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Improving and Reforming Health Care: Rediscovering the Basics

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Title: Improving and Reforming Health Care: Rediscovering the Basics


1
Improving and Reforming Health Care
Rediscovering the Basics
  • Steven Levenson, MD, CMD
  • September 21, 2010

2
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

3
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

4
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

5
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

6
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

7
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

8
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

9
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

10
What Can We Each Do?
11
Solution is Straightforward
12
Mostly Self-Evident
13
Logically Consistent
14
Little Changes Add Up
15
Key Principles
  • What constitutes biologically sound care?

16
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17
The Three Human Dimensions
PSYCHOSOCIAL
FUNCTIONAL
PHYSICAL
18
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

19
Homeostasis Water Balance
  • Maintaining water balance

20
Homeostasis Blood Sugar
  • Blood sugar regulation

21
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

22
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

23
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

24
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

25
Causes and Consequences
Consequences ? Causes One Multiple
One / /
Multiple / /
26
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

27
Causes and Consequences
28
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29
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

30
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

31
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

32
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33
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

34
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

35
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

36
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

37
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

38
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39
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

40
Health Care Role
  • What is the role of health care in providing
    biologically sound care?

41
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

42
Reform and Improvement
  • How and why do these principles affect efforts to
    improve health care?

43
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

44
Health Care Reform
  • Problem Definition and Cause Identification

45
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

46
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

47
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

48
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

49
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

50
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

51
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

52
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

53
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

54
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

55
Reconsider Current Improvement and Reform Efforts
56
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

57
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)

58
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

59
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
60
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
61
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
62
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

63
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64
Challenge the Conventional Wisdom
65
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

66
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
67
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
68
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

69
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

70
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

71
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

72
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.

73
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

74
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

75
Accountability and Alignment
76
Basic Principles Different Groups, Different
Approaches
2
3
1
4
10
30
50
10
77
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

78
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79
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

80
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

81
The ABCs
  • Bi f i (A,C)
  • Individual behavior (B) is a function of
    antecedents (A) but more importantly
    consequences (C)

82
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

83
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

84
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

85
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

86
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

87
Vigorously Subdue Political Correctness
88
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

89
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

90
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

91
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

92
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

94
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

95
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

96
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

98
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

99
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

103
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

106
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

113
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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