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Healthcare ’s Challenging Trio: Quality, Safety and Complexity

John L. Haughom, MD

Healthcare: The Way It Should Be

Section One

– Forces Driving Transformation • •

Chapter One

– Forces Defining and Shaping the Current State of U.S. Healthcare

Chapter Two

– Present and Future Challenges Facing U.S. Healthcare

Section Two

– Laying the Foundation for Improvement and Sustainable Change • What will it take to successfully ride the transformational wave?

Section Three

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Seminal IOM Publications

November 1, 1999:

The Institute of Medicine Committee on Quality of Health Care in America announces its first report:

44,000 to 98,000 deaths annually!

To Err is Human: Building a Safer Health System

“

Health care in the United States is not as safe as it should be



and can be.

Patient Safety: A known problem… Prevalence of adverse events is a known problem…

Given the existence of undesired circumstances, there is no insulation against error!

•

1964

Med.) – Schimmel et. al. (Ann. Int. – 20% of University Hospital admissions result in injury with 20% fatality rate •

1981

– Steel et. al. (NEJM) – 36% of Teaching Hospital admissions result in injury with 25% of such injuries being serious •

1989

– Gopher et. al. (Proc. Human Factors Society) – 1.7 errors/day/patient with 29% that are potentially serious •

See Table for more studies…

Reaching the Public ’s Attention

Error Institution

A 18 year old woman, Libby Zion, daughter of a prominent reporter, dies of a medical mistake, partly due to lax resident supervision Cornell ’s New York Hospital Betty Lehman, a Boston Globe healthcare reporter, dies of a chemotherapy overdose Willie King, a 51 year old diabetic, has the wrong leg amputated 18 year old Josie King dies of dehydration Harvard ’s Dana Farber Cancer Institute University Community Hospital, Tampa, Florida Johns Hopkins Hospital Jessica Santillan, a 17 year old girl from Mexico, dies after receiving a heart-lung transplant of the wrong blood type Duke University Medical Center The twin newborns of actor Dennis Quaid are nearly killed by a heparin overdose Cedars-Sinai Medical Center

Year

1984

Impact

Public discussion regarding resident training, supervision, and work hours. Led to New York law regarding supervision and work hours, ultimately culminating in ACGME duty hour regulations. 1994 1995 2001 2003 New focus on medication errors, role of ambiguity in prescriptions and possible role of computerized prescribing and decision support. New focus on wrong-side surgery, ultimately leading to Joint Commission ’s Universal Protocol, and later the surgical checklist, to prevent these errors. Josie ’s parents form an alliance with Johns Hopkins ’ leadership (leading to the Josie King Foundation and catalyzing Hopkins ’ safety initiatives), demonstrating the power of institutional and patient collaboration. New focus on errors in transplantation and on enforcing strict, high reliability protocols for communication of crucial data. 2007 Renewed focus on medication errors and the potential value of bar coding to prevent prescribing errors. © 2014 Health Catalyst www.healthcatalyst.com

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Adverse Events: Lethal & Expensive Medical errors are costly in terms of human suffering and in real dollar terms

• Adverse events are the 8th leading cause of death • Total cost of preventable adverse events = $19-29 billion annually • Cost of preventable medication errors = $16.4 billion annually • Cost of preventable readmissions = $17 billion annually Medical Errors estimate is midrange of IOM figures of 44,000-98,000 Proprietary and Confidential 6 © 2014 Health Catalyst www.healthcatalyst.com

And the Problem Extends to the Outpatient World…

For Every:

• 1000 patients coming in for outpatient care 1

There Appear to Be:

• 14 patients with life-threatening or serious ADEs • 1000 patients who are taking a prescription drug 2 • 1000 prescriptions written 3 • • 90 who seek medical attention because of drug complications 40 with significant medical errors • • 1000 women with a marginally abnormal mammogram 1000 referrals 5 4 • 360 who will not receive appropriate follow-up care • 250 referring physicians who have not received follow-up information in 4 weeks • 1000 patients who qualified for secondary prevention of high cholesterol 6 • 380 will not have a LDL-C, within 3 years, on record

(1) Gandhi T et al. Adverse drug events in primary care, under review, NEJM. (2) Gandhi T et al. Drug complications in outpatient settings J Gen Int Med 2000. (3) Gandhi TK et al. Adverse drug events in primary care, under review, NEJM. (4) Poon E, et. al. Failure to follow mammographers recommendations on marginally abnormal mammograms: determination of associated factors [abstract]. J Gen Intern Med 2001. (5) Gandhi T et. al. Communication breakdown in the outpatient referral process J Gen Intern Med 2000. (6) Maviglia SM, et.al. Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines J Gen Intern Med 2001

Seminal IOM Publications

March 1, 2001:

The Institute of Medicine Committee on Quality of Health Care in America announces its second report:

“

Crossing the Quality Chasm: A New Health System for the 21st Century

Between the health care we have and the care we could have lies not just a gap, but a chasm.

