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© 2014 Health Catalyst Proprietary and Confidential © 2014 Health Catalyst Proprietary and Confidential John L. Haughom, MD March 2014 Healthcare’s Challenging Trio: Quality, Safety and Complexity
© 2014 Health Catalyst Proprietary and Confidential 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? 2
© 2014 Health Catalyst Proprietary and Confidential Seminal IOM Publications 3 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 Health care in the United States is not as safe as it should be and can be. 44,000 to 98,000 deaths annually! “
© 2014 Health Catalyst Proprietary and Confidential Patient Safety: A known problem… 4 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…
© 2014 Health Catalyst Proprietary and Confidential Reaching the Public’s Attention ErrorInstitutionYearImpact 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 1984Public 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 1994New 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 1995New 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 Hospital2001Josie’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 2003New 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 2007Renewed focus on medication errors and the potential value of bar coding to prevent prescribing errors. 5
© 2014 Health Catalyst Proprietary and Confidential Adverse Events: Lethal & Expensive 6 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 Medical errors are costly in terms of human suffering and in real dollar terms
© 2014 Health Catalyst Proprietary and Confidential And the Problem Extends to the Outpatient World… 7 For Every: 1000 patients coming in for outpatient care patients who are taking a prescription drug prescriptions written women with a marginally abnormal mammogram referrals patients who qualified for secondary prevention of high cholesterol 6 There Appear to Be: 14 patients with life-threatening or serious ADEs 90 who seek medical attention because of drug complications 40 with significant medical errors 360 who will not receive appropriate follow-up care 250 referring physicians who have not received follow-up information in 4 weeks 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 (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 (5) Gandhi T et. al. Communication breakdown in the outpatient referral process J Gen Intern Med (6) Maviglia SM, et.al. Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines J Gen Intern Med 2001
© 2014 Health Catalyst Proprietary and Confidential Seminal IOM Publications 8 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. “
© 2014 Health Catalyst Proprietary and Confidential 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 9 Schuster MA, McGlynn EA, Brook RH. How good is the quality of healthcare in the United States? Millbank Quarterly.
© 2014 Health Catalyst Proprietary and Confidential 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 10
© 2014 Health Catalyst Proprietary and Confidential How Good is American Health Care? AspirinACE inhibitorsBeta-blockersReperfusion Medication % "ideal patients" receiving Major teachingMinor teachingNonteaching Allison JJ et al. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI. JAMA 2000; 284(10): (Sep 13) 11
© 2014 Health Catalyst Proprietary and Confidential Practice Variation in the U.S. 12 The Dartmouth Atlas of Healthcare is available at:
© 2014 Health Catalyst Proprietary and Confidential Practice Variation in the U.S. 13 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:
© 2014 Health Catalyst Proprietary and Confidential Unwarranted & Warranted Sources of Practice Variation 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 Warranted Patient-Centered 14 Variable access to resources and expertise Insufficient research Unfounded enthusiasm Parochial perspectives Faulty interpretation Poor information flow Poor communication Role confusion Unwarranted Knowledge-Based
© 2014 Health Catalyst Proprietary and Confidential15 Extensive research has made it very clear… …inappropriate variation… …harms patients, leads to poor quality, and results in waste…
© 2014 Health Catalyst Proprietary and Confidential Reasons for Practice Variation 16 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
© 2014 Health Catalyst Proprietary and Confidential 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):
© 2014 Health Catalyst Proprietary and Confidential Medical Progress Over Half a Century 18 Care circa 1960…Care circa 2011… The complexity of modern American medicine exceeds the capacity of the unaided human mind. - David Eddy, MD, PhD “
© 2014 Health Catalyst Proprietary and Confidential The Evidence Base is Expanding Year Number of RCTs 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
© 2014 Health Catalyst Proprietary and Confidential Rapidly Exploding Medical Knowledge 20 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: –20 articles per day, –365 days of the year This is an impossible task… Current estimates are this has grown to 1 article every 1.29 minutes in 2009!
© 2014 Health Catalyst Proprietary and Confidential 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, it may not represent the best patient care 21 Williamson et al. Medical Practice Information Demonstration Project: Final Report. Office of the Asst. Secretary of Health, DHEW, Contract # GS. 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).
© 2014 Health Catalyst Proprietary and Confidential Variation in Expert Opinion 22 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
© 2014 Health Catalyst Proprietary and Confidential Variation in Expert Opinion 23 Eddy. A Manual for Assessing Health Practices & Designing Practice Policies: The Explicit Approach. Philadelphia, PA: The American College of Physicians, 1992; pg. 14. 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." “
© 2014 Health Catalyst Proprietary and Confidential24 You can find a physician who honestly believes (and will testify in court to) anything you want. - David Eddy, MD “
© 2014 Health Catalyst Proprietary and Confidential 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. 25 It is a multidisciplinary field involving many different disciplines including biologists, mathematicians, anthropologists, economists, sociologists, management theorists, computer scientists, and many others.
© 2014 Health Catalyst Proprietary and Confidential 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. 26 In complex situations, A + B ≠ C
© 2014 Health Catalyst Proprietary and Confidential Characteristics of Complex Adaptive Systems Comparison of Organizational System Characteristics Complex Adaptive SystemsTraditional Systems Are living organismsAre machines Are unpredictableAre controlling and predictable Are adaptive, flexible, creativeAre rigid, self-preserving Tap creativityControl behavior Embrace complexityFind comfort in control Evolve continuouslyRecycle 27
© 2014 Health Catalyst Proprietary and Confidential Comparison of Leadership Styles Complex Adaptive SystemsTraditional Systems Are open, responsive, catalyticAre controlling, mechanistic Offer alternativesRepeat the past Are collaborative, co-participatingAre in charge Are connectedAre autonomous Are adaptableAre self-preserving Acknowledge paradoxesResist change, bury contradictions Are engaged, continuously emergingAre disengaged, nothing ever changes Value personsValue position, structures Are shifting as processes unfold Hold formal position Prune rulesSet rules Help othersMake decisions Are listeners Are knowers 28
© 2014 Health Catalyst Proprietary and Confidential The Need for a Better System 29 Every system is perfectly designed to produce the results that it does achieve. – Paul Bataldan, MD Insanity is doing the same thing over and over again and expecting a different result. – Albert Einstein ““
© 2014 Health Catalyst Proprietary and Confidential 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 30
© 2014 Health Catalyst Proprietary and Confidential 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? 31
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