Thursday, August 9, 2012

Message to ISM/FoSiM: this is what Real contributions to the Healthcare Reform debate look like.

Atul Gawande's piece in the New Yorker on "Big Medicine: Can Hospital Chains Improve the Medical Industry?" is a tour de force on the issues, benchmarks, solutions and challenges facing us in the current Healthcare Reform debate.

At 9,500 words, while it was a riveting read for me, it may be a tad long for many people.

Even if you only read a page or two, you'll be well rewarded.

This is the work of an insightful, competent and engaged (Medical) Professional who is actively looking to mend the US Medical system and has taken considerable time and effort to construct a readable and informed piece to bring the issues, challenges of Real World change to Healthcare to the general public and even posits some solution.

Here are his three books available on-line from Amazon:

A quick tour of the article:
  • Since the 1980's, the parts of the business world have progressed in leaps and bounds:
    •  Mass Customisation, Quality/Continuous Improvement, Performance Improvement and Process Re-Engineering and "Lean" (e.g. Toyota).
    • As embodied by the US's Cheesecake Factory - systematised delivery of consistent high-quality services where the outcomes, not the process/steps, are defined and checked.
  • Authority, Accountability and Responsibility for Service Delivery and Patient Outcomes are generally missing. Gives example of knee replacement under Dr John Wirth:
    • A large team working together with common procedures, checklists and guidelines based on proven Best Practice and Cost-Effectiveness.
    • Later he says:  "The fundamental question in medicine is: Who is in charge?"
  • The ability of successful, large-scale modern business to routinely roll-out significant changes every six months, versus the 15 years it takes for even half the medical establishment to pick-up simple changes (eg. beta-blockers).
  • He discusses "tele-ICU's", a remote monitoring station meant to double-check ICU operations and pick up errors or problems before they become injuries.
  • Gwande posits: "Reinventing medical care could produce hundreds of innovations" like:
    • email access to clinicians
    • more timely advice, reduced ER visits
    • smartphone App for chronically ill (eg Diabetics)
    • new ways to get specialist advice
    • systems to track outcomes and costs
    • instant delivery of "up to date" care protocols
  • and follows with "But most significant will be the changes that finally put people like John Wright and Armin Ernst in charge of making care coherent, coordinated, and affordable."
Generally, I was impressed that Gawande didn't invoke Aviation as his Gold Standard, but used people and places the general public know and visit everyday and indeed, many will have worked for, and the majority will personally know someone who works in them.

He quietly and unobtrusively lets us know that he's done a bunch of real journalistic research to write this piece, pounding the pavements, spending hours or days with people in their workplace and asking tough questions. He uses as his 'hook' a night out at a favourite restaurant, something that all of us are familiar with and enjoy, and then uses that framework to hang all the concepts and examples he wishes to bring us. This was a carefully planned, researched and executed piece, possibly months in the making. It would've taken a few weeks to edit down and polish into this relaxed, chatty style.

Some Quotes:

On "who's in charge?" and "who's responsible?":
The biggest complaint that people have about health care is that no one ever takes responsibility for the total experience of care, for the costs, and for the results.
On the rate of introduction of proven, effective new practices:
Even a month would be enviable in medicine, where innovations commonly spread at a glacial pace.
Intensive Care Units (ICU's) and tele-ICU centres being problematic to :
Although fewer than one in four thousand Americans are in intensive care at any given time, they account for four per cent of national health-care costs.
Across the country, several hospitals have decommissioned their (tele-ICU) systems. Clinicians have been known to place a gown over the camera, or even rip the camera out of the wall. 
He ends with:
The critical question is how soon that sort of quality and cost control
will be available to patients everywhere across the country.
We’ve let health-care systems provide us with the equivalent of
greasy-spoon fare at four-star prices, and the results have been ruinous.
The Cheesecake Factory model represents our best prospect for change.
Some will see danger in this.
Many will see hope.
And that’s probably the way it should be.
It's not a rant or tirade, it can't be mistaken for "personal attack" nor does it need a naive disclaimer like FoSiM's ("If you misunderstand what we've written, that's your problem, not ours."

To Dwyer and his little Friends in FoSim, this is what a real contribution to the healthcare Reform debate by a competent Professional/Journalist looks like. Compare and Contrast to the vapid, vitriolic and self-righeous outpouring of Ms Marron, your unpaid "CEO". It'd be unkind to say that she remains unpaid because nobody with money would pay for her efforts, though it may be accurate. Fanaticism and Zealotry in a cause, as demonstrated by FoSiM, don't make for persuasive journalism.

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