1. Quality of Health Care in America
Grand Rounds
Phillip M. Kibort, M.D., MBA
VPMA/CMO
March 2010

4. “The journey of a thousand miles begins with a step”
Quality
“The journey of a thousand miles begins with a step”
Lao Tzu

5. Quality All systems are perfectly designed
to achieve the results they do.
Batalden

6. 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

7. 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

8. First, do no harm….

9. Quality: A Strategic Necessity Because
Cost escalation
Variation in practice
Purchaser dominance
Issues of public trust
Integrated systems and managed care
New information systems

10. Quality/Safety “Safety” “Quality” Performance Improvement (Tools)
The Science
&
Theories
Performance
Improvement
(Tools)
The outcomes
of our product
& services

11. Quality
A) Patient-Centered
B) Systems-Based
C) Evidence-Based

12. 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.

14. 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

15. Our Challenge

16. Reality “Medicine used to be simple, ineffective and relatively safe.
“Now it is complex, effective, and potentially dangerous.”
Sir Cyril Chantler

17. 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):
Chassin, M. Is health care ready for six sigma quality? Milbank Quarterly 1998; 76(4):1-14.

18. We have a broken system
Quality Chasm
Uninformed Consumers
Spiraling Costs
“Pimp My Ride”

19. 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”

20. World’s Best Medical Care?
Do we have
World’s Best Medical Care?
Editorial New York Times, August 12, 2007

21. 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.

22. 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?

23. 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

24. Cadillac Prices, Yugo Quality… Condition % Receiving Recommended Care*
Breast cancer %
Heart attack & coronary artery disease 68%
Immunizations %
High blood pressure %
Osteoarthritis %
Asthma %
Diabetes %
Urinary tract infection %
Sexually transmitted diseases %
*McGlynn, et. Al, New England Journal of Medicine, 2003

25. But What About Pediatrics?
“Healthcare Quality for America’s Children
Even Worse Than for Adults, New Study Finds”
NEJM Mangione-Smith, et al 2007

26. Pediatric quality is different
Development
Differential
Demographics

27. What about Quality?
How good are we?

28. How hazardous is health care?
DANGEROUS REGULATED ULTRA-SAFE 
100,000
10,000
1,000
100 10 1
Health
Care 
Driving 
Scheduled
Airlines 
Chartered
Flights 
European
Railroads 
Mountain
Climbing 
Chemical
Manufacturing 
Nuclear
Power 
Bungee
Jumping
, , , ,000,000
Number of encounters for each fatality

29. Geography is Destiny!
 C-Sections
 Coronary Bypasses
 Back Surgery

30. 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

31. Equity To the shock of Mississippi officials who in 2004
Had seen the infant mortality rate – defined as
Deaths by the age of 1 year per thousand live
births- fall to 9.7, the rate jumped sharply in
2005, to The national average in 2003,
the last year for which data have been compiled,
was 6.9. Smaller rises also occurred in 2005 in
Alabama, North Carolina and Tennessee.
Louisiana and South Carolina saw rises in
2004…

32. 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.”

33. 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.

34. Three Fundamental Assumptions:
Change
Change
Three Fundamental Assumptions:
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.
Change

35. The public has replaced our paternalism with their consumerism
WHY DO THIS?
The public has replaced our
paternalism with their consumerism

36. WHY DO THIS?
Payer fury is becoming stronger

39. Health Care Costs 80% Costs 20% 70% of people 30% of people Cost: $800
Savings opportunity:
$400
Cost:
$400/person/year
Savings opportunity:
$0/person/year
Costs
Cost: $10,000
Savings opportunity:
$2,000-$4,000
20%
Preventive
Services
Vaccines, healthy
lifestyle, blood
pressure management
Ambulatory
Care
Physician
visits
Emergency Room
Care
Diagnostic imaging,
testing, ambulance
transportation
Chronic Disease
diabetes,
congestive heart
failure,
pneumonia
Accident
& Catastrophe
work injury,
car accident

40. Where do those dollars go?
$300 billion dollars greater
administrative costs than Canada.
Enough to support Medicare.
U. Reinhardt

41. 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

42. 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

43. Historical trends in U.S. healthcare expense
What have we tried?
Historical trends in U.S. healthcare expense
P4P
Managed
Care
15%
DRG’s
% GDP
HMO’s
Medicare 4%
s s s

44. Reality “For most of its history, Medicare has been
paying for services but not for results.”
Michael O. Levitt, Secretary of Health & Human Services

45. The best and worst providers receive the same payment
Is this crazy or what?
The best and worst providers
receive the same payment

46. 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

47. 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

48. 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): (Nov 28).

