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Plenary 3. Todd Allen - Fixing What Ails Us: Challenges in Health Care Delivery and Solutions Today

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Plenary 3. Todd Allen - Fixing What Ails Us: Challenges in Health Care Delivery and Solutions Today

  1. 1. Fixing What Ails Us: Challenges inHealth Care Delivery and SolutionsTodayMarch 1, 2013QF 2013: Inspiring ImprovementTodd L. Allen MD FACEPInstitute for Healthcare Delivery and ResearchIntermountain HealthcareSalt Lake City, Utah
  2. 2. OutlineThe success of modern medicineThe failures of modern medicineOur miracles fall short of their potentialMoving to a profession based practiceA brief history of QI theoryShared baselines and accountable care
  3. 3. DisclosuresNeither I, Todd L. Allen, nor anyfamily members, have any relevant financialrelationships to be discussed, directly orindirectly, referred to or illustrated with orwithout recognition within the presentation.I have no financial relationships beyond myemployment at Intermountain Healthcare.
  4. 4. We Live In An Age of Miracles
  5. 5. We Live In An Age of Miracles
  6. 6. We Live In An Age of MiraclesHuman genome is fully availableHeart disease deaths down by 40% in a decadeStem cell research and advancementsMinimally invasive surgical techniquesTargeted drug therapies for cancerHIV/AIDS turned into a chronic diseaseElectronic health records
  7. 7. Inflation What was the price of this product in: 1972? 1978? 2012?
  8. 8. Reform, Part Deux“The United States does not havedecades to wait for health systemreform; in 2009 about $1.15 trillion of thefederal budget was spent on healthcare. And health care expenditures aregrowing 2.7% per year faster than non-health care gross domestic product.[The current] reform bill does practicallynothing to slow health expenditures.” Alain Enthoven, PhD Stanford University
  9. 9. The Next Step Health Care Reform, as opposed to the health insurance reform that passed (PPACA) and was upheld by the Court.
  10. 10. Principles for Healthcare ReformThere is no perfect healthcare systemOther systems have useful componentsSimplicity in reform probably trumps complexityEvery efficient system imposes caps on spending and engages in strategic rationingFairness and access are fundamental principles of healthcare, but these are variously definedHigher spending does not correlate with improved outcomesAdministrative costs and complexity in the US are comparatively high Naylor CD. JAMA 2012; 307(9): 919
  11. 11. The Emergence of Modern Medicine: 1860-1910 • New high standards for clinical education • Flexner Report: more than half of all U.S. "medical schools" shut down • New model: hospital-based 2 year course of study (integrated clinical exposure) • Strict requirements for professional licensing • Clinical practice founded on scientific research • Shift to germ theory, rather than "an imbalance of the 4 bodily humors,“ as the basis for understanding disease and its treatment • Health cares first entry into "evidence-based medicine" • New internal organization for hospitalsPorter, R. The Greatest Benefit to Mankind: A Medical History of Humanity. New York, NY: W.W. Norton and Company; 1997.Barry, JM. The Great Influenza: The Epic Story of the Deadliest Plague in History. New York, NY: The Penguin Group; 2004.Starr, P. The Social Transformation of American Medicine. New York, NY: Basic Books (The Perseus Books Group; 1984.Rosenberg, CE. The Care of Strangers: The Rise of the American Hospital System. New York, NY: Basic Books; 1987.
  12. 12. 1912 : The Great Divide"... for the first time in human history, arandom patient with a random diseaseconsulting a doctor chosen at randomstands a better than 50/50 chance ofbenefitting from the encounter." Harvard Professor L. Henderson(Harris, Richard. A Sacred Trust. New York, NY: New American Library, 1966)
  13. 13. "I am sorry for you, young men (and women) ofthis generation. You will do great things. Youwill have great victories, and standing on ourshoulders, you will see far, but you can neverhave our sensations. To have lived through arevolution, to have seen a new birth of science,a new dispensation of health, reorganizedmedical schools, remodeled hospitals, a newoutlook for humanity, is not given to everygeneration." Sir William Osler At the opening of the Phipps Clinic in England, near the end of his career. Reid, Edith Gittings. The Great Physician: A Life of Sir William Osler. New York, NY: Oxford University Press, 1931 (p. 241).
