CROSSING THE QUALITY CHASM: HEALTH CARE FOR THE 21ST CENTURY

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CROSSING THE QUALITY CHASM HEALTH CARE FOR THE
21ST CENTURY

• Grand Rapids, MI
• October 1, 2003
• Donald Berwick, MD
• Institute for Healthcare Improvement

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The Foundation

• IOM Roundtable
• Presidents Advisory Commission
• National Cancer Policy Board
• IOM Program on Quality of Health Care in
  America
• IOM Committee on Quality of Health Care in
  America
• Subcommittee on Environment
• Subcommittee on the 21st Century Chassis

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The IOM Roundtable

• Serious and widespread quality problems exist
  throughout American medicine. These
  problems.occur in small and large communities
  alike, in all parts of the country, and with
  approximately equal frequency in managed care and
  fee-for-service systems of care. Very large
  numbers of Americans are harmed as a result.

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Congestive Heart Failure Discharges per 1000
Medicare Enrollees (1995-96)
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Percent of Medicare Decedents Admitted to ICU
During the Terminal Hospitalization (1995-96)
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The Problem

• 90,000 Americans die each year as a result of
  nosocomial infections
• The pain and suffering associated with the
  complication can be severe
• The cost of these infections is approximately 5
  billion per year
• Nearly 70 of these are due to micro organisms
  that are resistant to one or more antibiotics

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And the latest large American study..

• McGlynn, et al The quality of health care
  delivered to adults in the United States. NEJM
  2003 348 2635-2645 (June 26, 2003)
• 439 indicators of clinical quality of care
• 30 acute and chronic conditions, plus prevention
• Medical records for 6712 patients
• Participants had received 54.9 of scientifically
  indicated care (Acute 53.5 Chronic 56.1
  Preventive 54.9)
• Conclusion The Defect Rate in the technical
  quality of American health care is approximately
  45

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Hospital Death Rate (Standardized for Age, Sex,
Race, Payer, Admission Source Type) vs Charge
per Admission (Standardized for Age and
Diagnosis) -- AHRQ 1997 Data
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MANAGED CARE
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Now over 15
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Roundtables Categories

• Overuse (of procedures that cannot help)
• Underuse (of procedures that can help)
• Misuse (errors of execution)

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Roundtables Categories

• Overuse (of procedures that cannot help)
• Underuse (of procedures that can help)
• Misuse (errors of execution)

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Health Care Examples Overuse

• 30 of children receive excessive antibiotics for
  ear infections
• 20 to 50 of many surgical operations are
  unnecessary
• 50 of X-rays in back pain patients are
  unnecessary

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Health Care Examples Underuse

• 50 of elderly fail to receive pneumococcal
  vaccine
• 50 of heart attack victims fail to receive
  beta-blockers

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Misuse Health Care Safety

• 7 of hospital patients experience a serious
  medication error
• 44,000-98,000 Americans die in hospitals each
  year due to injuries from care

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What the IOM Said.

• The patient safety problem is large.
• It (usually) isnt the fault of health care
  workers.
• Most patient injuries are due to system failures.

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Stages of Facing Reality To live divided no
more

• The data are wrong
• The data are right, but its not a problem
• The data are right it is a problem but it is
  not my problem.
• I accept the burden of improvement

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• Quality is a system property

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The First Law of Improvement

• Every system is perfectly designed
  to achieve exactly
• the results it gets.

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Core Conclusions

• There are serious problems in quality
• Between the health care we have and the care we
  could have lies not just a gap but a chasm.
• The problems come from poor systemsnot bad
  people
• In its current form, habits, and environment,
  American health care is incapable of providing
  the public with the quality health care it
  expects and deserves.
• We can fix it but it will require changes

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The Chain of Effect inImproving Health Care
Quality
Patient and Community
Aims (safe, effective, patient-centered, timely,
efficient, equitable)
Experience
Simple rules/Design Concepts (knowledge-based,
customized, cooperative)
Micro-system
Process
Organizational Context
Facilitator of Processes
Design Concepts (HR, IT, finance, leadership)
Environmental Context
Facilitator of Facilitators
Design Concepts (financing, regulation,
accreditation, education)
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The Chain of Effect inImproving Health Care
Quality
Patient and Community
Aims (safe, effective, patient-centered, timely,
efficient, equitable)
Experience
Simple rules/Design Concepts (knowledge-based,
customized, cooperative)
Micro-system
Process
Organizational Context
Facilitator of Processes
Design Concepts (HR, IT, finance, leadership)
Environmental Context
Facilitator of Facilitators
Design Concepts (financing, regulation,
accreditation, education)
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The Overarching Aim

• The purpose of the health care system is to
  reduce continually the burden of illness, injury,
  and disability, and to improve the health status
  and function of the people of the United States.

