4“The journey of a thousand miles begins with a step” Quality“The journey of a thousand miles begins with a step”Lao Tzu
5Quality All systems are perfectly designed to achieve the results they do.Batalden
6Status 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
7Change “There is nothing more difficult to plan, more doubtful of success, nor moredangerous to manage, than the creationof a new system. For the initiator hasthe enmity of all who would profit bythe preservation of the old institutionsand merely lukewarm defenders inthose who would gain by the new ones.”MachiavelliThe Prince, 1518
14Where did this begin? … all hospitals are accountable to the public for their degree ofsuccess…If the initiative is not taken by themedical profession, it will be takenby the lay public.1918 Am College Surg
16Reality “Medicine used to be simple, ineffective and relatively safe. “Now it is complex, effective, and potentially dangerous.”Sir Cyril Chantler
17A 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 caredelivery 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.
18We have a broken systemQuality ChasmUninformed ConsumersSpiraling Costs“Pimp My Ride”
19The Battle for Quality: IOM versus “Pimp My Ride” The IOM Vision of Quality:Charles Schwab meetsNordstrom meets theMayo ClinicThe Prevailing Vision ofQuality in AmericanHealthcare:“Pimp My Ride”
20World’s Best Medical Care? Do we haveWorld’s Best Medical Care?Editorial New York Times, August 12, 2007
21World’s Best Medical Care? 1.The WHO ranked 191 nations eight years agoregarding the overall quality of their healthcare,France and Italy took the top two spots and theUnited States was 37th.2.The Common Wealth Fund compared theUnited 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 provideuniversal health coverage and most of them havecomprehensive benefits with no cost sharing by thepatients.
22World’s Best Medical Care? Top of the Line Care. Despite our poor showing inmany international comparisons it is doubtful thatmany Americans faced with a life threatening illnesswould rather be treated elsewhere. Is this a realisticassessment or merely a cultural preference for thehome team?
23IOM Add Injury to Insult 44,000-98,000 plus deaths fromerrors during hospitalizations7,000 deaths from medicationerrors alone$17-29 billion in added costsAmbulatory care unknownTo Err Is Human 1999
24Cadillac 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
25But What About Pediatrics? “Healthcare Quality for America’s ChildrenEven Worse Than for Adults, New Study Finds”NEJM Mangione-Smith, et al 2007
26Pediatric quality is different DevelopmentDifferentialDemographics
28How hazardous is health care? DANGEROUS REGULATED ULTRA-SAFE100,00010,0001,000100101HealthCareDrivingScheduledAirlinesCharteredFlightsEuropeanRailroadsMountainClimbingChemicalManufacturingNuclearPowerBungeeJumping, , , ,000,000Number of encounters for each fatality
29Geography is Destiny! C-Sections Coronary Bypasses Back Surgery
30Sunday, April 22, 2007 New York Times In turnabout, infant deaths climbin SouthRace disparity persistsPoverty, Obesity and Lack of PrenatalCare Cited – a Visible Toll
31Equity To the shock of Mississippi officials who in 2004 Had seen the infant mortality rate – defined asDeaths by the age of 1 year per thousand livebirths- fall to 9.7, the rate jumped sharply in2005, to The national average in 2003,the last year for which data have been compiled,was 6.9. Smaller rises also occurred in 2005 inAlabama, North Carolina and Tennessee.Louisiana and South Carolina saw rises in2004…
32Equitable Care …the IOM concluded that “(al)though myriad sources contribute to these disparities,some evidence suggests thatbias, prejudice, and stereotypingon the part of healthcare providersmay contribute to differences incare.”
33Three main ideas 1. Current American health care is very good, but… there is compelling evidence that healthoutcomes could be much better.2. Experience shows thatit is possible to close the quality gap.3. The business case for quality:better patient results can producesignificant cost savings.
34Three Fundamental Assumptions: ChangeChangeThree Fundamental Assumptions:A good physician takes quality personally.2. A good physician wants to practice thebest quality possible.3. Physicians hate change as much as everyoneelse.Change
35The public has replaced our paternalism with their consumerism WHY DO THIS?The public has replaced ourpaternalism with their consumerism
39Health Care Costs 80% Costs 20% 70% of people 30% of people Cost: $800 Savings opportunity:$400Cost:$400/person/yearSavings opportunity:$0/person/yearCostsCost: $10,000Savings opportunity:$2,000-$4,00020%PreventiveServicesVaccines, healthylifestyle, bloodpressure managementAmbulatoryCarePhysicianvisitsEmergency RoomCareDiagnostic imaging,testing, ambulancetransportationChronic Diseasediabetes,congestive heartfailure,pneumoniaAccident& Catastrophework injury,car accident
40Where do those dollars go? $300 billion dollars greateradministrative costs than Canada.Enough to support Medicare.U. Reinhardt
41Drivers of Health Care Costs Population dynamics: an aging populationwith chronic diseases Medical technology and treatment advances;genomics will fuel advances Healthcare delivery model - failure ofevidence-based care, medical errors,reactive interventions, lower threshold forinterventions Coverage mandates Health professional shortages
42Drivers of Health Care Costs (continued) Consumer education, information, navigatingthe complex systemUnnecessary care; duplication of medicalservices; Protecting the medical commons: failure to“ration” care Administrative costs: hospitals, insurers,medical practicesPhysician and hospital compensation incentivesMedical malpractice
43Historical trends in U.S. healthcare expense What have we tried?Historical trends in U.S. healthcare expenseP4PManagedCare15%DRG’s% GDPHMO’sMedicare4%s s s
44Reality “For most of its history, Medicare has been paying for services but not for results.”Michael O. Levitt, Secretary of Health & Human Services
45The best and worst providers receive the same payment Is this crazy or what?The best and worst providersreceive the same payment
46Are we like wine? “While practice makes perfect”, in some situations physicians knowledge andperformance may decline with the passageof time.N.K. Choudhry, et alAnnals of Internal MedicineFeb. 15, 2005
47Is it possible to keep up? During 2007, the U.S. National Library of Medicine added more than 14,000 new articles per weekto 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
48Exploding knowledge base 3 to 4 years after board certification, internists -both generalists and subspecialists - begin to showsignificant declines in general medical knowledge… 14 to 15 years post-certification, ~68% of internistswould not have passed the American Board ofInternal Medicine certifying exam... To maintain current knowledge, a pediatricianwould need to read> 20 articles per day,> 365 days of the yearan impossible task...Shaneyfelt, TM. Building bridges to quality. JAMA 2001; 286(20): (Nov 28).
