Improving and Reforming Health Care: Rediscovering the Basics

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Improving and Reforming Health Care
Rediscovering the Basics

• Steven Levenson, MD, CMD
• September 21, 2010

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Reform

• Reform is in the air
• But just what does reform aim to fix?
• Reform
• Improve by alteration or correction of errors or
  defects and put into a better condition
• Make changes for improvement in order to correct
  abuses
• Source http//www.google.com/search?hlenqdefin
  e3AreformbtnGGoogleSearchaqfoq

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Reform Hurdles

• AMA to White House Don't Dictate Care 3/9/09
• http//www.healthleadersmedia.com/content/229394/t
  opic/WS_HLM2_HR/AMA-to-White-House-Dont-Dictate-Ca
  re.html
• Any attempts by federal government to use
  evidence-based medicine to dictate how physicians
  provide individualized care would be a deal
  breaker

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Reform Hurdles

• It isnt just patients and doctors
• Health care reflects and impacts all major social
  institutions
• Education, government, economics / commerce,
  families, law
• Oversight, attempts to change performance,
  enforcement all reflect and influence health care
• Reflect beliefs and methods for example, how to
  investigate, draw conclusions, define truth,
  identify correct actions, attribute cause and
  effect

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Who Can Reform What?

• Limitations of legislatures and political
  processes in bringing about true reform
• Many of us are having trouble changing our
  thinking and actions
• Non-therapeutic substitution
• In American culture, prescriptions and
  procedures have become surrogates for real health
  care and real dialogue, Dr. Newman said. We
  need doctors and patients to conceive of medicine
  and health in a totally different way than they
  have been taught in the last 20 to 30 years.
• Source http//www.nytimes.com/2009/03/03/health/0
  3well.html?scp14sqhealth20carestcse

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Reform Efforts

• How much do current efforts really being about
  meaningful change and set appropriate
  expectations?
• Not surprisingly, current approaches are
• Often uncoordinated
• Sometimes self-contradictory
• Dont consistently result in good care
• May not define issues correctly or identify root
  causes

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Reform Prerequisites

• To reform something effectively, it helps to
  understand what we are trying to improve
• Clear issue statement
• Nature and components
• Causes of imperfections and problems
• What it should look like when done
• What should be changed or strengthened
• Options for changing things
• Obstacles to implementing reform
• Options for overcoming obstacles

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Our Subject Matter

• What will it take to do this right?
• A cohesive strategy and a meaningful plan
• Understand and apply biological foundation
• Reconsider current improvement and reform efforts
• Challenge the conventional wisdom
• Widespread, consistent accountability
• Rethink the research agenda

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Our Subject Matter

• What will it take to do this right?
• Focus attention on basic care principles and
  processes
• Promote desired performance and practice
• Suppress reductionism and jurisdiction
• Reconsider notions of competency and expertise
• Change approaches to assessing and trying to
  improve quality
• Develop biologically sound reimbursement

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What Can We Each Do?
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Solution is Straightforward
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Mostly Self-Evident
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Logically Consistent
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Little Changes Add Up
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Key Principles

• What constitutes biologically sound care?

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The Three Human Dimensions
PSYCHOSOCIAL
FUNCTIONAL
PHYSICAL
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Homeostasis

• A key biological principle
• An organism maintains relative stability through
  constant internal adjustment
• Adequately functioning organ systems adjust to
  compensate for stresses
• Including imbalances and impairments
• Disease and organ failure may
• Cause or exacerbate imbalances
• Impair physiological reserve capacity

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Homeostasis Water Balance

• Maintaining water balance

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Homeostasis Blood Sugar

• Blood sugar regulation

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Personal and Psychological Homeostasis

• Similar to physiological homeostasis
• Individuals strive for psychological balance and
  adequate function
• To thrive in personal and social setting
• Personal and psychological homeostasis require
  adequate physical homeostasis
• Example function and mood may decline when major
  medical illness causes physical instability

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Health, Illness, and Impairment

• Health can be defined as a state of complete
  physical, mental and social well-being and not
  merely the absence of disease or infirmity -
  World Health Organization (WHO)
• http//www.who.int/about/definition/en/print.html
• Limits of health care in producing complete
  well-being (i.e., health)
• However, can have profound effects, for better or
  worse

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Key Biological Principles When Things Go Astray