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Aims

• Safety
• Effectiveness
• Patient-centeredness
• Timeliness
• Efficiency
• Equity

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Clarifying National Aims for Improvement

• Safety -- As safe in health care as in our homes
• Effectiveness -- Matching care to science
  avoiding overuse of ineffective care and underuse
  of effective care
• Patient Centeredness -- Honoring the individual,
  and respecting choice
• Timeliness -- Less waiting for both patients and
  those who give care
• Efficiency -- Reducing waste
• Equity -- Closing racial and ethnic gaps in
  health status

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Four Levels of Change Required

• Clarifying national aims for improvement
• Changing the care, itself
• Changing the organizations that deliver care
• Changing the environment that affects
  organizational and professional behavior

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Aims Recommendations

• 1 Endorse the Statement of Purpose for the
  Health Care System
• 2 Endorse the Six Aims for Improvement
  (Safety, Effectiveness, Patient-centeredness,
  Timeliness, Efficiency, and Equity)
• 3 Link to Measurement and Annual Report to
  President and Congress on the State of Quality of
  Care in America

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The Chain of Effect inImproving Health Care
Quality
Patient and Community
Aims (safe, effective, patient-centered, timely,
efficient, equitable)
Experience
Simple rules/Design Concepts (knowledge-based,
customized, cooperative)
Micro-system
Process
Organizational Context
Facilitator of Processes
Design Concepts (HR, IT, finance, leadership)
Environmental Context
Facilitator of Facilitators
Design Concepts (financing, regulation,
accreditation, education)
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Four Levels of Change Required

• Clarifying national aims for improvement
• Changing the care, itself
• Changing the organizations that deliver care
• Changing the environment that affects
  organizational and professional behavior

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Zone of Complexity
Low
Chaos
Zone of Complexity
Professional/Social Agreement about Outcomes
Plan Control
Certainty about Outcomes
Low
High
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Three Guiding Frameworks

• Knowledge-based
• Patient-centered
• System-minded

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New Rules for Health Care

• Care based on continuous healing relationships
• Customization based on patient needs and values
• The patient as the source of control
• Shared knowledge and the free flow of information
• Evidence-based decision making

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New Rules for Health Care

• Safety as a system property
• The need for transparency
• Anticipation of needs
• Continuous decrease in waste
• Cooperation

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Results from Effective Improvement Efforts.

• Health Resources and Services Administration
  (HRSA)
• Chronic Disease Care Improvement Collaboratives

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Acknowledgements Improving Chronic Illness Care,
a national program of The Robert Wood Johnson
Foundation
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UKPDS Glycemic Control

• A 1.0 reduction in HbA1c
• 17 reduction in mortality
• 18 reduction in MI
• 15 reduction in stroke
• 35 reduction in cardiovascular endpoints
• 18 reduction in cataract extraction

Source GHC Contact David K. McCulloch, MD,
FRCP Email McCulloch.d_at_GHC.org
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PERCENT OF IDEAL CANDIDATES WHO RECEIVED
THERAPY(Allison JJ, et al. JAMA 2000 2841256)

Admission to a teaching hospital was associated
with better quality of care.
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Adding VISN 15s average performance (VHA)
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The Care, Itself Recommendations

• 4 Adopt the New Rules for care
• 5 Focus on 15 priority conditions first
• 6 Foster innovation - Health Care Quality
  Innovation Fund (1 billion)

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The Chain of Effect inImproving Health Care
Quality
Patient and Community
Aims (safe, effective, patient-centered, timely,
efficient, equitable)
Experience
Simple rules/Design Concepts (knowledge-based,
customized, cooperative)
Micro-system
Process
Organizational Context
Facilitator of Processes
Design Concepts (HR, IT, finance, leadership)
Environmental Context
Facilitator of Facilitators
Design Concepts (financing, regulation,
accreditation, education)
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Four Levels of Change Required

• Clarifying national aims for improvement
• Changing the care, itself
• Changing the organizations that deliver care
• Changing the environment that affects
  organizational and professional behavior

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Changing the Organizations that Deliver Care