49Number of Publications Listed in PubMed 2500200015001000500198019851990199520002005Figure 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 Medicineliterature search engine in PubMed for each year since the original report by Marshalland 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.
50What is your definition of it? QualityWhat is your definition of it?
51Quality James Todd (AMA) 1986 Quality is like pornography – “we know it when we see it”James Todd (AMA) 1986Potter Stewart(Supreme Court) 1964
52The Institute of Medicine’s Definition of Quality Quality of care is the degree to which healthservices for individuals and populationsincrease the likelihood of desired healthoutcomes and are consistent with currentprofessional knowledge.
53Definition of Quality For Health Care Quality Healthcare is: “Safe, effective,efficient, timely, patient-centered, andequitable”Institute of MedicineCrossing the Quality Chasm“no needless death, no needless pain,no unwanted waits, no helplessness,and no waste”Don Berwick, MD2003
54What’s The Problem? A. Under use: Failure to provide a service where benefit > riskB. OveruseService provided when risk >benefitC. MisuseRight services provided badly- wrong drug- wrong dose
55Great doctors Great nurses Great pharmacists Great facilities Everyone Believes That They HaveGreat doctorsGreat nursesGreat pharmacistsGreat facilitiesGreat reputation? Administrators
56Who Among You Is Below Average? How Good A Physician/Clinician Are You?Who Among You Is Below Average?OpinionReferral RatesAnecdotesNo reason to measure excellent care
59Americans’ 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 function5) Help me cope with pain and suffering
604 Main Things 1) Recognize patient 2) Acknowledge patient’s knowledge 3) Speak at eye level4) Wash your “damn”hands
68What We Have to Change… Not Much Except… Our values Our strategic focus: From Pimp my Rideto Primary Care and PreventionOur reimbursement systemOur delivery systemOur individual and collective behaviorOur expectations
69Three 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 forceThe adoption of information technology3) Financing and organizing primary careK. Davis
70Variance Analysis and Intervention The great majority of “outlying”physicians are GOOD physicianswho have developed a particularSTYLE of practice which can beMODIFIED
71Bottom Line……. Unexplained variance is the Essence of the Quality ImprovementProcess !!
72Improvement Success involves meeting the needs of those served Most problems originate in processesor systems, not in peopleSerial experimentation can be used toachieve improvement
73The Process Honor the data Identify key variances Look for explainable causes“Peel the onion” to the next levelSuggest process improvementsMonitor and measure
75“If you can’t describe what you are doing as a process,you don’t know what you’redoing.”- W. Edwards Deming
76Key Foci Intention to improve Focus on customers Focus on process and systemProper use of measurement and statisticsInvolvement of everyoneContinuous testing of changesImproving upstreamCollaboration, valuing interdependencyKey role of leaders
77You don’t get what you expect You get what you inspect Can we get better?You don’t get what you expectYou get what you inspect
78Donnabedian Old Quality Tripod StructureProcessOutcome
79Outcomes Measurement The Quality Compass CONVENTIONAL CLINICAL INDICATORSPATIENTSATISFACTIONFUNCTIONALSTATUSCOST-RELATEDMEASURES
8111 Ways to Effect Change Continuing Medical Education Individual/Small Group EducationAudit/Feedback/ProfilingAcademic DetailingOpinion LeadersClinical Decision Support/RemindersPatient-Specific Decision SupportPatient-Centered StrategiesClinical Process RedesignRegulatory StrategiesFinancial Incentives
82Philosophy of quality management Systems thinkingMicro and macro orientationPatient-focused orientationUse of metrics, data, and informationRecognition of multiple causes and co-producersParticipation and empowerment of the work forceContinuous individual and organizationaldevelopment as a goal8) External and internal orientation
83Crossing the Quality Chasm Current Rules New Rules1. “Do no harm” is an individualresponsibility.2. Secrecy is necessary.3. The system reacts to needs.Cost reduction is sought.Preference is given toprofessional roles over thesystem.1. Safety is a system property.2. Transparency is necessary.3. Needs are anticipated.4. Waste is continuouslydecreased.5. Cooperation among cliniciansis a priority.
84Traditional Improvement vs. Quality ManagementTraditionalQuality ManagementFocus on processesGood applesWork smarterData basedVariation is badContinuous improvementFocus on peopleBad applesTry harderOpinion basedVariation is normalArbitrary goals
85From Old To New We don’t have time We don’t have time not to Quality costs moneyUse intuition and anecdoteDefects come from peopleWe don’t have time not toQuality saves moneyCollect and analyze dateDefects come from defectiveprocesses
86A New Way of Thinking From Old To New Who did it What allowed it PunishmentErrors are rareMDs don’t participateWhat allowed itThank you!Errors are everywhereMDs, RNs, RPhs –everyone is involvedSimplify/standardizeNo thresholdsAdd more complexityCalculate error rates
87Remember Though The enemy is disease The enemy is error The enemy is wasteBatalden