  14. 14. Current Health CareIs the best the world has ever seenA few simple examples: From 1900 to 2000, average life expectancy at birth increased from only 49 years to almost 77 years. Since 1960, age-adjusted mortality from heart disease (#1) has decreased by 56%; and (from 307.4 to 134.6 deaths / 100,000) Since 1950, age-adjusted mortality from stroke (#3) has decreased by 70%. (from 88.8 to 26.5 deaths / 100,000) Initial life expectancy gains almost all resulted from public health initiatives -- clean water, safe food, and (especially) widespread control of epidemic infectious disease. But since about 1960, direct disease treatment has made increasingly large contributions.
  15. 15. Total health: How long, how well we live Behavior: Tobacco Ethanol (and other recreational drugs) ~40% MDD (movement deficit disorder - obesity) Sexually-transmitted disease (AIDS) Unwed teenage pregnancy Suicide, violence, & accidents (young men) Genetics ~30% ~20% ~10% Health care delivery (hospitals and clinics) McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA 1993; 270(18):2207-12 (Nov 10). McGinnis JM, Williams-Russo P, & Knickman JR. The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93 (Mar).
  16. 16. The Great Equation: Health = Medical Care and medical care = access to care "But the Great Equation is wrong ..."Aaron Wildavsky. Doing better and feeling worse: the political pathology of health policy. Doing Better and Feeling Worse: Health in the United States, John H. Knowles, ed. New York: W.W. Norton & Co., 1977.
  17. 17. What Do We Get For All That Money? W. Edwards Deming: Aim defines the system ...Three possible aims of a health care delivery system: 1. Total health -- how long and how well we live 2. High touch -- patients value their relationship with a trusted clinical advisor more than any other element in health care delivery (the clinician- patient relationship)
  18. 18. High touch: caring, not just curingA man stricken with disease today is assaulted by thesame fears and finds himself searching for the samehelping hand as his ancestors did five or tenthousand years ago. He has been told about theclever tools of modern medicine and somewhatvaguely, he expects that by-and-by he will profit bythem, but in his hour of trial his desperate want is forsomeone who is personally committed to him, whohas taken up his cause, and who is willing to go totrouble for him. D. Emerick Szilagyi, MD: In Defense of the Art of Medicine, 1965 (with thanks to Dr. Steven Kappes, Milwaukee, WI)
  19. 19. High Touch? Maybe not ... W. Edwards Deming: Aim defines the system ...Three possible aims of a health care delivery system:1. Total health -- how long and how well we live2. High touch -- patients value their relationship with a trusted clinical advisor more than any other element in health care delivery (the clinician-patient relationship)3. Rescue care -- the Rule of Rescue Primary care vs. Secondary care
  20. 20. Rapid Response: The Rule of Rescue Jonsen AR, 1986:The imperative people feel to rescue identifiable individuals facing (avoidable?) suffering or death.*• Subconscious personal identification at an emotional level;• A person instead of just a number; "a name and a face"  The child down the well  The whales trapped in the ice  The dog on the abandoned boat  "60 Minutes" program on pertussis vaccination "A single death is a tragedy, a million deaths is a statistic." (who killed more than 17 million of his own Russian people) * McKie J & Richardson J. The rule of rescue. Soc Sci Med 2003; 56(12):2407-19 (June). Richardson J & McKie J. Working Paper 112: The Rule of Rescue. West Heidelberg, Victoria, Australia: The Centre for Health Program Evaluation; 2000.
