Forum
To the Class of 2005:
Will You Be Ready for the Quality Revolution?
Blair L. Sadler, J.D.
oday, I want to begin with a story. Fifty years ago,
a successful American shoe manufacturer sent
two members of its marketing team to Africa to
study the prospects for expanding their business. The
two traveled together and observed similar things. After
a few days, the first sent back a telegram saying,
“Situation hopeless—Stop—No one wears shoes.” The
other wrote back triumphantly, “Glorious opportunity—
Stop—They have no shoes.” To the first, all the evidence
pointed to hopelessness. To the second, the same conditions described abundance and possibility.
Graduates, as you prepare to enter your next chapter,
you are becoming aware of the vast changes occurring in
the health care and scientific environments. They will
place unprecedented demands upon you. More will be
open to you—and more will be expected of you—than
ever before. You may be asking yourself, “With all this
coming at me, how can I possibly learn all this in the time
available?” In other words, “Is the situation hopeless or
are the possibilities truly unlimited?” How do you make
sense of what you are about to see?
When addressing a similar audience about 80 years
ago, the great Sir William Osler said, “I am sorry for you,
young men and woman of this generation. You will do
great things. You will have great victories, but you can
never have our sensations. To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools,
remodeled hospitals, a new outlook for humanity, is not
given to every generation.” He was referring, among
other things, to the 1910 Flexner report, which helped
transform how medicine was taught in American medical schools.
T
January 2006
Article-at-a-Glance
Background: Graduates are becoming aware of
the vast changes occurring in the health care and
scientific environments, which will place unprecedented demands on them.
A Second Revolution: It has been suggested that the
Institute of Medicine reports To Err Is Human and
Crossing the Quality Chasm have alerted health care
professionals and managers to system defects, enlisted a
broad array of stakeholders in the agenda, and accelerated changes in practice needed to eliminate errors and
unnecessary deaths. It is now commonplace for comparative data on the effectiveness of hospitals and medical
groups to be published in this new age of transparency.
Coalitions of employers are now urging the adoption of
safer practices in hospitals. In addition, the science of
quality improvement has flourished and become robust.
Coming Changes and Possibilities: The changes over
the next five years will be breathtaking. Those doctors
and hospitals with the best clinical outcomes will benefit from seeing more patients and may even be paid
more by Medicare, Medicaid, and insurance companies.
Patients will access, via the Web, the latest quality information and make more informed choices about where
to seek their care. The environment in which care is
provided is also undergoing a major transformation.
Hospital buildings themselves are becoming more healing, safer places. Graduates may ask themselves, “Will
my residency adequately prepare me to understand and
apply the science of quality improvement and evidencebased practice?”
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A Second Revolution
However, unlike Osler, I am not sorry for you in the
least—because I believe you are about to participate in a
second revolution. I believe that the changes you will
witness and help lead will be greater than any generation
in the last 80 years. And I believe that this second revolution, which has already begun, is really two revolutions
in one—they are occurring simultaneously. The first is
the remarkable breakthrough in stem cell research,
genomics, and regenerative medicine. The second is the
complete and fundamental overhaul of our health care
system that will—and must—occur if we are to provide
the quality and safe care that all Americans deserve.
Every day we are learning more about the potential of
stem cell research to turn the tide of such serious illnesses as Alzheimer’s, diabetes, and autism by providing
genetic explanations and interventions that will ultimately eliminate the underlying causes of these dreaded
diseases. How many lives will these research breakthroughs save and by when? It is hard to know. It will be
a large number—some day—but it will likely take a
decade or more to realize.
Today, I want to focus on the second revolution—the
quality revolution—and explore its own, equally
remarkable possibilities. How many lives could we save
if every one of our health care systems were error free?
If every one fully utilized all existing best practices? If
every one designed and implemented the highest-quality
and most reliable processes for every patient, every day,
everywhere, and without exception? To this question, we
do know the answer.
Just five years ago, the Institute of Medicine of the
National Academy of Sciences addressed this issue when
they concluded that between 48,000 and 98,000 Americans
die annually in hospitals as the result of medical errors
caused by defects in systems, not the caregivers themselves. The 1999 Institute of Medicine report, To Err Is
Human: Building a Safer Health System1 and its companion report, Crossing the Quality Chasm,2 changed the
health care landscape forever. Like the Flexner report in
1910, these two documents have truly altered the health
care conversation in America and the World.