• Symptoms and risk factors have causes
• Often combined effects of multiple issues
• Causes and consequences have various
  relationships
• Defining those links is crucial to providing
  safe, effective, and patient-centered care

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Biologically Sound Care

• Quality of life and quality of care are
  inseparable in all settings
• Effective care is based on linking each persons
  physical, functional, and psychosocial causes and
  consequences
• The essence of individualized (person-centered)
  care
• Requires context of underlying causes and
  consequences
• Recognizes that interventions may be beneficial,
  inconsequential, or harmful

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Causes and Consequences
Consequences ? Causes One Multiple
One / /
Multiple / /
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Causes and Consequences

• All consequences (e.g., impairments, symptoms,
  complications) have causes
• Causes and consequences occur in four major
  patterns and relationships
• Clarify links among causes and consequences
• Basis for providing care in any setting

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Causes and Consequences
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Causes and Consequences Examples

• One cause ? One consequence (11)
• Fracture ? impaired mobility until fracture heals
• Fatigue ? headache for a few hours
• One cause ? multiple consequences (1Multiple)
• Altered family processes ?mood disturbance ?
  social withdrawal and behavioral symptoms
• COPD (advanced) ? activity intolerance, altered
  breathing patterns, impaired gas exchange,
  self-care deficit

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Causes and Consequences Examples

• Multiple causes ? one impairment (Multiple1)
• Hydration or depression risks due to
• CVA and dementia (neurological), chronic renal
  failure (urinary), colitis related to antibiotic
  use (gastrointestinal)
• Multiple causes ? Multiple impairments (Multiple
  Multiple)
• New stroke diabetes ischemic heart disease
  chronic renal failure medication side effects
  mood disorder ? impaired mobility pain
  social withdrawal altered nutritional status
  risk of altered skin integrity

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Linking Causes and Consequences

• Four essential steps before interventions
• 1) Characterize the disabilities
• 2) Identify causal impairments
• 3) Determine specific diseases underlying
  identified causal impairments
• 4) Discover any contributing factors
• Hoenig H, Nusbaum N, Brummel-Smith K. Geriatric
  rehabilitation State of the Art. J Am Geriatr
  Soc 451371-1381, 1997

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Biologically Sound Care Key Underlying
Principles

• Impairments may often be prevented or improved by
  treating underlying causes
• Important to
• Identify all causes of impairments, to extent
  possible
• Determine which ones can be addressed and to what
  extent
• Choose interventions in the context of the whole
  situation, not just one symptom or risk factor
• Try to optimizenot underminephysical condition

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Biologically Sound Care Key Underlying
Principles

• Interventions may prevent or correct physical
  impairment by
• Resolving underlying cause(s)
• Improving homoeostatic balance
• Maintaining or improving physiological reserve
  capacity
• Reverse impairments
• Lessen severity or help reduce progression to
  disability

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Care in Context

• Coordinated and integrated care of people
• Especially those with multiple issues
• Consistent with biology because it
• Takes each symptom, condition, risk, or problem
  in context
• Including sequence of events
• Identifies proper combinations of cause-specific
  and symptomatic interventions
• Promotes care that optimizes physical,
  functional, and psychosocial homeostasis

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Care in Context

• Fragmented or uncoordinated care
• Biologically unsound because it
• Approaches issues as distinct entities
• Fails to identify root causes
• Fails to address causes and consequences in
  proper context
• May cause new or additional complications while
  trying to address issues in isolation

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Biologically Sound and Unsound Care

• Sound
• Care of person with Condition A Condition B
  Condition C Condition D Condition E
• ?
• Unsound
• Care of Condition A Care of Condition B
  Care of Condition C Care of Condition D
  Care of Condition E

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Patient History and Context

• What are the likely differences in cause,
  approach, and context if someone
• Gets delirium and then gets anorexia
• Gets anorexia and then gets delirium
• Has a significant condition change with change in
  mental function and anorexia at the same time

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Health Care Role

• What is the role of health care in providing
  biologically sound care?

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Implications for Care Provision

• Key goal of all health care
• Effectively integrate interventions and services
  related to physical, functional, and psychosocial
  dimensions
• Key goal of medical care
• Help individuals attain and preserve enough
  physiological function to enable the greatest
  possible personal and psychosocial function
• Within limits of whats reversible / preventable

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Reform and Improvement

• How and why do these principles affect efforts to
  improve health care?