  21. 21. Rule of Rescue - Personal LevelI grew up in Glasgow, Scotland, where death was seen as imminent ...I trained in Canada, where death was seen as inevitable ...I now live and work in California, where death is seen as optional. Ian Morrison, President, Institute for the Future (IFTF) c/o Richard Smith, editor, the British Medical Journal
  22. 22. Current care deliveryoffers opportunities ... OR Fixing what ails us, episode1
  23. 23. Todays problems are often yesterdays solutions.(We cant solve problems using the same kind of thinking we used when we created them) (It works better if you plug it in) Albert Einstein He that will not apply new remedies must expect new evils; for time is the greatest innovator. Francis Bacon (1561 - 1626); in Essays (1625), Of Innovations
  24. 24. Care Falls Short of its Theoretic Potential1. Well-documented, massive, variation in practices (beyond the level where it is even remotely possible that all patients are receiving good care)2. High rates of inappropriate care3. Unacceptable rates of preventable care- associated patient injury and death4. A striking inability to "do what we know works"5. Huge amounts of waste and spiraling prices, that limit access (48.2 million uninsured Americans, and still climbing)
  25. 25. To Improve Quality Eliminate inappropriate variation (process steps) Document continuous improvement (outcomes)
  26. 26. Waste In Healthcare American healthcare gets is right 54.9% of the time1 45-50+% of all resource expenditure in hospitals is quality-associated waste2 • Recovering from preventable mistakes • Building unusable products • Providing unnecessary treatments • Simple inefficiency1. McGlynn EA. The quality of healthcare delivered to adults in the United States. NEJM 2003; 348(26): 2635-452. James BC, Savitz L. 2006 AHRQ Report
  27. 27. The healing professions are changing ... OrThree methods for managing care, Fixing what ails us, episode 2
  28. 28. The Healing Professions are ChangingFrom craft-based practice• Individual physicians, working alone• Handcraft a customized solution for each patient• Based on a core ethical commitment to the patient and• Vast personal knowledge gained from training and experienceTo a profession-based practice• Groups of peers, treating similar patients in a shared setting• Plan coordinated care delivery processes• Which individual physicians adapt to specific patient needs
  29. 29. The Craft of Medicine (each physician an expert)An individual physician• Placing her patient’s healthcare needs before any other end or goal,• Drawing on extensive clinical knowledge gained through formal education and experienceCan craft• A unique diagnostic and treatment regimen customized for that particular patientMedicine’s promise:This approach will produce the best resultpossible for each patient
  30. 30. Quality arises from personalcompetence;Thus,Errors represent professionalincompetence.
  31. 31. Organized CareHow could we create a system that:1. Consistently documents "the best medical outcome at the lowest necessary cost" under each patients full control (true "patient-centered" care)2. Learns from every case - generates scientifically reliable knowledge from routine practice, quickly filling the 80-90% evidence gap regarding best practice; while empirically validating every new treatment.3. Creates a life-long "residency training while in practice“ - organization-level capacity to (1) identify critical new knowledge, (2) blend it into daily workflows, (3) package it for rapid learning, and (4) push it out to all who need it - reduce the time for widespread adoption of major new scientific findings from ~17 years to less than 6 months.4. Generates true transparency - anytime any clinician says "in my experience" they mean "in my measured experience." Eliminate reliance on subjective recall; make physicians and nurses better counselors as they advise and support patients faced with treatment decisions.5. Addresses innate clinical complexity - provide support around critical clinical decisions (Shared Baselines)
  32. 32. Why a Profession-Based Practice?1. It produces better outcomes for our patients2. It eliminates waste, reduces costs, and increases available resources for a patient’s care3. It puts the caring professions back in control of care delivery4. It is the foundation for useful shared electronic data – an important next step in continuous quality improvement
  33. 33. Scientific ManagementDeveloped by Frederick Taylor about 1911Defined mass production (assembly line) methodsTime and motion studiesBased on the idea of processes• On one side: well educated engineers who designed the processes• On the other side: uneducated workers who did as they were toldTransformed the world – quickly and thoroughly supplanted craft style productionStill in use throughout the world
  34. 34. Scientific Management Fails in the face of increasing complexity
  35. 35. Method 1: Data Feedback• History in Intermountain’s QUE studies• Use data for learning versus judgment• Limitations of data feedback 1. Challenges balancing comorbidities and complications 2. Challenges with sample size 3. Physician profiling is methodologically unsound in a quality improvement setting
