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

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Presentation on theme: "Quality of Health Care in America Grand Rounds Phillip M. Kibort, M.D., MBA VPMA/CMO March 2010."— Presentation transcript:

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 Lao Tzu Quality

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

6 unacceptable 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 Status Quo

7 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 Change

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

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

12 What is the Problem? If you dont think something is broken, you wont try to fix it. There may be a problem but not with my doctor or hospital.


14 … 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 Am College Surg Where did this begin?

15 Our Challenge

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

17 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. A failure of execution

18 Quality Chasm Uninformed Consumers Spiraling Costs We have a broken system 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 Worlds Best Medical Care? Editorial New York Times, August 12, 2007 Do we have

21 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 37 th. 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. Worlds Best Medical Care?

22 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? Worlds Best Medical Care?

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 76% Heart attack & coronary artery disease 68% Immunizations 66% High blood pressure 65% Osteoarthritis 57% Asthma 53% Diabetes 45% Urinary tract infection 41% Sexually transmitted diseases 37% *McGlynn, et. Al, New England Journal of Medicine, 2003

25 Healthcare Quality for Americas Children Even Worse Than for Adults, New Study Finds NEJM Mangione-Smith, et al 2007 But What About Pediatrics?

26 Development Differential Demographics Pediatric quality is different

27 What about Quality? How good are we?

28 How hazardous is health care? 100,000 10,000 1, ,000 10, ,000 1,000,000 DANGEROUSREGULATEDULTRA-SAFE Health Care Driving Chartered Flights Mountain Climbing Bungee Jumping Chemical Manufacturing Scheduled Airlines European Railroads Nuclear Power 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 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… Equity

32 …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. Equitable 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: 1.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.

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

36 Payer fury is becoming stronger WHY DO THIS?



39 Health Care Costs 80% Costs 20% 70% of people 30% of people 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 Cost: $400/person/year Savings opportunity: $0/person/year Cost: $800 Savings opportunity: $400 Cost: $10,000 Savings opportunity: $2,000-$4,000

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

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 15% % GDP 4% Medicare HMOs DRGs Managed Care P4P s 1980s 1990s 2008 What have we tried?

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

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

46 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 Are we like wine?

47 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 Is it possible to keep up?

48 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). Exploding knowledge base

49 Number of Publications Listed in PubMed 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

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

52 The Institute of Medicines 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 Whats 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 Everyone Believes That They Have Great doctors Great nurses Great pharmacists Great facilities Great reputation ? Administrators

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

57 Available Affable Able How do you evaluate?

58 What Do Patients Want? 1. competence 2.communication 3.cognizance 4.caring 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 1) Recognize patient 2) Acknowledge patients knowledge 3) Speak at eye level 4) Wash your damnhands 4 Main Things

61 Can you have better quality with less cost? Quality

62 Value = Quality Cost x Volume Value x Service

63 Confusion? Why is there so much

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

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


67 So how do we improve? OK

68 What We Have to Change… Our values Not Much Except… Our individual and collective behavior Our strategic focus: From Pimp my Ride to Primary Care and Prevention Our reimbursement system Our delivery system Our expectations

69 1)Systematically adopt policies that: assess the comparative cost effectiveness of drugs, devices, national diagnostic tests, and treatment procedures with a national government task force 2)The adoption of information technology 3)Financing and organizing primary care Three major things we can learn from international experience to control costs: 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 Unexplained variance is the Essence of the Quality Improvement Process !! Bottom Line…….

72 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 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


75 If you cant describe what you are doing as a process, you dont know what youre 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 dont get what you expect You get what you inspect Can we get better?

78 Donnabedian Old Quality Tripod Structure Process Outcome


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 1)Systems thinking 2)Micro and macro orientation 3)Patient-focused orientation 4)Use of metrics, data, and information 5)Recognition of multiple causes and co-producers 6)Participation and empowerment of the work force 7)Continuous individual and organizational development as a goal 8)External and internal orientation Philosophy of quality management

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. 4.Cost reduction is sought. 5.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 people Bad apples Try harder Opinion based Variation is normal Arbitrary goals Focus on processes Good apples Work smarter Data based Variation is bad Continuous improvement

85 From OldTo New We dont have time Quality costs money Use intuition and anecdote Defects come from people We dont 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 Punishment Errors are rare MDs dont 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 The enemy is disease The enemy is error The enemy is waste Batalden Remember Though

88 If you will it It is no dream


90 Those are my principles. If you dont like them, I have others. Groucho Marx

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