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Reform and Improvement

• Meaningful efforts to improve and reform health
  care must
• 1) be consistent with, or at least not
  contradict, aforementioned key principles
• 2) promote, or at least not undermine, adherence
  to those principles

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Health Care Reform

• Problem Definition and Cause Identification

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Essential Support for Reform

• Mutual influence between health care and all
  other social institutions
• Other social institutions and public policy must
• Reflect and respect underlying biology
• Understand what they are alleging to try to
  improve and reform
• Promoting individualized care means much more
  than just functional and psychosocial
  interventions

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Essential Support for Reform

• Less helpful efforts
• Promote interventions out of context
• Focus on fragments of the care delivery process
• For example, care planning or treatment
• Are too focused on artificial distinctions
• Such as medical and social models of care

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Approach to Health Care Reform

• IF biologically sound care is required in order
  to meet key quality attributes
• Safe, effective, efficient, timely, equitable,
  patient-centered
• AND only some of the care is biologically sound
• THEN
• We must focus on improving the biological
  soundness of all care, in all settings

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Approach to Health Care Reform

• IF the three human dimensions are closely related
• AND health care only partially reflects that
  reality
• THEN
• We must focus on properly integrating and
  coordinating services in all settings
• We must suppress and reverse excesses of thinking
  about medical and social models

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Approach to Health Care Reform

• IF human beings have mechanisms to maintain
  physical, functional, and psychosocial stability
  despite change
• AND health care only partially reflects that
  reality
• THEN
• We must ensure that care in all settings respects
  and reflectsand does not impair or damagethose
  balances

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Approach to Health Care Reform

• IF biologically sound care provides treatment in
  context and as a means to an end, instead of an
  end in itself
• AND health care only partially reflects this
  understanding
• THEN
• We must try to get care in all settings to be
  given in the proper context

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Approach to Health Care Reform

• IF causes and consequences have identifiable
  relationships, and those links are important to
  identifying care
• AND health care only partially reflects this
  understanding
• THEN
• We must try to get care in all settings to be
  based on identifying and linking causes and
  connecting causes and consequences

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Foundation For Subsequent Reforms

• Further tinkering is inadequate because
• Resources are limited
• Waste is problematic
• Results count more than ever
• Important to consider reasons for success or
  failure of previous efforts

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Recommendations to Improve Reform Health Care
Summary

• Reconsider current improvement and reform efforts
• Challenge the conventional wisdom
• Vigorously subdue political correctness
• Rethink the research agenda
• Focus attention on basic care principles and
  processes

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Recommendations to Improve Reform Long-Term
Summary

• Suppress reductionism and jurisdiction over care
• Reconsider notions of competency and expertise
• Change approaches to assessing and trying to
  improve quality
• Develop biologically sound reimbursement

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Reconsider Current Improvement and Reform Efforts
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Sources of Efforts to Improve and Reform Health
Care

• Various sources
• Governmental
• Industry groups and coalitions
• Public and consumer initiatives
• Physician initiatives
• Insurance initiatives
• Non-industry organizations and associations

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Types of Efforts Targeting Reform

• Various types
• Laws and regulations
• Assessment tools
• Workforce initiatives
• Quality-improvement strategies
• Work groups
• Campaigns
• Consumer initiatives (e.g., culture change)

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Problems and Solutions

• Current reform initiatives
• A potpourri of approaches
• Still lacks a comprehensive problem statement and
  cohesive strategies
• Inadequate to just aggregate multiple solutions
  and reform agendas, e.g.
• Agenda A Idea B Campaign C Proposal
  D Notion E

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Reform Efforts Desirable and Problematic

Desirable Efforts Problematic Efforts
- Cohesive and compatible - Fragmented, piecemeal, uncoordinated, inconsistent, incompatible
- Arise from thoughtful discourse - Based on inadequate understanding of problems and underlying causes
- Respect precedent - Tend to reinvent the wheel
- Biologically sound - Biologically unsound
- Promote all essential elements - Overly complicated missing key elements
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Reform Efforts Desirable and Problematic

