Healthcare’s Challenging Trio: Quality, Safety, and Complexity
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Dr. John Haughom expands upon the challenges with patient safety and quality in today’s modern healthcare system. First brought to light in the Institute of Medicine’s (IOM) publication of “To Err is Human: Building a Safer Health System”, the situation has only grown more complex since that seminal report. With the total cost of preventable adverse events at as much as $29 billion, preventable readmissions at $17 billion, and preventable medication errors at $16.4 billion, these are all examples of terrible medical waste that must be eliminated.
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Healthcare’s Challenging Trio: Quality, Safety, and Complexity
- 1. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential © 2014 Health Catalyst www.healthcatalyst.comProprietary and Confidential John L. Haughom, MD March 2014 Healthcare’s Challenging Trio: Quality, Safety and Complexity
- 2. © 2014 Health Catalyst www.healthcatalyst.com 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
- 3. © 2014 Health Catalyst www.healthcatalyst.com 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! “
- 4. © 2014 Health Catalyst www.healthcatalyst.com 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…
- 5. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Reaching the Public’s Attention Error Institution Year Impact 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 1984 Public 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 1994 New 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 1995 New 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 Hospital 2001 Josie’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 2003 New 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 2007 Renewed focus on medication errors and the potential value of bar coding to prevent prescribing errors. 5
- 6. © 2014 Health Catalyst www.healthcatalyst.com 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
- 7. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential And the Problem Extends to the Outpatient World… 7 For Every: • 1000 patients coming in for outpatient care1 • 1000 patients who are taking a prescription drug2 • 1000 prescriptions written3 • 1000 women with a marginally abnormal mammogram4 • 1000 referrals5 • 1000 patients who qualified for secondary prevention of high cholesterol6 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 2000. (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 2001. (5) Gandhi T et. al. Communication breakdown in the outpatient referral process J Gen Intern Med 2000. (6) Maviglia SM, et.al. Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines J Gen Intern Med 2001
- 8. © 2014 Health Catalyst www.healthcatalyst.com 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. “
- 9. © 2014 Health Catalyst www.healthcatalyst.com 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.
- 10. © 2014 Health Catalyst www.healthcatalyst.com 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
- 11. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential How Good is American Health Care? Aspirin ACE inhibitors Beta-blockers Reperfusion Medication 0 10 20 30 40 50 60 70 80 90 100 %"idealpatients"receiving Major teaching Minor teaching Nonteaching Allison JJ et al. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI. JAMA 2000; 284(10):1256-62 (Sep 13) 11
- 12. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Practice Variation in the U.S. 12 The Dartmouth Atlas of Healthcare is available at: http://www.dartmouthatlas.org
- 13. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Practice Variation in the U.S. 13 0.0 20.0 40.0 60.0 80.0 100.0 %ReceivingBetaBlockers 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0 55.0 %AdmittedtoICU 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: http://www.dartmouthatlas.org
- 14. © 2014 Health Catalyst www.healthcatalyst.com 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
- 15. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential 15 Extensive research has made it very clear… …inappropriate variation… …harms patients, leads to poor quality, and results in waste…
- 16. © 2014 Health Catalyst www.healthcatalyst.com 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
- 17. © 2014 Health Catalyst www.healthcatalyst.com 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):81-97 17
- 18. © 2014 Health Catalyst www.healthcatalyst.com 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 “
- 19. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential The Evidence Base is Expanding 19 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 12000 10000 8000 6000 4000 2000 12000 10000 8000 6000 4000 2000 00 Year NumberofRCTs 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 1966-1995
- 20. © 2014 Health Catalyst www.healthcatalyst.com 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!
- 21. © 2014 Health Catalyst www.healthcatalyst.com 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 #282-77-0068GS. 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).
- 22. © 2014 Health Catalyst www.healthcatalyst.com 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
- 23. © 2014 Health Catalyst www.healthcatalyst.com 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." 0 20 40 60 80 100 “
- 24. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential 24 You can find a physician who honestly believes (and will testify in court to) anything you want. - David Eddy, MD“
- 25. © 2014 Health Catalyst www.healthcatalyst.com 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.
