ACHIEVING WORLD-CLASS
HEALTH CARE: What it Takes to be a
High Performing Health Care
Organization
Kenneth W. Kizer, M.D., M.P.H.
Distinguished Professor and Director,
Institute for Population Health Improvement
University of California Davis Health System
March 8, 2013
Presentation Objectives
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To stimulate you to think about what you do in a
broader context and to reflect on what you could
do to improve health care performance
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Highlight key problems in America’s health and
health care and the essentiality of change
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Review some of what is known about achieving
higher performing health care systems and what
it means to be a world-class medical facility

Discuss the evolving concept of “systemness”
in healthcare
WHAT IS THE INSTITUTE FOR
POPULATION HEALTH IMPROVEMENT,
UC DAVIS HEALTH SYSTEM?
Institute for Population Health Improvement
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Established as an independent operating unit in the University
of California Davis Health System in mid-2011; has since
developed a diverse portfolio of funded activities >$70M
Population health – the intersection of public health and the
clinical sciences
New value-based health care payment models require that
population health management be a core competency for health
care systems
Serves as a resource for health care reform, health policy and
clinical quality improvement
Assists government health-related agencies in designing,
implementing and administering programs
Seeks to
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Improve the effectiveness and efficiency of clinical care
Build health leadership and health care management capacity
Leverage data sources to develop clinical intelligence
Promotes understanding of the multiple determinants of health
and appreciation of health being a function of the totality of
one’s circumstances
The Turbulent Waters of Early 21st
Century American Health Care
 Deteriorating population health
 Rapidly rising demand for
health care services
 An underperforming health
delivery system – major
deficiencies in quality and
safety
 Unsustainable cost of health
care
 Explosive growth of new
technology
 Health care personnel shortages
 Many vested interests in
maintaining the status quo
Up to 75 Percent of US Youth
Ineligible for Military Service
Lack of Education, Physical
Problems Disqualify Most
By Robert Longley, About.com Guide
14 Apr 2011
Health of U.S. Workforce Declining and Driving Up Employer
Costs, According to New Index from Thomson Reuters
Overweight and Obese Have Largest Impact on Employers’
Healthcare Expenditures
Ann Arbor, MI, April 14, 2011 – The unhealthy behaviors of the U.S. workforce cost employers an
average of $670 per employee annually, according to the new Thomson Reuters Workforce Wellness
Index.
New Health Rankings: Of 17 Nations, U.S. Is Dead Last
Jan 10 2013
U.S. Health Care Quality
 McGlynn, et al – 54.9% adults received
recommended care (NEJM 2003; 348:2635-45)
 Mangione-Smith, et al – 46.5% ambulatory
children received recommended care (NEJM
2007; 357: 1515-23)
 Hicks, et al - <50% adults with chronic
conditions received recommended care in CHCs
(Health Aff 2006; 25:1212-23)
 Landon, et al – Medicaid managed care
enrollees receive lower quality care than
commercial managed care enrollees (JAMA
2007; 298: 1674-1681)
IF ALL OF THE NEARLY
3,000 HOSPITALS
STUDIED PERFORMED AT
THE SAME LEVEL AS THE
TOP 100 HOSPITALS:
 >164,000 LIVES COULD BE
SAVED
 82,000 PATIENTS COULD BE
COMPLICATION FREE
 $6 B COULD BE SAVED
“…almost 75,000
needless deaths could
have been averted in
2005 if every state had
delivered care on par
with the best
performing state.”
Temporal Trends in Rates of Patient Harm Resulting from
Medical Care
Christopher P. Landrigan, M.D., M.P.H., Gareth J. Parry, Ph.D., Catherine B. Bones, M.S.W., Andrew D. Hackbarth, M.Phil.,
Donald A. Goldmann, M.D., and Paul J. Sharek, M.D., M.P.H.
N Engl J Med 2010;363:2124-34.