Desirable Efforts Problematic Efforts
- Promote full care delivery process - Do not emphasize all care delivery process components
- Emphasize empirical methods for clinical problem solving - Underemphasize rational clinical problem solving
- Emphasize good outcomes - Emphasize good intentions
- Assess both results and related processes - Unbalanced emphases
- Valid approaches to identifying care quality - Inadequate approaches to identify care quality
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Reform Efforts Desirable and Problematic

Desirable Efforts Problematic Efforts
- Focus on underlying care as well as treating specific conditions - Overemphasize treatment of specific conditions at expense of underlying concepts
- Promote balanced care and treatment in context - Promote unbalanced or superficial care
- Avoid false medical / social model dichotomies - Unbalanced emphasis on medical or social models
- Balanced approaches to regulatory compliance - Excessive preoccupation with regulatory compliance
- Promote vital management role in effective care - Downplay or overlook key management role
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Strategies Reconsider Current Improvement
Reform Efforts

• The chief cause of problems is solutions Eric
  Sevareid (CBS News Reporter / Commentator,
  1939-1977)
• Evaluate compatibility of reform efforts with key
  principles
• Focus more on defining issues correctly and
  identifying root causes
• Restrain tendencies to try to do something in
  vague hope it works

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Challenge the Conventional Wisdom
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Challenging the Conventional Wisdom

• Genuine reform and improvement requires
  rethinking and undoing much of the conventional
  wisdom
• Many common practices in health care are
  unfounded
• Many beliefs about health care are incorrect or
  misleading
• Current CW often prevails because it serves
  diverse agendas

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Conventional Wisdom The Other Side

Conventional Wisdom Unconventional Viewpoint
- Reformers are above reproach - Reformers deserve scrutiny - Reformers may be blocking legitimate solutions
- More laws and regulations are needed - Laws and regulations need a biologically sound basis
- All settings need to measure performance - Measurement has limits in improving performance
- Stronger enforcement is needed - Accountability needs to be consistent and evidence-based
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Conventional Wisdom The Other Side

Conventional Wisdom Unconventional Viewpoint
- More research is needed to solve these big issues - Implementation of existing knowledge is vital
- Interdisciplinary teams are essential - IDTs must function properly and know their limits
- The more care that is given, the better the quality - More care may simply be irrelevant or hazardous
- Quality measurement measures care quality - Relevance of some current quality measurement is unclear
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Strategy Challenge the Conventional Wisdom

• Seek and use available evidence to assess
  conventional wisdom
• Regardless of its source
• Identify and contest common practices that have
  questionable basis
• Including undesirable de facto standards of
  care, despite incompatibility with evidence

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Conventional Wisdom and Accountability

• Major obstacles to health care reform today
  include
• Insurance companies
• Food and Drug Administration (FDA)
• Drug companies
• Doctors
• To some extent, these and other challenges are
  pertinent

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Unconventional Wisdom

• Major obstacles to health care reform today
  include
• Failures of accountability
• The Defensive Triad
• Rationalization
• Projection
• Denial
• At all levels, in all settings

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The Defensive Front

• Rationalization
• I had to do it because. . .
• I had to do it this way (instead of another way)
  because. . .
• It was beyond my control / I couldnt help it
• Projection
• Its someone elses problem, not mine
• Denial
• I dont have a problem
• I didnt do it
• I am not responsible for what happened

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Defenses and the Brain

• Defenses are the brains way of protecting us
  from too much anxiety
• I know the answer before I even hear the
  question
• More automatic, little cortical involvement
• Defy reasoning, logic, or common sense
• Reference Jacobs C. Management Rewired. New
  YorkPenguin Group, 2009.

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Accountability The Unconventional Wisdom

• Definition answerable for actions and decisions
• The means of attaining responsibility
• By applying basic principles and tactics to
  attain desired performance

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Responsibility

• Definitions
• Having an obligation to do something, or having
  control over or care for someone
• Morally accountable for one's behavior
• Capable of being trusted
• Of a job or position Involving important duties
  or decisions or control over others
• Responsible to Having to report to and be
  answerable to

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Accountability and Alignment
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Basic Principles Different Groups, Different
Approaches
2
3
1
4
10
30
50
10
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Different Schools of Amateur Management

• Cant everyone just get along?
• They are adults
• They have a license
• Hard to find good people
• Wheres their critical thinking?
• You cant change personalities