• Redesign care based on best practices
• Use information technology to improve access to
  information and to support clinical
  decision-making
• Improve workforce knowledge and skills
• Develop effective teams
• Coordinate care among services and settings
• Measure performance and outcomes

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Changing Organizations Recommendations

• 7 Redesign
• Care Processes
• Information Systems
• Human Resource Development
• Effective Teams
• Coordination across Boundaries
• Incorporating Measurement
• 8 Moving Science into Practice
• 9 National Commitment to Information
  Infrastructure

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The Chain of Effect inImproving Health Care
Quality
Patient and Community
Aims (safe, effective, patient-centered, timely,
efficient, equitable)
Experience
Simple rules/Design Concepts (knowledge-based,
customized, cooperative)
Micro-system
Process
Organizational Context
Facilitator of Processes
Design Concepts (HR, IT, finance, leadership)
Environmental Context
Facilitator of Facilitators
Design Concepts (financing, regulation,
accreditation, education)
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Four Levels of Change Required

• Clarifying national aims for improvement
• Changing the care, itself
• Changing the organizations that deliver care
• Changing the environment that affects
  organizational and professional behavior

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Changing the Environment

• 10 Reform payment (not more money, but
  different ways to pay)
• For chronic care
• To encourage improvement in care
• To move payment toward high quality
• To encourage best practices, not variation
• To increase cooperation and decrease
  fragmentation
• 11 Social experiments on payment
• 12 Design new workforce requirements
• 13 Start toward change of the tort system

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Core Conclusions

• There are serious problems in quality
• Between the health care we have and the care we
  could have lies not just a gap but a chasm.
• The problems come from poor systemsnot bad
  people
• In its current form, habits, and environment,
  American health care is incapable of providing
  the public with the quality health care it
  expects and deserves.
• We can fix it but it will require changes

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THE GRAND RAPIDS VERSION LEVEL A - AIMS

• Adopt the Six Aims for Improvement for the
  community as a whole Safe, Effective,
  Patient-Centered, Timely, Efficient, Equitable
• Develop a community-wide measurement system to
  track progress
• Review progress annually

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THE GRAND RAPIDS VERSION LEVEL B - MICROSYSTEMS

• Adopt the Ten Simple Rules to guide redesign of
  office practices, the hospital, and
  community-based care
• The New Care IOM Rules Made Real, e.g
• Non-Visit Care Email, Phone, Groups, Internet
• Standardize Care to Science Community-Wide
  Protocols
• Put Patients in Charge Shared Decision Making
• Free Flow of Knowledge Grand Rapids Web Health
  Care
• Patient-Carried Medical Record
• Reducing Waste in All Its Forms
• Cooperation as the Main Value

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THE GRAND RAPIDS VERSION LEVEL C - ORGANIZATION

• Health Care Information Infrastructure for the
  Entire Community
• Uniform Electronic Patient Record
• Community-Wide Training Scheme for All Health
  Care Personnel (e.g., Ten Rules, Shared
  Decision Making, etc.)
• Physicians in a Single Group Practice
• Inter-Agency Coordination Uniform Data
• Shared Measurement Systems - Transparent

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THE GRAND RAPIDS VERSION LEVEL D - ENVIRONMENT

• Seek Capitated Payment Global Budget
• Medicare and Medicaid Waivers for Flexibility
  Total Cost Neutral
• No-Fault Malpractice Compensation Project
• Focus on Design of Payment for Chronic Illness
  Care
• Design Specialty Supply through Planning and
  Contracts

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WHAT IT WOULD TAKE

• Everyone on the same team including the doctors
  shared vision
• Information technology infrastructure, including
  an electronic medical record
• Measuring performance and public reporting
• A commitment to non-visit care options email,
  phone, internet, groups
• Shared decision-making technologies
• Community-wide protocols, agreed, and world-class

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VISION

• THE GRAND RAPIDS MODEL FOR POPULATION-BASED
  CARE
• The Best in the Nation, Instructive to All

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Health care that has.

• No needless deaths
• No needless pain or suffering
• No unwanted waits
• No helplessness
• No waste

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The Chain of Effect inImproving Health Care
Quality
Patient and Community
Aims (safe, effective, patient-centered, timely,
efficient, equitable)
Experience
Simple rules/Design Concepts (knowledge-based,
customized, cooperative)
Micro-system
Process
Organizational Context
Facilitator of Processes
Design Concepts (HR, IT, finance, leadership)
Environmental Context
Facilitator of Facilitators
Design Concepts (financing, regulation,
accreditation, education)