Friday, October 26, 2012

YGBEHR: Models of real & successful healthcare improvement

Your Great Big Expensive Healthcare Reform: What measurable benefits will you deliver?
Part 2 of 4
Models of real & successful healthcare improvement

[695 wds]

After 5 years, if the ISM had a real and useful message from strong, credible people, it would be appearing everywhere. The US AMA’s site has just two references to ISM, both author affiliations in the same article. There are just 27  references to "science in medicine" on the site. Hardly noteworthy or impacting.

The US AMA has a dozen current “Advocacy topics” [1], none of which comes comes near the ISM/FSM position. They do have very clear strategies to address the most pressing healthcare problems:

The American Medical Association (AMA) has identified four broad strategies to contain health care costs and get the most for our health  care dollars:
  • Reduce the burden of preventable disease
  • Make health care delivery more efficient
  • Reduce nonclinical health system costs that do not contribute to patient care
  • Promote value-based decision-making at all levels
The Institute of Medicine (IOM) has for 40+ years been the health arm of the 150-yr old National Academy of Sciences. It has released two major reports, 1999 and 2001, [2] [3], into addressing healthcare problems in the USA.

The Texas Medical Institute of Technology site “Safety Leaders” [4], follows on from the work of the IOM and has a number of fine programmes and films directed at important areas of Healthcare improvement. None resemble the ISM 

Dr Brent James, executive director of Research and Quality at Intermountain HealthCare, Utah, (IHI) runs an “Advanced Training Program”, slides to his talks are available on-line. E.g. "Managing Clinical Processes: Doing Well by Doing Good" [5]. This talk embraces a large sweep of material that underpins his Quality Improvement methodology, forming a consistent, complete theory driving his decades of successful Reform - all based in hard data, solid evidence and good processes.

Dr James must be listened to as he’s not just radically improved Patient Safety and Quality of Care at IHI, but also reduced costs 20-30% compared to average US hospitals.

Compare this depth of evidence and with ISM/FoSiM’s untested Ideological assertions: More Science will fix things. It must because we say so.

In 2008, Dr James participated in a forum organised by his University, Panel on Health Care Reform - Fall 2008, Continuum, Utah University [6].

This is what he has to say on the common Challenges facing Healthcare around the world:

JAMES: Another point is that we're getting exactly what we pay for. We tend to pay for procedures and rescue care, so we get lots of procedures and lots of rescue care. This is a key factor.

Another thing you need to know is that other countries have exactly the same problems. So don't look for solutions in Europe. Don't look for solutions in Canada.

I get a ton of those guys coming through visiting to see how care's delivered in Utah, believe it or not, because they face exactly the same problems.

There's a standard working list of the top five problems within health care, and nobody's solved them.

Travel the world and it's the same list of five things [italics added]:
1. The first problem is variation in care on a geographic basis.
It's so high that it's impossible that all Americans are getting good care, even with full access.
2. The second biggest problem is high rates of care directly judged to be inappropriate.
This is where the medical risk treatment outweighed any potential benefit to the patient and we did it anyway . . . usually in a rescue setting.
3. The third problem is unacceptable rates of care-associated injury and death.
This is where the care delivered actively killed somebody, whose death was judged to be preventable upon review.
4. The fourth problem is that the system does it right only 55 percent of the time.
There are things that we know for a fact should be done every time but the system does right only 55 percent of the time.
Now, that's better than zero, but it's not nearly 95 percent or 98 percent, where it ought to be.
      1. And the last one is that there's at least 50 percent waste in the system.

This is non-value-adding from a patient's perspective, and that's where the opportunity exists.

[1] US AMA’s Advocacy topics

Access to Care, Affordable Care Act, Combating Prescription Drug Abuse & Diversion, Health Care Costs, Health Insurance Market Reforms, Independent Payment Advisory Board, Medical Students & Residents, Medicare Physician Payment Action Kit, Patient Safety and Quality Improvement, Practice Management, Public Health, SGR.

And “additional topics of”:  Medical Liability Reform, Patient safety and quality improvement in health care, Managed Care Reform, Antitrust Reform, Funding research and medical education, Resident work hours and working conditions

Getting the most for our health care dollars: Strategies to address rising health care costs

Getting the most for our health care dollars: Health care quality

Getting the most for our health care dollars: Prevention and wellness

[2] To Err is Human: Building A Safer Health System

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

Texas Medical Institute of Technology (TMIT) is a medical research organization, founded in 1984, dedicated to accelerating performance solutions that save lives, save money, and build value in the communities we serve and ventures we undertake. Our core values drive our behaviors and in turn drive our culture. TMIT applies the Institute of Medicine's (IOM) design principles of patient-centeredness, evidence-based medicine, and systems performance improvement.

Annotated excerpts from "Managing Clinical Processes: Doing Well by Doing Good" [5]

Slide 9, "Total health: How long, how well we live", Dr James lays out what the Evidence says on the contributors to Good Health, with a little humour:
  • 40% - Behaviour under control of the Individual (loosely, 'lifestyle choices'). Tobacco, Alcohol, Movement Deficit Disorder
  • 30% - Genetics
  • 20% - Environment and Public Health
  • 10% - Health care Delivery (Hospitals and Clinics)
On the next slide (10), "The Great Equation", he states, citing sources: 
  • Health = medical care 
and medical care = "access to care"
  • "But the Great Equation is wrong ..."
Then goes into a lot of detail on why that is so and no summary can do it justice. This “Great Equation” contains the fundamental attribution error that leads to ever escalating Healthcare costs around the world while delivering successively poorer outcomes: More Care isn’t Better Care unless you design it to be.

slide 29, "Dr. John Wennberg", he describes Wennberg's research/analysis:
  • Geography is destiny ("Who you see is what you get")
  • There is no health care "system"
  • Supplier-induced demand: [many examples follow]

slide 31, "Care-associated injuries in hospitals", Dr James describes one of the primary source of waste in Medical care, which he addressed at IHI, providing net savings of 20-32% in delivering services. Not to mention much better Patient outcomes:
  • Injuries drive direct health care costs totalling $9 - 15 billion per year [Thomas et al. 1999, Johnson et al. 1992]

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