  36. 36. Managing Clinical Variation Year Author/Idea1911 Frederick Taylor: Principles of Scientific Management (mass assembly line production)1931 Walter Shewhart: Economic Control of Quality Manufactured Product (introduced SPC techniques)1939 Shewhart: Statistical Method from the Viewpoint of Quality Control World War II – Wallis contacts Deming Year Author/Idea1951 W. Edwards Deming: Elementary Principles of the Statistical Control of Quality1990 James Womack et al: The Machine that Changed the World
  37. 37. Deming’s Core Theory• All productive activity happens through definable processes• All processes produce three categories of parallel outcomes - Physical, cost and service outcomes• All processes contain built-in variation (called “common cause” variation• All processes are also affected by external factors (called “special cause” variation)• Quality controls cost• Common variation can be modified or controlled through good system design
  38. 38. Lean or Pull-Through ProductionStandardized processes withSmart cogs thatAdapt to individual needsThat is, “MASS CUSTOMIZATION”(efficient process that can deal with complexity)
  39. 39. Methods to Manage ComplexitySubspecialize (analytic method; reductionism; divide and conquer) (old joke: Know more and more about less and less until you know everything about nothing)Mass customize (a shared baseline: focus on that relatively small subset of factors that are unique by and for each individual patient [typically 5-15%], concentrating your most important resource -- the trained human mind -- where it can have the greatest impact)
  40. 40. Clinical Uncertainty (a hundred years of science)1. Lack of valid clinical knowledge regarding best treatment (poor evidence)2. Exponentially increasing new medical knowledge doubling time has decreased to ~8 years; at current rates, a clinician will need to learn, unlearn, then relearn half of their medical knowledge base 5 times during a typical career3. Continued reliance on subjective judgment (subjective recall is dominated by anecdotes, and notoriously poor when estimating results across groups or over time)4. Limitations of the expert mind when making complex decisions Miller, 1956: The magic number 7, plus or minus 2: some limits on our capacity for processing information Eddy: "The complexity of modern medicine exceeds the capacity of the unaided human mind" Which, combined with the craft of medicine, leads to:  Enthusiasm for unproven methods ... Mark Chassin, MD  The maxim, "If it might work, try it" ... David Eddy, MD, PhD  Quality means "spare no expense" ... Brent James, MD, MStat
  41. 41. Until now, we have believed that the best way to transmit knowledge from its source to its use in patient care is to first load the knowledge into human minds … and then expect those minds, at great expense, to apply the knowledge to those who need it. However, there are enormous ‘voltage drops along this transmission line for medical knowledge. Lawrence L. WeedWeed LL. New connections between medical knowledge and patient care. BMJ 1997; 315(7102):231-5 (Jul 26).
  42. 42. The Core Assumption"Our minds are interpreters of evidence. We can accurately convert all forms of evidence (formal evidence, observations, experiences, colleagues experiences) into conclusions, which in turn determine our actions." Our Evidence Conclusions Actions minds"Therefore, no one has to tell us what to do. Just give us the evidence and we will figure it out. Besides, there are lots of other factors that need to be considered. This can only be done with clinical judgment." Dr. David Eddy
  43. 43. The Core Assumption is Untenable• Poor evidence for most practices• The inherent complexity of modern medicine, versus the limitations of the human mind Lead to• Huge variations in beliefs• Well-documented, massive, variations in practices• High rates of inappropriate care• Unacceptable rates of preventable patient injury• A striking inability to "do what we know works"• Wasted resources on a large scale (= decreased access to care) Dr. David Eddy
  44. 44. Other Factors Affect Our Decisions If our minds cant do the work very well, there are all sorts of other things to fill the void: Our Evidence Conclusions Actions mindsLimited, complex Huge ranges of uncertainty Massive variation, inappropriate care  Professional interests  Financial interests  Clinician preferences and personal tastes  Desire to have something to offer (Rule of Rescue)  Love for the work  Wishful thinking  Selective memory  Pressure from patients and family (direct to consumer advertising)  Legal considerations (defensive medicine) Dr. David Eddy
  45. 45. Method 2: Practice Protocols1. There is insufficient evidence base for most treatment choices2. Expert medical opinion is essential random3. Practice guidelines do not often change practice4. Most guidelines lack sufficient specificity to actually guide practice5. Most guidelines have no validation data
  46. 46. We Have Found Proven SolutionsShared Baselines (a form of Lean Production)• Select a high priority care process• Generate an evidence based “best practice” guideline• Blend the guideline into the flow of clinical work • Training, staffing, supplies, physical layout, educational materials, measurement and information flow• Use the guideline as a shared baseline with clinicians free to vary based on individual patient needs• Measure, learn from, and (over time) eliminate variation arising from professionals, but retain variation arising from patients (mass customization)