- 26. © 2014 Health Catalyst www.healthcatalyst.com 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
- 27. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Characteristics of Complex Adaptive Systems Comparison of Organizational System Characteristics Complex Adaptive Systems Traditional Systems Are living organisms Are machines Are unpredictable Are controlling and predictable Are adaptive, flexible, creative Are rigid, self-preserving Tap creativity Control behavior Embrace complexity Find comfort in control Evolve continuously Recycle 27
- 28. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Comparison of Leadership Styles Comparison of Leadership Styles Complex Adaptive Systems Traditional Systems Are open, responsive, catalytic Are controlling, mechanistic Offer alternatives Repeat the past Are collaborative, co-participating Are in charge Are connected Are autonomous Are adaptable Are self-preserving Acknowledge paradoxes Resist change, bury contradictions Are engaged, continuously emerging Are disengaged, nothing ever changes Value persons Value position, structures Are shifting as processes unfold Hold formal position Prune rules Set rules Help others Make decisions Are listeners Are knowers 28
- 29. © 2014 Health Catalyst www.healthcatalyst.com 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 “ “
- 30. © 2014 Health Catalyst www.healthcatalyst.com 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
- 31. © 2014 Health Catalyst www.healthcatalyst.com 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
- 32. © 2014 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Placeholder, enter your own text here For Information Contact: John.Haughom@healthcatalyst.com Questions, discussion, etc… 32 The Top Trends that Matter in 2014 By Bobbi Brown, Vice President; Dan Burton, CEO; and Paul Horstmeier, Senior Vice President of Health Catalyst March 19th | 1-2 PM ET Transforming Healthcare: Data Alone is Not Sufficient By John Kenagy, MD, Physician Executive March 27th | 1-2 PM ET Upcoming Webinars – register at www.healthcatalyst.com
Editor's Notes
- Beyond the inpatient world, a large number of studies have demonstrated that the patient safety problem extends outside the hospital into the outpatient arena. In fact, the patient safety issues in the outpatient world are probably an even bigger problem. It is just harder to get good data in the outpatient space. Many instances of medical harm in the outpatient world elude detection. This slide summarizes just a few of the many studies that have appeared in recent years looking at patient safety in the outpatient setting. There are many more studies beyond these few.
- The second seminal report from the Institute of Medicine was the 2001 report entitled “Crossing the Quality Chasm: A New Health System for the 21st Century.” The report clearly documented that the U.S. health care delivery system does not provide consistent, high-quality medical care to all people. Americans should be able to count on receiving care that meets their needs and care that is based on the best scientific knowledge—yet there is strong evidence that this frequently is not the case. Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, as the report suggested, “between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.” Hence the title of the report. A number of factors have combined to create this chasm. Medical science and technology have advanced at an unprecedented rate during the past half-century. In tandem with exploding knowledge has come growing complexity of health care, which today is characterized by more to know, more to do, more to manage, more to watch, and more people involved than ever before. Faced with such rapid changes, the nation’s health care delivery system has fallen far short in its ability to translate knowledge into practice and to apply new technology safely and appropriately. And if the system cannot consistently deliver today’s science and technology, it is even less prepared to respond to the extraordinary advances that surely will emerge during the coming decades. The Crossing the Chasm report makes an urgent call for fundamental change to close the quality gap, recommends a redesign of the American health care system, and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others.
- The next factor that feeds clinical uncertainty – is the lack of valid clinical knowledge for much of what we do. Or, stated another way, inadequate evidence for much of what we do. There have been three published studies looking at the percentage of clinical care that is based on published scientific research. These studies have concluded that only between 10% and 20% of routine medical practice has a basis in scientific research. Thus, much of what we do in routine clinical practice is based on tradition or opinion. That doesn&apos;t necessarily mean it is wrong as much of it has likely been shown to work over time. But it may not represent the best patient care. We just do not know because we have no “solid rock” evidence. Thus, there can be legitimate reasons to disagree and it is not surprising that we will see variation in clinical practice. All of this suggests that clinicians and healthcare delivery organizations should use their own data to determine the efficacy of clinical practice and to determine how to improve it over time. This implies the need to create a data-driven continuous learning environment. I will discuss this topic in great detail in Section Two of my book and in a future webinar.