Healthcare’s Challenging Trio:
Quality, Safety and Complexity
John L. Haughom, MD
March 2014
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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
• What will it take to successfully ride the
transformational wave?
Section Three – Looking into the Future
• What will it take to successfully ride the
transformational wave?
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Seminal IOM Publications
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
44,000 to 98,000
deaths annually!
“
Health care in the United States is not
as safe as it should be and can be.
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Patient Safety: A known problem…
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…
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Reaching the Public’s Attention
Error
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
Medical errors are costly in terms of human suffering
and in real dollar terms
• 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
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And the Problem Extends to the
Outpatient World…
For Every:
There Appear to Be:
• 1000 patients coming in for
outpatient
care1
• 1000 patients who are taking a
prescription
drug2
• 14 patients with life-threatening or
serious ADEs
• 90 who seek medical attention
because of drug complications
• 1000 prescriptions written3
• 40 with significant medical errors
• 1000 women with a marginally
• 360 who will not receive
abnormal
mammogram4
• 1000 referrals5
appropriate follow-up care
• 250 referring physicians who have
not received follow-up information
in 4 weeks
• 1000 patients who qualified for
secondary prevention of high
cholesterol6
• 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
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Seminal IOM Publications
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.
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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
Schuster MA, McGlynn EA, Brook RH. How good is the
quality of healthcare in the United States? Millbank Quarterly.
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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?
Minor teaching
Nonteaching
30
55.2
58.9
55.5
20
36.4
40
40.3
50
48.8
63.7
60
58.0
70
60.0
80
81.4
90
86.4
100
91.2
% "ideal patients" receiving
Major teaching
10
0
Aspirin
ACE inhibitors
Beta-blockers
Reperfusion
Medication
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.
The Dartmouth Atlas of Healthcare is available at: http://www.dartmouthatlas.org
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Practice Variation in the U.S.
55.0
100.0
% Receiving Beta Blockers
50.0
% Admitted to ICU
45.0
40.0
35.0
30.0
25.0
20.0
80.0
60.0
40.0
20.0
15.0
10.0
0.0
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
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Unwarranted & Warranted Sources
of Practice Variation
Unwarranted
Warranted
• Variable access to
resources and expertise
• Insufficient research
• Unfounded enthusiasm
• Parochial perspectives
• Faulty interpretation
• Poor information flow
• Poor communication
• Role confusion
• 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
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…
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Reasons for Practice Variation
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
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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
Care circa 1960…
“
Care circa 2011…
The complexity of modern American medicine
exceeds the capacity of the unaided human mind.
- David Eddy, MD, PhD
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The Evidence Base is Expanding
12000
12000
Number of RCTs
10000
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
10000
8000
8000
6000
6000
4000
4000
2000
2000
0
0
Year
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Rapidly Exploding Medical Knowledge
In 2004, the U.S. National Library of Medicine added
almost 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:
Current estimates are
this has grown to 1
article every 1.29
minutes in 2009!
– 20 articles per day,
– 365 days of the year
This is an impossible task…
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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, Williamson
it may
represent
bestProject:
patient
care
et al.not
Medical
Practice Information the
Demonstration
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).
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Variation in Expert Opinion
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
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Variation in Expert Opinion
“
0
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."
20
40
60
100
80
Eddy. A Manual for Assessing Health Practices & Designing Practice Policies: The Explicit Approach.
Philadelphia, PA: The American College of Physicians, 1992; pg. 14.
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“
You can find a physician who honestly believes
(and will testify in court to) anything you want.
- David Eddy, MD
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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.
• 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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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.
In complex situations,
A+B≠C
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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
“
“
Insanity is doing the same thing over and over
again and expecting a different result.
– Albert Einstein
Every system is perfectly designed to produce the
results that it does achieve.
– Paul Bataldan, MD
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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
• What will it take to successfully ride the
transformational wave?
Section Three – Looking into the Future
• What will it take to successfully ride the
transformational wave?
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Questions, discussion, etc…
For Information Contact:
John.Haughom@healthcatalyst.com
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