  47. 47. The Principles Of Shared Baselines (or we have found proven solutions)• Select a high priority care process• Generate an evidence-based best practice guideline• Blend the guideline into the flow of clinical work Staffing Training Supplies Physical layout Education Measurement materials and feedback• Use the guideline as a shared baseline with clinicians free to vary based on individual patient needs• Measure, learn from and (over time) • Eliminate (smooth out) variation arising from the professional and retain variation arising from patients • This is the “mass customization”
  48. 48. The Setting is Critical • Real cases -- not abstract discussion • Single decisions intellectually approachable can bring special methods to bear: lit review, experts, etc. • A group of clinical peers who see similar patients in the same environment learning together, and holding each other accountable
  49. 49. Only Three Choices• Decide the protocol is wrong and change it on the spot• Decide the protocol is right -- a normative message from ones peers• Decide that it is random noise -- while the care was appropriate and the protocol didnt cover it, it represents a rare event that would add unnecessary complexity to the protocol
  50. 50. Practical Limitations on Protocol Use When abstract guidelines hit real patient care, experience clearly shows that (with very rare exception) No protocol fits every patient; more important, No protocol (perfectly) fits any patient.
  51. 51. PhysiciansIt is more important that you do it the same than that you do it “right.”When you “do it the same:”• Error rates fall – less complexity = fewer mistakes = better outcomes• Costs fall – staff is more efficient; you are more efficient• You can apply the scientific method to systematically improve – regardless of where you start you will end up with demonstrated care practices. “Truth is found more often from mistakes than from confusion ...” Francis Bacon (1561-1626)
  52. 52. Professional AccountabilityWe will not tell you how to practice medicine • We will argue the science, but if we cannot convince physicians "on the data," we will not expect them to change how they manage patients.We will create an environment of professional accountability • Where groups of physicians and other professionals; • who manage similar patients in similar settings; • discuss best patient care practices; • with recourse to the medical literature, expert opinion, and credible data showing their own performance and outcomes.(A redefinition of traditional peer review)
  53. 53. Traditional Quality Assurance Before After threshold better worse better worse Quality Quality
  54. 54. Quality Improvement Before After better Quality worse better worse Quality
  55. 55. The Healing Professions • We put our patients first -- as clinicians, we place our patients health needs before any other end or goal; we act as our patients advocates. We accept, promote, and honor a fiduciary trust on behalf of our patients. • We maintain a special body of knowledge -- as clinicians, (1) We practice - we apply knowledge not generally available outside of the professions (information disparity). (2) We teach - we transmit that knowledge to the next generation. And (3) We learn - we improve the knowledge we ourselves received. (e.g., Geisinger Health System mission: Heal. Teach. Discover. Serve.) • We police our own ranks -- acting on behalf of patients, we assure that all members of the healing profession respect our fiduciary trust and are competent (a social contract; the official definition of "professional autonomy")
  56. 56. Realized Clinical Integration• You must assume that front-line clinicians are • As smart as you are • As dedicated to patients as you are • As hard working as you are • As motivated as you are • Are the ones with the fundamental knowledge of how the system actually works• But they do not control the system that houses the context of their work• How will our efforts MAKE IT EASIER FOR THEM TO DO IT RIGHT?
  57. 57. The 5 Axioms of IntermountainHealthcareMost treatments for a specific condition have similar characteristicsThere is still massive variation in clinician’s practicesAll have something to learn and something to teachClinicians will lead most changes themselvesClinical integration is our strategic plan
  58. 58. "I am sorry for you, young men (and women) ofthis generation. You will do great things. Youwill have great victories, and standing on ourshoulders, you will see far, but you can neverhave our sensations. To have lived through arevolution, to have seen a new birth of science,a new dispensation of health, reorganizedmedical schools, remodeled hospitals, a newoutlook for humanity, is not given to everygeneration." Sir William Osler At the opening of the Phipps Clinic in England, near the end of his career. Reid, Edith Gittings. The Great Physician: A Life of Sir William Osler. New York, NY: Oxford University Press, 1931 (p. 241).
  59. 59. Better has no limit ... an old Yiddish proverb

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