These reports concluded three things:
1. The distance between the care we now have and the
care we could have is not just a gap but a chasm.
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January 2006
2. The problems come from poor systems, not bad people. In its current form, habits, and environment,
American health care is incapable of providing the public with the quality care it expects and deserves.2
3. We can fix it, but it will require significant system
changes, including learning from other industries.
Like Kubler-Ross’s well-known stages of acceptance
of an impending death, the initial response from doctors
and hospitals was not universally favorable. But their
responses have evolved from
1. Denial: “The data are wrong” and “There is no problem” to
2. Anger: “If there is one, it’s not with me” and “Who are
you to judge my practice?” to
3. Bargaining: “My patients are sicker, so those measures just don’t apply to me.” to
4. Depression: An overall downturn in morale, as
reflected in “The situation is hopeless” and “I’m leaving
medicine” to
5. Acceptance: “Like it or not, we must be at the table
and earn to play by the new rules” to
6. Leadership: “We will actually help make the new
rules and lead the field”
If Flexner and Osler were among the leaders of that
first revolution, Don Berwick, a pediatrician and president and CEO of the Institute for Healthcare
Improvement, is unquestionably one of the leaders of
this one. I have had the pleasure of learning from, and
collaborating with, Don over the last 10 years. We share
the same beliefs—that every person should get exactly
the care they need (no more, no less), exactly when they
need it (no waits, no delays) and without any errors
(anywhere, any time). And this care should be equally
available to everyone whether they can personally afford
it or not (whether they own many shoes or none at all).
He also believes, as I do, that the problem is not a lack of
resources but a failure to utilize and implement everything we already know.
In the Journal of the American Medical
Association just three weeks ago,3 Don and his colleague Lucian Leape, a former pediatric surgeon, provided their assessment of what has changed since
1999. They concluded that the Institute of Medicine’s
reports have awakened health care professionals and
managers about system defects, enlisted a broad array
Volume 32 Number 1
Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations
of stakeholders in the agenda, and have accelerated
changes in practice needed to eliminate errors and
unnecessary deaths.
It is now commonplace for comparative data on the
effectiveness of hospitals and medical groups to be published on the front pages of newspapers, as occurred
here about cardiac mortality in San Diego just five weeks
ago. Within the next year, all hospitals in California, and
throughout most states, will be required to publish their
results on an array of key conditions. We have entered a
new age—the age of transparency.
Coalitions of employers, most notably, The Leapfrog
Group, formed by several major U.S. Corporations—are
now urging the adoption of safer practices in hospitals.
And the science of quality improvement has flourished and become robust. The literature is now full of
peer-reviewed, rigorous work describing breakthroughs
in error reduction and improved, streamlined practices.
While progress has been made, it has been painfully
slow. Consumer groups are becoming increasingly angry
over the unnecessary deaths and harm that occur in hospitals. While politicians debate the merits and ethics of
stem cell research, there is no debating the need for
transforming our health care system to eliminate unnecessary errors and harm.
Payors of health care are beginning to reward better
quality by hospitals and doctors. It’s called pay-for-performance. Competing on quality, as well as price—
whether a dream or a nightmare—has now arrived.
For example, the Medicare program is in the second
year of a pay-for-performance demonstration project
involving 277 hospitals and will financially reward those
that provide the best care. They are focusing on six conditions that account for 40% of the money they spend. In
six months, those hospitals that score in the top half on
quality will be listed on the Medicare Web site.
Consumers can choose among them based on these data.
Hospitals in the top 10% will also get a financial bonus.
The result? Care is improving. Every hospital is getting
better! Blue Cross, PacifiCare, and Medicaid are beginning similar demonstrations.
It appears that a true social movement is occurring
stimulated by all these pressures and capped off by a
bold new patient safety campaign. It is similar to our
commitment in the 1960s when President Kennedy said
January 2006
that, by the end of the decade, we would send a man to
the moon and return him safely to earth.
Recently, another moon shot has been launched. It is
equally bold, and I believe, equally achievable. Titled the
100K Lives Campaign, it was launched in December
2004 by Don Berwick in a plenary speech, “Some is not a
Number: Soon is not a Time.”4 The campaign has the full
support of the Federal government, the Joint
Commission, the American Medical Association, the
American Nursing Association, and many other organizations. Borrowing from the lessons learned from successful political campaigns, this campaign has set a
target—to save 100,000 lives by 9:00 a.m. Eastern
Daylight Time on June 14, 2006. That’s just 53 weeks and
2 days from now—and still in your first year of residency! Is the goal achievable? Or is it pie in the sky? In one
year, we will know. And you can be an integral part of
this campaign.