How Good is American Healthcare?

Only 50% of Americans receive recommended preventive care Patients with acute illness:

• • 70% received recommended treatments 30% received contraindicated treatments

Patients with chronic illness:

• • 60% received recommended treatments 20% received contraindicated treatments Schuster MA, McGlynn EA, Brook RH. How good is the quality of healthcare in the United States?

Millbank Quarterly

Types of Quality Problems

Several types of quality problems in healthcare have been documented by the IOM: • Variation in services • Underuse of services • Overuse of services • Misuse of services • Disparities in quality 10 © 2014 Health Catalyst www.healthcatalyst.com

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How Good is American Health Care?

100 90 80 70 60 50 40 30 20 10 0 Aspirin Major teaching Minor teaching Nonteaching ACE inhibitors Beta-blockers Medication Reperfusion

Allison JJ

et al

. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI.

JAMA

Practice Variation in the U.S.

The Dartmouth Atlas of Healthcare is available at: http://www.dartmouthatlas.org

Practice Variation in the U.S.

55.0

50.0

45.0

40.0

35.0

30.0

25.0

20.0

15.0

10.0

Red Dots Indicate HRRs Served by U.S. News 50 Best Hospitals for Geriatric Care 100.0

80.0

60.0

40.0

20.0

0.0

Red Dots Indicate HRRs Served by U.S. News 50 Best Hospitals for Cardiovascular Care

The Dartmouth Atlas of Healthcare is available at: http://www.dartmouthatlas.org

Unwarranted & Warranted Sources of Practice Variation Unwarranted

• Variable access to resources and expertise • Insufficient research • Unfounded enthusiasm • Parochial perspectives • Faulty interpretation • Poor information flow • Poor communication • Role confusion

Warranted

• Clinical differences among patients • Variable risk attitudes • Variable preferences among health outcomes • Variable willingness to make time trade-offs • Variable tolerance for decision responsibility • Variable coping styles

Knowledge-Based Patient-Centered

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Extensive research has made it very clear … …inappropriate variation… … harms patients, leads to poor quality , and results in waste …

Reasons for Practice Variation

Inadequate levels of safety and inconsistent quality result from

clinical uncertainty

which in turn results from: • An increasingly complex healthcare environment • Rapidly exploding medical knowledge • Lack of valid clinical knowledge (poor evidence) • Over reliance on subjective judgment Proprietary and Confidential 16 © 2014 Health Catalyst www.healthcatalyst.com

Human Limitations

Miller, G.A.

The magic number is

seven

, plus or minus two: limits on our capacity for processing information.

Medical Progress Over Half a Century

Care circa 1960… Care circa 2011…

“

The complexity of modern American medicine exceeds the capacity of the unaided human mind.

- David Eddy, MD, PhD

The Evidence Base is Expanding

12000 10000 First RCT published:

1952

First five years (66-70):

1% of all RCTs published from 1966 to 1995

Last five years (91-95):

49% of all RCTs published from 1966-1995

8000 6000 4000 2000 0

Year

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12000 10000 8000 6000 4000 2000 0

Rapidly Exploding Medical Knowledge

In 2004, the U.S. National Library of Medicine added almost 11,000 new articles per week to its on-line archives That represented about 40% of all articles published, world-wide, in biomedical and clinical journals.

(1,500 – 3,500 completed references per day, 5 days a week) To maintain current knowledge, a general internist would need to read: – 20 articles per day, – 365 days of the year Current estimates are this has grown to 1 article every 1.29 minutes in 2009!

This is an

impossible task

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The Science of Medicine

Of what we do in routine medical practice, what proportion has a basis (for

best

research?

practice) in published scientific • • • Williamson (1979): OTA (1985): OMAR (1990): < 10% 10- 20% < 20% The rest is

opinion

• That doesn't mean that it's wrong – much of it probably works • But, it may not represent the best patient care Williamson

et al

. Medical Practice Information Demonstration Project: Final Report. Office of the Asst. Secretary of Health, DHEW, Contract #282-77-0068GS. Baltimore, MD: Policy Research Inc., 1979).

Institute of Medicine.

Assessing Medical Technologies

. Washington, D.C.: National Academy Press, 1985:5.

