Title: Demanding Medical Excellence:
1Demanding Medical Excellence A Call to Action
The Leapfrog Conference on the Future of Hospital
Governance Santa Monica, CA Jan.
29, 2008
Presented by Michael L. Millenson President Healt
h Quality Advisors LLC Highland Park,
IL mm_at_healthqualityadvisors.com
2How We Talk About Safety
- Inpatient
- 44,000 - 98,000 deaths from preventable errors
during hospitalization more deaths than
fromauto accidents or AIDS - 17 billion - 29 billion in added costs (lost
income, lost household production, disability
and direct health care costs) - Outpatient
- 1 of 131 outpatient deaths due to medication
errors - Potentially avoidable admissions due to
drug-related problems of 177 billion greater
than drugs cost
Sources IOM Phillips et al. Lancet 1998
Johnson and Bootman Arch Int Med 1995 Ernst and
Grizzle J Am Pharm Assoc 2001.
3What Doctors and Patients Experience
Doctors
Patients
- 35 experienced an error in their own or family
members care - 18 reported a serious adverse consequence
- Death 7
- Long-term disability 6
- Severe pain 11
- 42 experienced an error in their own or family
members care - 24 reported a serious adverse consequence
- Death 10
- Long-term disability 1
- Severe pain 16
Source Blendon et al. NEJM 2002
4Data Experience No One Cares
Biggest Problem in Health Care
Doctors
Patients
- 29 - malpractice costs
- 27 - cost of health care
- 22 - insurer and health plan problems
- 5 - medical errors
- 38 - cost of health care
- 31 - cost of prescription drugs
- 6 - medical errors
Source Blendon et al. NEJM 2002
5Why the Disconnect? (Guess)
- My health insurance premiums are rising
- My malpractice premiums are rising
- Drugs I need every day are expensive
- If some day I have to go to the hospital, and if
I can afford it, and if my doctor hasnt been
driven out of business, I may not receive safe,
evidence-based care
6Visionaries vs. Pragmatists
Visionaries
Pragmatists
Intuitive Support revolution Contrarian Break
away from the pack Follow their own dictates Take
risks Motivated by future opportunities See what
is possible
Analytic Support evolution Conformist Stay with
the herd Consult with colleagues Manage
risks Motivated by present problems Pursue what
is probable
Visionaries See with their eyes closed
Pragmatists See with their eyes open
Source Geoffrey Moore,Inside the Tornado
7Presenting a Present Problem
53 Shaquille ONeal makes a free
throw 54 Doctors provide acute care
indicated by the medical literature 56
Doctors provide chronic care indicated by the
medical literature 63 On-time airline
departures during worst month on record
Sources NBA career stats 1-1-08 NEJM, 2003 DOT
2007 data
8Worse than Baggage Handling
Source General Electric Co.
9Sorrel Kings Lost BabyAnother Kind of Story
Josie was 18 months old.in January of 2001
when she was admitted to Johns Hopkins after
suffering first and second degree burns from
climbing into a hot bath...Two days before she
was to return home she died of severe dehydration
and misused narcotics.
Josie's heart stopped as I was rubbing her feet.
Her eyes were fixed, and I screamed for help. I
stood helpless as a crowd of doctors and nurses
came running into her room. I was ushered into a
small room with a chaplain. The next time I saw
Josiedoctors and nurses were standing around her
bed. No one seemed to want to look at me. She was
hooked up to many machines, and her leg was black
and blue. I looked into their faces, and said to
them. You did this to her now YOU must fix her. I
was told to pray.
10Community Costs Risks of Inaction
American Society of Civil Engineers
Infrastructure Report Card - 1.6 trillion fix
over five years
Public Assistance 2.0
Medicaid 22.9
Higher Education 10.6
Corrections 3.5
Medicaid dominates state budgets
Transportation 8.6
Elementary Secondary Education 21.8
All Other 30.8
11Who Pays for Poor Quality? (Us)
When surgical complications occur, hospitals
experience a decline in profits and profit margin
per case, but reimbursement usually covers their
costs. In contrast, payors always lose money with
complications.
Source JB Dimick et al. J Am Coll Surg, 2006
12If we can show adjusted wins per dollar for
Major League Baseball
Front-office Efficiency - 1999-2006
Source Bucco Blog, 11-15-06
13why not adjusted hospital deaths per dollar in
hospitals?
Source Jarman for IHI AHRQ data, 1997
14Shattering Perceptions About Prestige Variation
Unrelated to Value
33.0
Inpatient days per Medicare beneficiary with
serious chronic illness during last six mos. of
life
28.0
Hospital days per decedent
23.0
18.0
13.0
8.0
Source J Wennberg et al., BMJ, 2004
15Higher Spend, Lower Quality
Decreased Risk
Increased Risk
Q1 Lowest Spend Q5 Highest Spend
ColorectalCancer
Q1
Q2
Q3
Q4
Q5
MyocardialInfarction
Q1
Q2
Q3
Q4
Q5
Source Fisher and Wennberg, Ann. Int. Med.,
2003
1.00
1.05
1.10
0.95
16Information for Action Clear, Relevant
Comparisons
- Benchmark facilities generally do better
- Client not equal to top hospitals nationally
- High volume facilities have robust quality
improvement processes
Source Health Quality Advisors
17Evolutionary on the way to Revolution Ascension
Health 2006
reductions compared to national averages
0
10
20
30
40
35
50
60
62
70
67
80
74
90
86
92
100
Ventilator- Associated Pneumonia
Birth Trauma
Neonatal Mortality
Pressure Ulcer
Blood Stream Infections
Falls with Serious Injury
18Change Faces Obstacles
- Economics Pain level remains unevenly
distributed and health care inefficiency impact
unclear dilemma of the commons - Technology More is Better
- Zeitgeist Deus ex machina approach to reform
more attractive than climbing into the machine
and fixing it. Providers belief in selves and
patients belief in my doctor, my hospital
override statistics.
19But Failure to Change Carries Consequences
- Squeeze Payments
- Price controls
- Rules, rules, rules
- More uninsured
- Export jobs to reduce insured employee costs
- Export care
20Public Opinion Danger Signs
Employees Must Wash Hands Signs Top Iraqi
Hospital Wish List
21Diffusion of Innovation
Will Health Care Change Quickly Enough?
2.5
13.5
34
34
16
Innova- tors
Late Majority
Early Adopters
Early Majority
Laggards
Source Rogers Shoemaker,Communication of
Innovations
22Will Professionalism Be Redefined?
Trying harder will not work. Changing systems of
care will. Institute of Medicine, 2001
As a result of the information revolution, the
magic, mystery and power of the profession may be
somewhat diminished, but it will create
unanticipated opportunities for physicians to
bolster the cognitive and moral pillars of their
professional identities. David Blumenthal, MD,
2002
Source Crossing the Quality Chasm, 2001
Milbank Quarterly 2002
23A Call to Action
Science and Technology revolutionize our lives,
but memory, tradition and myth frame our
response. --Arthur Schlesinger, Jr.