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

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

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

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

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

First, do no harm….

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

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

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

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.

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

Our Challenge

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

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):1000-1005. Chassin, M. Is health care ready for six sigma quality? Milbank Quarterly 1998; 76(4):1-14.

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

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”

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

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.

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?

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

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

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

Pediatric quality is different Development Differential Demographics

What about Quality? How good are we?

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 1 10 100 1,000 10,000 100,000 1,000,000 Number of encounters for each fatality

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

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

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 11.4. 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…

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.”

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.

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

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

WHY DO THIS? Payer fury is becoming stronger

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

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

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

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

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% 1965 1970s 1980s 1990s 2008

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

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

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

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. 2010. Http://www.nim.nig.gov/pubs/factsheets/medline.html

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):2600-2601 (Nov 28).

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 1984. The database was searched using the terms “pylori” or “pyloridis” for each year, while a search on “Marshall” and “Warren” was used for 1984.

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

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

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.

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

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

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

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

How do you evaluate? Available Affable Able

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

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

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

Can you have better quality with less cost?

Value Value = Quality Cost x Volume x Service

Why is there so much Confusion?

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

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

“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

OK So how do we improve?

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

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

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

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

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

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

HOW TO GET TO QUALITY? STEPS TO IMPROVEMENT

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

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

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

Donnabedian Old Quality Tripod Structure Process Outcome

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

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

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

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

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.

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

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

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

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

If you will it It is no dream

THANK YOU

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