49. Number of Publications Listed in PubMed
2500
2000
1500
1000
500
1980
1985
1990
1995
2000
2005
Figure 1. Impact of H pylori discovery on the number of publications found in PubMed.
This figure shows the number of publications found in the National Library of Medicine
literature search engine in PubMed for each year since the original report by Marshall
and Warren in The database was searched using the terms “pylori” or “pyloridis”
for each year, while a search on “Marshall” and “Warren” was used for 1984.

50. What is your definition of it?
Quality
What is your definition of it?

51. Quality James Todd (AMA) 1986 Quality is like pornography –
“we know it when we see it”
James Todd (AMA) 1986
Potter Stewart
(Supreme Court) 1964

52. 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.

53. 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

54. 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

55. Great doctors Great nurses Great pharmacists Great facilities
Everyone Believes That They Have
Great doctors
Great nurses
Great pharmacists
Great facilities
Great reputation
? Administrators

56. Who Among You Is Below Average?
How Good A Physician/Clinician Are You?
Who Among You Is Below Average?
Opinion
Referral Rates
Anecdotes
No reason to measure excellent care

57. How do you evaluate?
Available
Affable
Able

58. What Do Patients Want?
1. competence
2. communication
3. cognizance
4. caring
5. contact
6. coordination
7. continuity

59. 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

60. 4 Main Things 1) Recognize patient 2) Acknowledge patient’s knowledge
3) Speak at eye level
4) Wash your “damn”hands

61. Can you have better quality
with less cost?

62. Value
Value = Quality
Cost
x Volume
x Service

63. Why is there so much
Confusion?

64. Value = Quality Cost Leapfrog/FACCT MQC AHCPR CMS IHI URAC JCAHO NCQA
AAAHC
AMAP
URAC
IOM
MPAQ
HCQIP
PROS
Integration
Pathways CQI
HEDIS
PSROS
Certification
SQC
Regulation
QIOS
Breakthrough Series
Flow Charts
SERVQUAL
NQF
Accreditation
Prospective Reminders
AHRQ
Licensure
Standards
Integration
Control Charts
Re-engineering
Report Cards
Benchmarks
Rapid cycle change
Guidelines
TQM
outcomes
Balanced Scorecards
education
Focus PDCA
feedback
Satisfactory Survey
Access
1. National Patient Safety Foundation of the AMA
Auditing
Value = Quality
Cost
Leapfrog/FACCT

65. Quality Value = Cost COPQ Reengineering Episodes of Care (DRG)
Nonvalue added
cost analysis
COPQ
Activity based
costing
RBRVU’s
Pricing over
instances
Mergers
Budget cuts
Capitation
Price slashing
Restructuring
downsizing
Utilization
Review
Layoffs
Rightsizing

66. “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

67. OK
So how do we improve?

68. 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

69. Three major things we can learn from
international experience to control costs:
Systematically adopt policies that:
assess the comparative cost effectiveness of drugs, devices, national diagnostic tests, and treatment procedures with a national government task force
The adoption of information technology
3) Financing and organizing primary care
K. Davis

70. 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

71. Bottom Line……. Unexplained variance is the
Essence of the Quality Improvement
Process !!

72. 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

73. 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

74. HOW TO GET TO QUALITY?
STEPS TO IMPROVEMENT

75. “If you can’t describe what
you are doing as a process,
you don’t know what you’re
doing.”
- W. Edwards Deming

76. Key Foci Intention to improve Focus on customers
Focus on process and system
Proper use of measurement and statistics
Involvement of everyone
Continuous testing of changes
Improving upstream
Collaboration, valuing interdependency
Key role of leaders

77. You don’t get what you expect You get what you inspect
Can we get better?
You don’t get what you expect
You get what you inspect

78. Donnabedian Old Quality Tripod
Structure
Process
Outcome

79. Outcomes Measurement The Quality Compass CONVENTIONAL
CLINICAL INDICATORS
PATIENT
SATISFACTION
FUNCTIONAL
STATUS
COST-RELATED
MEASURES

80. The “Triple Aim”
Population
Health
Experience of
Care
Per Capita
Cost

81. 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

82. Philosophy of quality management
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

83. 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.
Cost reduction is sought.
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.

84. Traditional Improvement
vs. Quality Management
Traditional
Quality Management
Focus on processes
Good apples
Work smarter
Data based
Variation is bad
Continuous improvement
Focus on people
Bad apples
Try harder
Opinion based
Variation is normal
Arbitrary goals

85. From Old To New We don’t have time We don’t have time not to
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

86. A New Way of Thinking From Old To New Who did it What allowed it
Punishment
Errors are rare
MDs don’t participate
What allowed it
Thank you!
Errors are everywhere
MDs, RNs, RPhs –
everyone is involved
Simplify/standardize
No thresholds
Add more complexity
Calculate error rates

87. Remember Though The enemy is disease The enemy is error
The enemy is waste
Batalden

88. If you will it
It is no dream

89. THANK YOU

90. Those are my principles. If you don’t like them, I have others.
Groucho Marx