Background - In the 10 years since publication of the Institute of Medicine’s report To Err Is Human,
extensive efforts have been undertaken to improve patient safety. The success of these efforts
remains unclear.
Methods - We conducted a retrospective study of a stratified random sample of 10 hospitals in North
Carolina. A total of 100 admissions per quarter from January 2002 through December 2007 were
reviewed in random order by teams of nurse reviewers both within the hospitals (internal reviewers)
and outside the hospitals (external reviewers) with the use of the Institute for Healthcare
Improvement’s Global Trigger Tool for Measuring Adverse Events….
Results - Among 2341 admissions, internal reviewers identified 588 harms (25.1 harms per 100
admissions; 95% confidence interval [CI], 23.1 to 27.2). Multivariate analyses of harms identified by
internal reviewers showed no significant changes in the overall rate of harms per 1000 patient-days
(reduction factor, 0.99 per year; 95% CI, 0.94 to 1.04; P = 0.61) or the rate of preventable harms. There
was a reduction in preventable harms identified by external reviewers that did not reach statistical
significance (reduction factor, 0.92; 95% CI, 0.85 to 1.00; P = 0.06), with no significant change in the
overall rate of harms (reduction factor, 0.98; 95% CI, 0.93 to 1.04; P = 0.47).
Conclusions- In a study of 10 North Carolina hospitals, we found that harms remain common, with
little evidence of widespread improvement. Further efforts are needed to translate effective safety
interventions into routine practice and to monitor health care safety over time.
U.S. Health Care Quality
 Commonwealth Fund - across 37 indicators of
quality, access, efficiency, and equity, the US
achieves "an overall score of 65 out of a
possible 100 when comparing national
averages with benchmarks of best performance
achieved internationally and within the United
States."
 Overall, the US is performing well below the
standards of health, efficiency, and care that
are realistic and have been achieved in the
most successful U.S. states and other
developed nations.
These Are The 36 Countries That Have Better
Healthcare Systems Than The US
Adam Taylor and Samuel Blackstone | Business Insider International
Jun. 29, 2012, 2:44 PM
12 years ago, the World Health Organization released the World Health Report
2000. Inside the report there was an ambitious task — to rank the world's best
healthcare systems.
The results became notorious — the US healthcare system came in 15th in
overall performance, and first in overall expenditure per capita. That result
meant that its overall ranking was 37th.
The results have long been debated, with critics arguing that the data was outof-date, incomplete, and that factors such as literacy and life expectancy were
over-weighted.
So controversial were the results that the WHO declined to rank countries in
their World Health Report 2010, but the debate has raged on. In that same year,
a report from the Commonwealth Fund ranked seven developed countries on
their health care performance — the US came dead last.
Read more: http://www.businessinsider.com/best-healthcare-systems-in-the-world-2012-6?op=1#ixzz28FnNzpKf
International Comparison of Spending on Health, 1980–2008
Total expenditures on health
as percent of GDP
Average spending on health
per capita ($US PPP)
8000
6000
5000
4000
United States
Norway
Switzerland
Canada
Netherlands
Germany
France
Denmark
Australia
Sweden
United Kingdom
New Zealand
14
12
10
8
6
2000
4
1000
2
0
0
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
3000
Source: OECD Health Data 2010 (June 2010).
United States
France
Switzerland
Germany
Canada
Netherlands
New Zealand
Denmark
Sweden
United Kingdom
Norway
Australia
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
7000
16
Premiums Rising Faster Than Inflation and Wages
Cumulative Changes in Components of
U.S. National Health Expenditures and
Workers’ Earnings, 2000–09
Projected Average Family Premium as
a Percentage of Median Family
Income, 2008–20
Percent
Percent
125
25
108%
Insurance premiums
Workers' earnings
100
23
21 21
22 22
20 20
20
18 18 18 18 18
Consumer Price Index
16
15
75
24
13
11
19 19 19
17
14
12
10
50
32%
5
25
24%
Projected
* 2008 and 2009 NHE projections.