The goal is based on the assumption that at least 2,000
hospitals and their affiliated doctors will agree to participate and that they will adopt some or all of six proven
practices that have been shown to save lives—rapid
response teams for intensive care patients, improved
care for acute myocardial infarction, prevention of
adverse drug events, prevention of blood stream and surgical site infections, and prevention of ventilator associated pneumonia.
Where We Can Improve
Let me give you one example of where we can really
improve. Today, in treating pneumonia in Medicare
patients:
■ Only 63% receive the first dose of antibiotics within
the recommended time of four hours of hospital arrival
■ Only 68% receive an antibiotic consistent with other
guidelines
■ Only 81% have blood cultures collected before treatment
When these three components are put together, the
composite score indicates that only 26% of Medicare
patients receive all three of these proven interventions.
Data shows that we can reduce the number of deaths
substantially if we did all three, all the time.
Time does not permit reviewing all six interventions.
But the good news is: all have been tested, are in place in
some hospitals, and are saving lives.
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Can we save 100K lives? I am pleased to tell you: as of
this week, over 2,300 hospitals have already signed up
and committed themselves to implement all or most of
these six interventions.* Many of you will be practicing
at these hospitals. Get involved! Together, we could save
100,000 lives in one year, and every year thereafter!
The possibility of providing safe and timely care to all
our patients is as exciting as a moon shot. But today,
only a few hospitals and their physicians have developed
the skills and systems needed to make these interventions commonplace throughout. Children’s Hospital is
one of those. Ten years ago, we created the first
Outcomes Center in a children’s hospital. Its goal was to
systematically examine the quality of care we provide
and to develop evidence-based pathways to ensure that
the best practice for treating a child was in fact being followed. Initially, progress was slow. There were outcries
of “cookbook medicine!” and “Who are you to tell me
how to practice?” But pathways do help to reduce inappropriate variations in practice and shorten the delay
between the publication of best practices and those
actually being used in everyday care. They also encourage a coordinated, systems approach to care.
The outcomes of these clinical pathways were so positive that our physicians and nurses concluded that welldesigned, scientifically based pathways should be our
standard system of care. Once approved, a pathway was
automatically utilized unless the physician involved made
a decision not to do so due to unique patient needs. Our
compliance rate with pathways skyrocketed from 20% to
80% overnight! Then, this rate climbed to 90%, which is
unheard of in health care. For this work, Children’s
received the prestigious Ernest A. Codman award for
quality in 2002 from the Joint Commission, the first pediatric hospital to be so honored.5 Like Children’s, more
hospitals are transforming their clinical systems with the
ultimate goal of becoming error free and harm free.
Coming Changes and Possibilities
The changes over the next five years will be breathtaking. Those doctors and hospitals with the best clinical
outcomes will benefit from seeing more patients and
* At the time of publication, more than 2,800 hospitals have joined the
campaign. Institute for Healthcare Improvement: 100K Lives Campaign.
http://www.ihi.org/IHI/Programs/Campaign/.
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January 2006
may even be paid more by Medicare, Medicaid, and
insurance companies. Patients will access, via the Web,
the latest quality information and make more informed
choices about where to seek their care. More than two
million Americans have already done so. In a world of
transparency, we will no longer be able to survive on reputation scores alone. These will be replaced by more easily understood measures of actual clinical performance.
The environment in which care is provided is also
undergoing a major transformation. Hospital buildings
themselves are becoming more healing, safer places. To
accomplish this, double patient rooms are being
replaced by single ones to reduce hospital-acquired
infections and improve patients’ privacy. Patient rooms
are being designed so that fewer transfers are required,
thus reducing errors. Noise levels are being reduced,
thus improving care and reducing stress on patients and
their caregivers.
But as you sit here today, you may be asking yourself,
“Will my residency adequately prepare me to understand
and apply the science of quality improvement and evidence-based practice?” After all, we know residencies
are highly intense experiences, packed with an extraordinary array of information. Let me tell you about how
Dr. Craig Swanson addressed this issue. Craig received
his Ph.D. in biophysics from Stanford and his M.D. in
2003 from UCSD. This month, he is completing the second year of his pediatric residency at UCSD/Children’s
and, after his third year, is looking forward to a fellowship in pediatric intensive care.