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Defending Against Defenses

• Effective manager / leader
• Accepts personal responsibility
• Uses defenses / makes or accepts excuses lt 5 of
  the time
• Demands / fosters accountability
• Ineffective manager / leader
• Denies personal responsibility
• Makes / accepts excuses much of the time
• Rationalizes other peoples poor performance
• Much like dysfunctional staff they supervise

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Problematic Health Care Professionals in LTC

• Dont know what they should do
• Dont agree it is their responsibility
• Dont know why they should do it
• Dont know how to do it properly
• Fear negative consequences for doing or not doing
  something
• Have few positive consequences for acting in
  desired manner
• Have no negative consequences for inappropriate,
  undesired performance

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The ABCs

• Bi f i (A,C)
• Individual behavior (B) is a function of
  antecedents (A) but more importantly
  consequences (C)

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Antecedents and Consequences

• Antecedents - Things That Precede Performance
• Slogans and pep talks
• Policies and procedures
• Training
• Consequences - Things That Follow Performance
• Things that increase performance frequency
• Things that decrease performance frequency

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Vital Management Activities

• Make sure they know what to do
• Make sure they know why they should do it
• Make sure they know how to do it
• Check their performance
• If performance still inadequate
• Systematically review and address other reasons
  for non-performance until
• Performance satisfactory OR
• Consequences unimportant OR
• Individual no longer involved

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Some Core Management Functions

• Identify expectations, and explain their basis
• Explain how to fulfill those expectations
• Identify criteria for satisfactory fulfillment of
  expectations
• Determine whether those expectations are be met
• Provide feedback to individuals about how well
  they are meeting those expectations
• Help individuals refine performance to meet
  expectations better

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Realization

• Management is an intervention more like bridge
  building than rain dancing
• Management is a concrete, identifiable
  intervention
• Like cake baking or orchestra conducting to lead
  towards a desired outcome
• Best ingredients or best musicians alone do not
  guarantee a good cake or concert

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Management As Intervention

• Preventive management is like preventive
  maintenance
• Manipulate elements to get predicted outcome that
  would not have happened otherwise
• Convert management philosophies and theories into
  things to influence performance
• Misdiagnosis by a manager may lead to treating
  symptoms or wrong causes
• Less likely to correct performance problems

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Vigorously Subdue Political Correctness
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Vigorously Subdue Political Correctness

• Politics
• The means by which societies try to accommodate
  and reconcile diverse needs, desires, and
  perspectives.
• Politics can be constructive or problematic
• Presently, some serious imbalances

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Political Correctness

• Political correctness (PC)
• Promote or expect certain beliefs, words,
  attitudes, or actions
• Avoid, sanction, or fail to even consider others
• Operates at all levels
• Within social institutions, facilities,
  organizations
• Often merely a rationalization for
• Gaining personal advantage
• Avoiding accountability

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Genuine Reform Subdue Political Correctness

• Genuine improvement and reform require more open
  and balanced public dialogue about
• Responsibility for inadequate performance
• In all settings, at all levels, in all social
  institutions
• Appropriateness of proposed solutions from
  diverse sources
• Alleged expertise

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Strategies Subdue Political Correctness

• Broaden dialogue about
• Virtues and weaknesses of various settings
• Proposals to improve and reform care
• Reinforce accountability at all levels
• Stop excusing inappropriate performance and
  practice
• Contest incorrect and misleading advice
• Regardless of the sources

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Rethink the Research Agenda
93
Knowledge and Its Effective Implementation

• Many contributions from decades of research
• Huge gap between knowledge and its effective
  application
• Research is a means to an end
• Not an end in itself
• An evidence basis for care does not necessarily
  improve that care

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Respecting Precedent

• Desirable improvement and reform activities
  respect existing knowledge
• Consider effectiveness of applying existing
  knowledge
• Emphasize enduring and universal clinical and
  management principles
• For example, problem solving and linking causes
  and consequences

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Example Medications

• For example, issues related to medications have
  been identified for decades
• Researchers keep studying the topic
• Conclusions not remarkably different from the
  past
• Problem of adverse medication consequences
  remains widespread
• Perhaps worse than ever

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Meaningful Research Hypotheses Examples

• What is impact of proper and improper care
  process and clinical problem solving and decision
  making on outcomes?
• Proper care delivery process task performance
  essential to high-quality care
• Lapses in care delivery process-related task
  performance underlie care / quality issues
• Failures of cause identification are major source
  of avoidable negative outcomes