Data: Calculations based on M. Hartman et al., “National Health Spending in 2007,” Health Affairs, Jan./Feb.
2009 and A. Sisko et al., “Health Spending Projections Through 2018,” Health Affairs, March/April 2009.
Insurance premiums, workers’ earnings, and CPI from Henry J. Kaiser Family Foundation/Health Research and
Educational Trust, Employer Health Benefits Annual Surveys, 2000–2009.
Source: K. Davis, Why Health Reform Must Counter the Rising Costs of Health Insurance Premiums (New York:
The Commonwealth Fund, Aug. 2009).
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2007 2008* 2009*
2006
2006
2005
2005
2004
2004
2003
2003
2002
2002
2001
2001
2000
2000
1999
0
0
Why are Healthcare Costs Rising?
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Population growth and aging
Uncontrolled proliferation of technology
Increasing chronic care needs
Direct to consumer marketing of healthcare
products and services
American culture
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High value placed on ‘choice’
Excessive demand (“consumptive society”)
Legislated healthcare service mandates
Consolidation of healthcare providers
Rising liability insurance costs
Care variation from best evidence (i.e., poor
quality)
THE COST OF POOR QUALITY*
 Healthcare error rates are orders of magnitude
higher than in other industries
 Poor quality care accounts for 35-45% of
healthcare expenditures ($585B in 2000)
 Poor quality care costs employers about $2000
per covered employee/yr
*Midwest Business Group on Health & The Juran Institute, 2002
“…waste diverts
resources; the
committee estimates
$750 billion in
unnecessary health
spending in 2009
alone.”
Growth of Mandatory Expenditures
Recent factors impacting mandatory expenditures
 Increased Medicaid expenditures (recession)
 Rapidly rising numbers Medicare and Social Security
beneficiaries
 ARRA-HITECH (economic stimulus)
 PPACA (health care reform)
26
Macroeconomic Realities
 Greater mandatory expenditures means less
discretionary spending (unless revenue
increases)
 The demand for discretionary spending for
infrastructure, education, environmental concerns
and other needs is growing while non-defense
discretionary funds are decreasing
1 in 4 Bridges in the U.S. is Unstable:
Our Infrastructure Needs Help
by Beth Buczynski, September 19, 2012
27
The U.S. Health Care Tipping Point
 IOM National Roundtable on Health Care Quality. “The
Urgent Need to Improve Health Care Quality.” JAMA
1998: 280: 1000-1005
 Quality First: Better Health Care for All Americans,
President’s Advisory Commission on Consumer
Protection and Quality in the Health Care Industry. 1998
 The Milbank Quarterly, 1998; Vol 76 : #4 – esp paper by
Schuster, McGlynn and Brook, “How Good is the Quality
of Health Care in the United States” pp 517-63
 Ensuring Quality Cancer Care. IOM. 1999
 To Err is Human: Building a Safer Health System. IOM.
2000
 Crossing the Quality Chasm: A New Health System for
the 21st Century. IOM. 2001
“Quality problems are everywhere,
affecting many patients. Between the
health care we have and the care we
could have lies not just a gap but a
chasm.”
Crossing the Quality Chasm. IOM/NAS, 2001
American health care is in a period of dramatic
and accelerating change, transitioning from an
unsustainable and in some respects inglorious
past to an uncertain but very different future
that will be driven by the quest for high
performing health care systems.
Stein’s Law
“Things that can’t
go on forever,
don’t.”
