Title: CROSSING THE QUALITY CHASM: HEALTH CARE FOR THE 21ST CENTURY
1CROSSING THE QUALITY CHASM HEALTH CARE FOR THE
21ST CENTURY
- Washington, DC
- January 6, 2004
- Donald Berwick, MD
- Institute for Healthcare Improvement
2The 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
3The 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.
4Congestive Heart Failure Hospitalizations per
1000 Medicare Enrollees (1995-96)
5Hospital Death Rate (Standardized for Age, Sex,
Race, Payer, Admission Source Type) vs Charge
per Admission (Standardized for Age and
Diagnosis) -- AHRQ 1997 Data
6MANAGED CARE
7Now over 15
8Roundtables Categories
- Overuse (of procedures that cannot help)
- Underuse (of procedures that can help)
- Misuse (errors of execution)
9Roundtables Categories
- Overuse (of procedures that cannot help)
- Underuse (of procedures that can help)
- Misuse (errors of execution)
10Health 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
11Percent of Medicare Decedents Admitted to ICU
During their Final Hospitalization (1995-96)
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14Health Care Examples Underuse
- 50 of elderly fail to receive pneumococcal
vaccine - 50 of heart attack victims fail to receive
beta-blockers
15Misuse 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
16What 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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18Stages of Facing Reality
- Stage 1. The data are wrong
- Stage 2. The data are right, but its not a
problem - Stage 3. The data are right it is a problem
but it is not my problem. - Stage 4. I accept the burden of improvement
19- Quality is a system property
20The First Law of Improvement
- Every system is perfectly designed
to achieve exactly - the results it gets.
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22Core 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
23The 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)
24The 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)
25The 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.
26Aims
- Safety
- Effectiveness
- Patient-centeredness
- Timeliness
- Efficiency
- Equity
27Clarifying 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
28To have health care with.
- No needless deaths
- No needless pain or suffering
- No unwanted waiting
- No helplessness
- No waste
29Four 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
30Aims 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
31The 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)
32Four 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
33Three Guiding Frameworks
- Knowledge-based
- Patient-centered
- System-minded
34New 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
35New Rules for Health Care
- Safety as a system property
- The need for transparency
- Anticipation of needs
- Continuous decrease in waste
- Cooperation
36Results from Effective Improvement Efforts.
- Health Resources and Services Administration
(HRSA) - Chronic Disease Care Improvement Collaboratives
37Acknowledgements Improving Chronic Illness Care,
a national program of The Robert Wood Johnson
Foundation
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39UKPDS 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
40PERCENT 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.
41Adding VISN 15s average performance (VHA)
42The 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)
43The 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)
44Four 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
45Changing 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
46Changing 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
47The 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)
48Four 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
49Changing 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
50Core 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
51THE COMMUNITY VERSION LEVEL A - AIMS
- Adopt the Six Aims for Improvement for the
community as a whole Safe, Effective,
Patient-Centered, Timely, Efficient, Equitable - Develop an community-wide measurement system to
track progress - No needless deaths
- No needless pain
- No helplessness
- No unwanted waiting
- No waste
- Review progress annually
52THE COMMUNITY 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 Web Health Care
- Patient-Carried Medical Record
- Registry use
- Reducing Waste in All Its Forms
- Cooperation as the Main Value
53THE COMMUNITY VERSION LEVEL C - ORGANIZATION
- Health Care Information Infrastructure for the
Entire Community - Uniform Electronic Patient Record
- Community-wide Registries
- Community-Wide Training Scheme for All Health
Care Personnel (e.g., Ten Rules, Shared
Decision Making, etc.) - Physicians in a Single Group Practice
(effectively) - Inter-Agency Coordination Uniform Data
- Shared Measurement Systems - Transparent
54Congestive Heart Failure Hospitalizations per
1000 Medicare Enrollees (1995-96)
55Hospital Death Rate (Standardized for Age, Sex,
Race, Payer, Admission Source Type) vs Charge
per Admission (Standardized for Age and
Diagnosis) -- AHRQ 1997 Data
56THE COMMUNITY VERSION LEVEL D - ENVIRONMENT
- Seek Capitated Payment Global Budgets
- 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
57WHAT IT WOULD TAKE
- Everyone on the same team including the doctors
shared vision - Information technology infrastructure, including
an electronic medical record and registries - 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
58Cross-Cutting Issues
- Measurement
- Information Technology
- Financing
- Community Activation
- Coordination of Care
- Patient Co-Management
59Imagine Your Communitys Health Care with.
- No needless deaths
- No needless pain or suffering
- No unwanted waiting
- No helplessness
- No waste
60The 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)