Title: Improving and Reforming Health Care: Rediscovering the Basics
1Improving and Reforming Health Care
Rediscovering the Basics
- Steven Levenson, MD, CMD
- September 21, 2010
2Reform
- 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
3Reform 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
4Reform 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
5Who 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
6Reform 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
7Reform 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
8Our 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
9Our 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
10What Can We Each Do?
11Solution is Straightforward
12Mostly Self-Evident
13Logically Consistent
14Little Changes Add Up
15Key Principles
- What constitutes biologically sound care?
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17The Three Human Dimensions
PSYCHOSOCIAL
FUNCTIONAL
PHYSICAL
18Homeostasis
- 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
19Homeostasis Water Balance
- Maintaining water balance
20Homeostasis Blood Sugar
21Personal 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
22Health, 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
23Key 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
24Biologically 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
25Causes and Consequences
Consequences ? Causes One Multiple
One / /
Multiple / /
26Causes 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
27Causes and Consequences
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29Causes 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
30Causes 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
31Linking 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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33Biologically 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
34Biologically 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
35Care 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
36Care 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
37Biologically 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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39Patient 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
40Health Care Role
- What is the role of health care in providing
biologically sound care?
41Implications 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
42Reform and Improvement
- How and why do these principles affect efforts to
improve health care?
43Reform 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
44Health Care Reform
- Problem Definition and Cause Identification
45Essential 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
46Essential 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
47Approach 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
48Approach 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
49Approach 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
50Approach 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
51Approach 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
52Foundation 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
53Recommendations 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
54Recommendations 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
55Reconsider Current Improvement and Reform Efforts
56Sources 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
57Types 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)
58Problems 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
59Reform 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
60Reform 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
61Reform 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
62Strategies 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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64Challenge the Conventional Wisdom
65Challenging 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
66Conventional 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
67Conventional 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
68Strategy 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
69Conventional 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
70Unconventional Wisdom
- Major obstacles to health care reform today
include - Failures of accountability
- The Defensive Triad
- Rationalization
- Projection
- Denial
- At all levels, in all settings
71The 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
72Defenses 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.
73Accountability The Unconventional Wisdom
- Definition answerable for actions and decisions
- The means of attaining responsibility
- By applying basic principles and tactics to
attain desired performance
74Responsibility
- 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
75Accountability and Alignment
76Basic Principles Different Groups, Different
Approaches
2
3
1
4
10
30
50
10
77Different 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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79Defending 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
80Problematic 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
81The ABCs
- Bi f i (A,C)
- Individual behavior (B) is a function of
antecedents (A) but more importantly
consequences (C)
82Antecedents 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
83Vital 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
84Some 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
85Realization
- 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
86Management 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
87Vigorously Subdue Political Correctness
88Vigorously 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
89Political 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
90Genuine 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
91Strategies 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
92Rethink the Research Agenda
93Knowledge 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
94Respecting 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
95Example 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
96Meaningful 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
97Meaningful 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
98Meaningful 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
99Strategies 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
100Strategies 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
101Focus Attention on Basic Care Principles and
Processes
102Focus 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
103Strategies 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
104Suppress Reductionism and Jurisdiction Over Care
105Suppress 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
106Suppress 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
107Strategies 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
108Reconsider Notions of Competency and Expertise
109Critical 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
110Critical 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
111Reasons 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
112Strategies 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
113The 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
114Strategies 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
115Strategies 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
116Suppress 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
117Change Approaches to Assessing and Improving
Quality
118Change 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
119High 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
120Path to Quality Care
How Done ? What Is Done Right Way Wrong Way
Right Thing / / -
Wrong Thing - / - / -
121Limits 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
122Balancing 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
123Limits 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
124Root 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
125Strategies 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
126Develop Biologically Sound Reimbursement
127Develop 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
128Develop 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
129Root 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
130Summary
- 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
131Summary 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
132Summary 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
133Summary 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
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