Herbert Stein
Chairman, Council of Economic Advisors
for Presidents Nixon and Ford
Characteristics of a High-Performing
Health System*
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Ensures healthy and productive lives
Care is
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Effective
Safe
Patient-centered
Timely
Efficient
Equitable
Coordinated
Universal participation
Has the capacity to continuously improve
and innovate
*Institute of Medicine; The Commonwealth Fund Commission
on a High Performance Health System
Characteristics of a High-Performing
Hospital (Cochrane Review)*
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Qualitative studies
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Culture
Leadership
Structure
Strategy
Information management
Good communication pathways
Skills training
Physician engagement
Quantitative studies
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EHRs-CPOE
Maybe work-force design, financial incentives, nursing
leadership, hospital volume
*International Journal for Quality in Health Care 2012; 24:483-494
“There is limited, mainly low
quality evidence, supporting the
association between hospital
characteristics and healthcare
performance”
International Journal for Quality in Health
Care 2012; 24:483-494
Framework for Kaiser Permanente’s Quality
Systems Assessment
What is a World Class Medical Facility?
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Congressionally-mandated review (2009) of the
new Walter Reed National Military Medical Center
and Fort Belvoir Community Hospital that it had
directed (2005) to be designed and constructed to
be world-class medical facilities
Medical facility – the totality of the physical
environment; the processes and practices of
providing care; the diagnostic, treatment and
other technologies used; the adequacy, expertise
and morale of the staff; and the organizational
culture
Congressionally mandated review focused on
facility architecture and design characteristics
linked to health care outcomes
What is a World Class Medical Facility?
 The NCR BRAC HSAS organized
specifications into 18 categories
within 6 domains
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Basic Infrastructure
Leadership and Culture
Processes of Care
Performance
Knowledge Management
Community and Social
Responsibility
Codified into federal law 2010
What is a World Class Medical Facility?*
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World-class health care is achieved by going
above and beyond compliance with professional,
accreditation, and certification standards to bring
the best of the art and science of medicine
together in a focused effort to meet the physical,
mental, social, and spiritual needs of the patient.
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World-class health care is achieved when highly
skilled professionals work together as practiced
teams with precision, passion, and a palpable
commitment to excellence within an environment
of inquiry and discovery that creates an ambience
that inspires trust and communicates confidence.
*Kizer KW. Am J Med Qual 2010 (2)
What is a World Class Medical Facility?*
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World-class health care is achieved by routinely
performing at the theoretical limit of what is
possible and consistently and predictably
delivering high-quality care and optimal treatment
outcomes at a reasonable cost to the patient and
society.
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World-class health care routinely envisions what
could be and goes beyond the best known
practices to advance the frontiers of knowledge
and pioneer improved processes of care so that
the extraordinary becomes ordinary and the
exceptional routine.
*Kizer KW. Am J Med Qual 2010
(2)
Foundational elements
1. Governance priority
2. Culture of continuous
improvement
Infrastructure fundamentals
3. IT best practices
4. Evidence protocols
5. Resource utilization
Care delivery priorities
6. Integrated care
7. Shared decision making
8. Targeted services patients
Reliability and feedback
9. Embedded safeguards
10. Internal transparency
“SYSTEMNESS” – THE NEW
FRONTIER FOR HEALTH CARE
PERFORMANCE IMPROVEMENT
Systems and Systemness
 Historically, systemness has been thought of
as referring to the characteristics or
functionalities of a system
 Healthcare systems are highly heterogeneous
and many (?most) do not yet demonstrate
tangible synergies from systematizing
 Increasing attention is now being directed at
determining what systemness means in
healthcare and how can it be achieved
 Systemness leaders include Kaiser
Permanente, VA and Geisenger, among others
44
The Evolving Concept of “Systemness”
45
“Systemness” Defined
“Systemness” refers to the functional
state of a collection of interconnected
discrete parts that behave as a coherent
whole in ways that are distinct from the
component parts and that predictably and
consistently produce results that are
superior to the sum of the parts.
A FEW OBSERVATIONS ABOUT
SYSTEMNESS
Observation #1
Achieving systemness is essential to
improving healthcare value and
sustainability.
48
Observation #2
Systemness does not just happen; it
results from intentional design and can
be replicated.
49
Observation #3
Achieving systemness must be
grounded on an understanding of the
concepts of complexity or chaos theory
(because healthcare operates as a
complex adaptive system).