97
Meaningful Research Hypotheses Examples

• Do treatment and care decisions have a valid
  clinical rationale?
• Valid rationale often missing or incompatible
  with patient-specific evidence
• Too much care is based on guesswork and rote
  interventions

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Meaningful Research Hypotheses Examples

• To what extent do organizational and operational
  issues impact care quality and outcomes?
• Facility management and care systems profoundly
  influence
• Care delivery process
• Provision of appropriate, safe, and effective care

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Strategies Rethink the Research Agenda

• Shift balance towards implementing existing
  knowledge
• Analyze failures in implementation
• Recognize precedents, including existing
  knowledge
• Consider more pragmatic approaches to influencing
  and improving performance
• Broaden scope of research hypotheses and
  questions

100
Strategies Rethink the Research Agenda

• Redirect funding more towards rethinking
  traditional approaches
• Reduce repetition of conventional wisdom
• Reexamine conflicts of interest that impede free
  inquiry and dialogue
• Focus much more attention on basic care
  principles and processes

101
Focus Attention on Basic Care Principles and
Processes
102
Focus Attention on Basic Care Principles and
Processes

• Good care results from painstaking detective work
• All settings need more individuals with basic
  generic competencies
• All settings need
• A return to the roots of primary care medicine
  and nursing
• Faithful adherence to the care delivery process

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Strategies Focus on Basic Care Principles and
Processes

• Focus on
• Strengthening care delivery process
• Minimizing diagnostic fallacies and avoid
  treating the chief complaint
• Addressing challenges to providing safe and
  effective care
• Strengthening clinical problem solving and
  decision making to help compensate for these
  challenges

104
Suppress Reductionism and Jurisdiction Over Care
105
Suppress Reductionism and Jurisdiction Over Care

• Time to reverse the trend to excessive
  reductionism and jurisdiction in health care
• Reductionism
• Misconception that aggregating pieces of care
  managing the whole patient
• Jurisdiction
• Giving various disciplines or settings rights of
  supremacy to diagnose and treat

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Suppress Reductionism and Jurisdiction

• Shortages of qualified staff and practitioners do
  not justify inappropriate practices with adverse
  consequences
• Political correctness must not inhibit
  accountability for performance and practices
• Including setting appropriate limits on clinical
  decision making prerogatives

107
Strategies Suppress Reductionism and Jurisdiction

• Apply evidence and manage issues in the proper
  context (phronesis)
• Ensure that care is consistent with basic
  physiological principles
• Inhibit claims of primary or exclusive rights to
  diagnose and treat specific problems and body
  parts
• Faithfully implement correct interdisciplinary
  team approach

108
Reconsider Notions of Competency and Expertise
109
Critical Generic Workforce Competencies

• Make, report, document observations
• Collect and organize information
• Examine evidence
• Provide a chronological story of events
• Reason inductively and deductively
• Formulate hypotheses
• Draw conclusions
• Providing rationale for those conclusions

110
Critical Generic Workforce Competencies

• Solve problems
• Seek and identify causation
• Give detailed answers to questions
• Deal with multiple simultaneous causes and
  consequences
• Follow instructions and procedures
• Abide by limits of personal knowledge and skills

111
Reasons For Variable Performance

• Diverse reasons for desirable and inadequate
  performance for example
• Inadequate knowledge
• Failure to apply knowledge
• Deficient clinical problem solving and decision
  making skills
• Effective reform efforts must address these
  diverse issues and root causes

112
Strategies Workforce Functions and Competencies

• Rethink key strategies about what constitutes
  competency and expertise
• Topical knowledge is important
• Each topic must be applied in the proper context
• Knowledge about a topic does not guarantee
  expertise in clinical problem solving and patient
  management

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The Cascade of Competent Performance and Practice

• Collect and analyze information
• in order to perform
• - Accurate problem definition cause
  identification
• resulting in
• - Effective clinical problem solving and
  decision making
• leading to
• - Evidence-based, individualized care

114
Strategies Reconsider Notions of Competency and
Expertise

• Reconsider notion of expertise and criteria for
  determining who is an expert
• Distinguish genuine clinical and management
  expertise
• Rethink strategies and core competencies for
  training work force