Early in his second year, Craig expressed to me his
interest in health care leadership and advocacy. Last
January, he spent his one-month elective working with
me to broaden his understanding. We discussed the
quality and safety of the work at Children’s. Craig then
read everything he could find. He talked to several members of our medical staff, including Dr. Paul Kurtin, who
leads our Outcomes Center.
Craig suggested, “Blair, let’s do a Journal Club on this
topic. Most of my colleagues don’t know enough about
this.” In March, we led a discussion with the residents to
generate ideas about how our curriculum could include
more exposure to these issues. These changes are now
under consideration. Craig is here today and is a great
example of the kind of leadership we can expect from
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Copyright 2006 Joint Commission on Accreditation of Healthcare Organizations
UCSD graduates. Thank you for recognizing how important it is to prepare residents to understand quality
improvement and your help leading these efforts.
The American College of Graduate Medical Education
has decided that all specialties must develop competencies in this field. When you selected your residency, you
asked many questions about the curriculum, the faculty,
and its overall reputation. When you arrive in July, why
don’t you also ask if they are part of the 100K Lives
Campaign and how you can participate? You will want
to know whether your program will adequately prepare
you for the brave new world of transparency. You might
also ask such questions as: “What is the adjusted cardiac
mortality rate for the hospital?” or “Are the hospital and
its physicians participating in any quality improvement
projects?” or “How much emphasis is devoted to learning about quality improvement?”
While we have been talking about systems of care, the
cornerstone of improved care will always be excellent
communication with each patient you see. By now, you
all have your favorite examples. One of mine is actually
from a talk Don Berwick gave and it is about Kevin, a
teenager with a catastrophic, chronic illness that began
at age 2. At age 15, Don asked Kevin to write three things
about the care he received that especially pleased him
and three things where caregivers had failed him. This is
what Kevin wrote:
Care is best when
1. They tell you what is going on right away.
2. You get the same answer from everyone.
3. They don’t make you scared.
Care is worst when
1. They keep you waiting.
2. They don’t listen to what you say, even when sometimes you know better.
3. They do everything twice instead of once.
Don asked Kevin to evaluate his own hospital experience. Kevin said:
1. Only 35% of the time, do they tell you what’s going on
right away.
2. Only 30% of the time, do you get the same answer
from everyone.
3. Only 40% of the time, they don’t make you scared.
As you pursue your training, I hope you will remember that some patients you see will have plenty of shoes.
Others will have none. Some patients will easily understand what you say, others will not. Let’s never forget
Kevin’s words. And, let’s work together in new ways that
ensure every patient—every Kevin—gets all and only the
care they need, when they need it. And let’s do this with
communication styles that would make Kevin applaud!
Revolutions like the one we are entering are both
exhilarating and frightening. Like the two men looking
for opportunities in Africa, what sense do we make of
this? The situation could easily seem overwhelming, as
you will be expected to learn a new science of improvement on top of everything else, and in an increasingly
transparent environment.
Situation hopeless? Absolutely not! With physicians
as talented, dedicated, and energetic as you, I see only
unlimited possibilities. As you enter the next revolution
in American medicine, I wish you a career as productive
and exciting as Sir William Osler’s. J
Blair L. Sadler, J.D., is President and Chief Executive
Officer, Children’s Hospital and Health Center of San Diego,
San Diego. This article is based on the commencement
address Mr. Sadler delivered on June 5, 2005, to the graduating class of the University of California at San Diego
School of Medicine. Please address reprint requests to Blair
L. Sadler, J.D., bsadler@chsd.org.
References
1. Institute of Medicine: To Err is Human: Building a Safer Health
System. Washington, D.C.: National Academy Press, 1999.
2. Institute of Medicine: Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington, D.C.: National Academy
Press, 2001.
3. Leape L.L., Berwick D.M.: Five years after To Err Is Human: What
have we learned? JAMA 293:2384–2390, May 18, 2005.
January 2006
4. Institute for Healthcare Improvement: 100K Lives Campaign.
http://www.ihi.org/IHI/Programs/Campaign/ (last accessed Oct. 14,
2005).
5. Joint Commission on Accreditation of Healthcare Organizations:
Ernest Armory Codman Award. Children's Hospital and Health Center,
San Diego, California. http://www.jcaho.org/accredited+organizations/
codman+award/02_codman_hospital.htm (last accessed Oct. 14, 2005).
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