50
Key Characteristics of Complex
Adaptive Systems
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They are nonlinear, dynamic and do not
inherently reach fixed equilibrium points.
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Composed of independent (autonomous) agents
which have disparate needs and desires,
resulting in behaviors that often conflict.
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Component agents are intelligent; they learn and
adapt, resulting in self-organization and new
behaviors.
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There is no single point of control; no one is
truly “in charge”.
51
Achieving Change in Complex
Adaptive Systems
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Change cannot be specified and controlled the
way it can be in simpler, more linear systems
such as manufacturing.
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Achieving desired change requires making
selective changes in a few critical change
levers.
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Change strategies and tactics should be
overlapping and mutually reinforcing.
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Unintended consequences are unavoidable;
these should be anticipated and vigilance
designed into the system.
52
Observation #4
The evidence base and theory underlying
healthcare “systemness” is very immature;
however, enough is known to conclude that there
is no single blueprint or ideal template for
achieving systemness. Instead, there are a
number of defining functionalities or operating
characteristics. These can be achieved in
various ways.
53
Defining Functionalities of Healthcare
Systemness
1. It is driven by a compelling mission and a shared,
values-based vision.
2. Diverse clinical , social support and administrative
services are coordinated and integrated by intentional
design using strategies and tactics tailored to local
circumstances.
3. Operational strategies and plans consistently include
frontline practitioners and service recipients in their
development and implementation.
4. Services are readily accessible across time and space
when the recipient determines they are needed.
5. Information and data flow freely between and among
care settings and caregivers and is available whenever
and wherever needed.
54
Defining Functionalities of Healthcare
Systemness
6. Service needs are anticipated and planned for - and
especially for those having the greatest needs.
7. Non-beneficial services and unnecessary variation in
service delivery are minimized, but legitimate
uniqueness is recognized.
8. Health promotion, disease deterrence and population
health mindfulness are integral to all services.
9. Has strong and respected leadership.
10. May be integrated vertically and/or virtually (IT, data
sharing and management agreements, contracts are
the glue when virtual).
11. An enabling infrastructure is necessary but not
sufficient.
55
Healthcare Systemness Infrastructure
 Knowledge transfer and communication tools (eg, EHR,
decision support, registries, HIE, open access scheduling,
tele-health, social media, etc.)
 Performance management system (eg, performance
measurement and benchmarking methods, standardized
performance metrics, reporting and data analysis tools,
feedback mechanisms, accountability and rewards methods)
 Care/disease management tools (eg, clinical guidelines and
care protocols) and competencies, care review and adherence
mechanisms
 Systems learning methods and continuous improvement
policies and practices
 Teams and team processes
 Agile human capital management, including an education and
training system to develop and nurture new competencies
 Shared decision making and other patient/family engagement
mechanisms
 A broadly participatory and structured method to balance
patient and provider freedom of choice with efforts to
56 coordinate care and manage costs
Defining Functionalities of Healthcare
Systemness
12. The enabling infrastructure must be embedded in a
culture of collaboration and quality improvement.
13. Finances are aligned with desired outcomes using
various methods. In altruistic activities, removing
financial disincentives may be more important than
providing positive financial incentives.
14. Strategic communication utilizing both conventional
and unconventional methods widely employed.
15. Both governance and management addressed in
policies and procedures.
16. Care delivery assets are structured to support the
mission but are flexible so that they can be quickly
modified to adapt to changing circumstances.
57
Observation #5
More than anything else, systemness is
about culture, and culture is more about
sociology than technology – but a culture
of collaborative synergies will only
develop if the finances are supportive.
58
Conclusion
21st Century healthcare will be increasingly
delivered by integrated healthcare systems
that are intentionally designed to
demonstrate systemness by providing
continuous healing relationships through
patient-aligned caregiver teams enabled
with "smart" technologies to facilitate and
support ready access across time and
geography, collaboration, evidence-based
care and systems learning.
59