115
Strategies Reconsider Notions of Competency and
Expertise

• Focus public education on improving key generic
  competencies
• Shift health care professional education to
  include key concepts
• Shift approaches to training and educating staff
  in all settings

116
Suppress Reductionism and Jurisdiction

• Capable staff and practitioners
• Willingly explain evidence basis for their
  conclusions and decisions
• Take responsibility for results
• Can analyze and recover from unexpected or
  avoidable complications
• Less capable individuals do not
• Offer a valid basis for conclusions
• Accept responsibility appropriately

117
Change Approaches to Assessing and Improving
Quality
118
Change Approaches to Trying to Improve Quality

• Rethink current approaches to assessing and
  improving quality
• Some current approaches are pertinent and
  meaningful
• Others may actually impede definitive improvement

119
High Quality Care

• High quality care has certain attributes
• Safe, effective, efficient, person-centered,
  equitable, timely
• Attained by consistently doing the right things
  in the right way
• This approach may be most likely to attain
  desirable results

120
Path to Quality Care
How Done ? What Is Done Right Way Wrong Way
Right Thing / / -
Wrong Thing - / - / -
121
Limits of Measurement

• Numerous efforts to improve quality by collecting
  and analyzing data
• Not everything being measured is meaningful
• Only some meaningful things are being measured
• Quality measurement and quality indicators are a
  means to an end

122
Balancing Outcome and Process Emphasis

• Care process compliance is not paper compliance
• Effective clinical problem solving and decision
  making are vital for outcomes
• Genuine reform requires better balance between
  outcomes and care processes as basis for
  assessing care quality

123
Limits of Impact of Measuring Quality

• Ultimately, quality measurement can only improve
  performance somewhat
• For example, giving more statistics to an athlete
  does not necessarily produce additional
  improvement
• Also need capacity to improve and proper guidance

124
Root Causes Are Vital

• Addressing root causes may improve multiple
  performance aspects
• Not just finding more things to measure
• For example
• Identifying deficits in clinical problem solving
  and decision making
• Identifying inadequate accountability for
  ineffective performance and clinical decision
  making

125
Strategies Change Approaches to Assessing
Improving Quality

• Balance assessing outcomes and underlying
  processes and practices
• Emphasize internal systems for identifying and
  addressing quality issues
• Recognize limits of using aggregate outcomes to
  judge care quality for individuals
• Recognize limits of fixed data sets as basis to
  evaluate quality

126
Develop Biologically Sound Reimbursement
127
Develop Biologically Sound Reimbursement

• Incentives ultimately are a major influence on
  human behavior
• Money is a major incentive in many societies
• Reimbursement must be compatible withand not
  inhibitdesirable care
• Physiology does not obey payment rules
• Payment must be biologically sound
• At present, it is only partially sound

128
Develop Biologically Sound Reimbursement

• Care is often reimbursed despite incompatibility
  with key concepts, practices, and processes
• Payment sources still unduly influenced by less
  significant things
• Primary diagnoses / DRGs
• Facility licensure or category
• Treatments and services rendered

129
Root Causes of Wasteful Care

• Much concern expressed about waste and
  inefficiency in health care
• Reform must identify and tackle key root causes
  
• For example, failures of the care delivery
  process in diverse settings
• Reimbursement must not distort care approaches
  for example,
• Labeling patients based on treatment

130
Summary

• Enduring improvement and reform require focus on
  things not commonly considered
• Essential biological, medical, and philosophical
  principles
• Consider whether reform efforts
• Reflect and promote desirable approaches
• Avoid and inhibit undesirable approaches

131
Summary General Responsibilities For Reform

• Better understanding by overseers and reformers
  of
• What they are trying to oversee and improve
• Their appropriate roles
• Impact of social institutions and culture on
  identifying and solving problems
• Need for improvement in every component of health
  care system

132
Summary Reforming the Reform Efforts

• Respecting essential, enduring, and universal
  concepts and approaches typically brings
  desirable results
• Defying them brings perilous consequences for
  health and well-being
• Need much more attention to the basics
• Not inadequate workaround solutions
• Need universal accountability

133
Summary Applying the Lessons

• Lessons of efforts to reform health care apply to
  all facets of the health care system
• Reform and improvement are entirely possible
• Only by respecting and applying key concepts and
  approaches
• Law of gravity is universal
• Either respect it to our advantage or defy it at
  our own risk

134
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