation in practice
Purchaser dominance
Issues of public trust
Integrated systems and
managed care
 New information systems
Quality/Safety
“Safety”
“Quality”
Performance
The Science Improvement The outcomes
&
of our product
(Tools)
Theories
& services
Quality
A)
Patient-Centered
B)
Systems-Based
C)
Evidence-Based
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.
Where did this begin?
… all hospitals are accountable
to the public for their degree of
success…
If the initiative is not taken by the
medical profession, it will be taken
by the lay public.
1918 Am College Surg
Our Challenge
Reality
“Medicine used to be simple, ineffective and
relatively safe.
“Now it is complex, effective, and potentially
dangerous.”
Sir Cyril Chantler
A failure of execution
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.
We have a broken system
Quality Chasm
Uninformed Consumers
Spiraling Costs
“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 of
Quality in American
Healthcare:
“Pimp My Ride”
Do we have
World’s Best Medical Care?
Editorial New York Times, August 12, 2007
World’s Best Medical Care?
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?
IOM
Add 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
Heart attack & coronary artery disease
Immunizations
High blood pressure
Osteoarthritis
Asthma
Diabetes
Urinary tract infection
Sexually transmitted diseases
*McGlynn, et. Al, New England Journal of Medicine, 2003
76%
68%
66%
65%
57%
53%
45%
41%
37%
But What About Pediatrics?
“Healthcare Quality for America’s Children
Even Worse Than for Adults, New Study Finds”
NEJM Mangione-Smith, et al 2007
Pediatric quality is different
• Development
• Differential
• Demographics
What about Quality?
How good are we?
How hazardous is health care?
DANGEROUS
REGULATED
ULTRA-SAFE

100,000
Health
Care

Driving
10,000
1,000

Scheduled
Airlines

100
Chartered
Flights


European
Railroads
Mountain
Climbing
10

Chemical
Manufacturing

Bungee
Jumping
1
1
10
100
1,000
Number of encounters for each fatality

Nuclear
Power
10,000
100,000
1,000,000
Geography is Destiny!
 C-Sections
 Coronary Bypasses
 Back Surgery
Sunday, April 22, 2007
New York Times
In turnabout, infant deaths climb
in South
Race disparity persists
Poverty, Obesity and Lack of Prenatal
Care Cited – a Visible Toll
Equitable Care
…the IOM concluded that
“(al)though myriad sources
contribute to these disparities,
some evidence suggests that
bias, prejudice, and stereotyping
on the part of healthcare providers
may contribute to differences in
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 that
it 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.
WHY DO THIS?
The public has replaced our
paternalism with their consumerism
WHY DO THIS?
Payer fury is becoming stronger
Health Care Costs
70% of people
80%
30% of people
Cost: $800
Cost:
$400/person/year
Savings opportunity:
$400
Savings opportunity:
$0/person/year
Cost: $10,000
Savings opportunity:
$2,000-$4,000
20%
Preventive
Services
Ambulatory
Care
Vaccines, healthy
Physician
lifestyle, blood
visits
pressure management
Emergency Room
Care
Diagnostic imaging,
testing, ambulance
transportation
Accident
Chronic
Disease & Catastrophe
diabetes,
congestive
heart
failure,
pneumonia
work injury,
car accident
Where do those dollars go?
$300 billion dollars greater
administrative costs than Canada.
Enough to support Medicare.
U. Reinhardt
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
What have we tried?
Historical trends in U.S. healthcare expense
Managed
Care
15%
P4P
DRG’s
% GDP
HMO’s
Medicare
4%
1965
1970s
1980s
1990s
2008
Reality
“For most of its history, Medicare has been
paying for services but not for results.”
Michael O. Levitt, Secretary of Health & Human Services
Is this crazy or what?
The best and worst providers
receive the same payment
Are we like wine?
“While practice makes perfect”, in some
situations physicians knowledge and
performance may decline with the passage
of time.
N.K. Choudhry, et al
Annals of Internal Medicine
Feb. 15, 2005
Is it possible to keep up?
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
Exploding knowledge base
 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).
Quality
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
The Institute of Medicine’s
Definition of Quality
Quality of care is the degree to which health
services for individuals and populations
increase the likelihood of desired health
outcomes and are consistent with current
professional knowledge.
Definition of Quality For Health Care
Quality Healthcare is: “Safe, effective,
efficient, timely, patient-centered, and
equitable”
Institute of Medicine
Crossing 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.
Overuse
Service provided when risk >benefit
C.
Misuse
Right 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?
Who Among You Is Below Average?
•
Opinion
•
Referral Rates
•
Anecdotes
No reason to measure excellent care
How do you evaluate?
• Available
• Affable
• Able
What Do Patients Want?
1.
2.
3.
4.
5.
6.
7.
competence
communication
cognizance
caring
contact
coordination
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
4 Main Things
1) Recognize patient
2) Acknowledge patient’s knowledge
3) Speak at eye level
4) Wash your “damn”hands
Quality
Can you have better quality
with less cost?
Value
Value = Quality x Volume x Service
Cost
Why is there so much
Confusion?
“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
OK
So how do we improve?
What We Have to Change…
Not Much Except…
• Our values
• Our strategic focus: From Pimp my Ride
to Primary Care and Prevention
• Our reimbursement system
• Our delivery system
• Our individual and collective behavior
• Our expectations
Three major things we can learn from
international experience to control costs:
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
K. Davis
Variance Analysis and Intervention
The great majority of “outlying”
physicians are GOOD physicians
who have developed a particular
STYLE of practice which can be
MODIFIED
Bottom Line…….
Unexplained variance is the
Essence of the Quality Improvement
Process !!
Improvement
• 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
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
Can we get better?
You don’t get what you expect
You get what you inspect
Donnabedian
Old Quality Tripod
Structure
Process
Outcome
Outcomes Measurement
The Quality Compass
CONVENTIONAL
CLINICAL INDICATORS
PATIENT
SATISFACTION
FUNCTIONAL
STATUS
COST-RELATED
MEASURES
The “Triple Aim”
Population
Health
Experience of
Care
Per Capita
Cost
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
Philosophy of quality management
1)
2)
3)
4)
5)
6)
7)
Systems thinking
Micro and macro orientation
Patient-focused orientation
Use of metrics, data, and information
Recognition of multiple causes and co-producers
Participation and empowerment of the work force
Continuous individual and organizational
development as a goal
8) External and internal orientation
Crossing the Quality Chasm
Current 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.
New Rules
1.
2.
3.
4.
5.
Safety is a system property.
Transparency is necessary.
Needs are anticipated.
Waste is continuously
decreased.
Cooperation among clinicians
is a priority.
Traditional Improvement
vs. Quality Management
Traditional
Quality Management
• Focus on people
• Focus on processes
• Bad apples
• Good apples
• Try harder
• Work smarter
• Opinion based
• Data based
• Variation is normal
• Variation is bad
• Arbitrary goals
• Continuous improvement
From Old
To New
• We don’t have time
• We don’t have time not to
• Quality costs money
•
Quality saves money
• Use intuition and anecdote •
Collect and analyze date
• Defects come from people •
Defects come from defective
processes
Remember Though
The enemy is disease
The enemy is error
The enemy is waste
Batalden
THANK YOU
Those are my principles.
If you don’t like them,
I have others.
Groucho Marx