Ferguson JH. Forward. Research on the delivery of medical care using hospital firms. Proceedings of a workshop. April 30 and May 1, 1990, Bethesda, Maryland.

Med Care

1991; 29(7 Suppl):JS1-2 (July).

Variation in Expert Opinion

Experts ’ estimates of the chance of a spontaneous rupture of a silicone breast implant

0% 0.2% 0.5% 1% 1% 1% 1.5% 1.5% 2% 3% 3% 4% 5% 5% 5% 5% 5% 5% 5% 6% 6% 6% 8% 10% 10% 10% 10% 13% 13% 15% 15% 18% 20% 20% 20% 25% 25% 25% 30% 30% 40% 50% 50% 50% 62% 70% 73% 75% 75% 75% 75% 80% 80% 80% 80% 80% 80% 100% Proprietary and Confidential Courtesy of David Eddy, MD, PhD 22 © 2014 Health Catalyst www.healthcatalyst.com

“

Variation in Expert Opinion

The practitioners, all experts in the field, were then asked to write down their beliefs about the probability of the outcome ... "that would largely determine his or her belief about the proper use of the health practice, and the consequent recommendation to a patient."

0 20 40 60 80 100

Eddy.

A Manual for Assessing Health Practices & Designing Practice Policies: The Explicit Approach.

Philadelphia, PA: The American College of Physicians, 1992; pg. 14.

“

You can find a physician who honestly believes (and will testify in court to) anything you want .

- David Eddy, MD

Complexity Science

• Complexity science is the study of complex adaptive systems , the relationships within them, how they are sustained, how they self-organize, and how outcomes result. • Complexity science is made up of a variety of theories and concepts . • It is a multidisciplinary field involving many different disciplines including biologists, mathematicians, anthropologists, economists, sociologists, management theorists, computer scientists, and many others. 25 © 2014 Health Catalyst www.healthcatalyst.com

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Viewing Healthcare as a Complex Adaptive System

• Complexity science is the study of complex adaptive systems , the relationships within them, how they are sustained, how they self-organize, and how outcomes result. • Complexity science is made up of a variety of theories and concepts. • It is a multidisciplinary field involving many different disciplines including biologists, mathematicians, anthropologists, economists, sociologists, management theorists, computer scientists, and many others. In complex situations,

A + B ≠ C

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Characteristics of Complex Adaptive Systems

Comparison of Organizational System Characteristics Complex Adaptive Systems Traditional Systems

Are living organisms Are unpredictable Are adaptive, flexible, creative Are machines Are controlling and predictable Are rigid, self-preserving Tap creativity Embrace complexity Evolve continuously Control behavior Find comfort in control Recycle Proprietary and Confidential 27 © 2014 Health Catalyst www.healthcatalyst.com

Comparison of Leadership Styles

Comparison of Leadership Styles Complex Adaptive Systems Traditional Systems

Are open, responsive, catalytic Offer alternatives Are collaborative, co-participating Are connected Are adaptable Acknowledge paradoxes Are engaged, continuously emerging Value persons Are shifting as processes unfold Prune rules Help others Are listeners Are controlling, mechanistic Repeat the past Are in charge Are autonomous Are self-preserving Resist change, bury contradictions Are disengaged, nothing ever changes Value position, structures Hold formal position Set rules Make decisions Are knowers Proprietary and Confidential 28 © 2014 Health Catalyst www.healthcatalyst.com

The Need for a Better System

“ “

Insanity is doing the same thing over and over again and expecting a different result.

– Albert Einstein

Every system is perfectly designed to produce the results that it does achieve.

– Paul Bataldan, MD

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In Summary…

• The levels of quality and harm in modern clinical care are not acceptable • Inadequate levels of safety and inconsistent quality result largely from clinical uncertainty • Clinical uncertainty results from an increasingly complex healthcare environment , a rapidly expanding healthcare knowledge base , a lack of valid clinical knowledge for much of what we do, and an over reliance on expert opinion • Extensive research has made it very clear that inappropriate variation harms patients , leads to poor quality , and results in high levels of waste • Healthcare can be viewed as a complex adaptive system , and going forward complexity science will play an increasingly large role in the design of new care delivery systems and new care models 30 © 2014 Health Catalyst www.healthcatalyst.com

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Healthcare: The Way It Should Be

Section One

– Forces Driving Transformation • •

Chapter One

– Forces Defining and Shaping the Current State of U.S. Healthcare

Chapter Two

– Present and Future Challenges Facing U.S. Healthcare

Section Two

– Laying the Foundation for Improvement and Sustainable Change • What will it take to successfully ride the transformational wave?

Section Three

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Questions, discussion, etc…

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