As Good As It Should Get:
Making Health Care Better In The New Millennium

NCHC Writers
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By: Donald M. Berwick
Institute For Healthcare Improvement

TABLE OF CONTENTS

EXECUTIVE SUMMARY
INTRODUCTION
REDUCING OVERUSE OF CESAREAN SECTIONS IN GREEN BAY
REDUCING COSTS WHILE IMPROVING OUTCOMES IN INTENSIVE CARE UNITS
FOCUSING ON PATIENTSí NEEDS, REDUCING COSTS, AND IMPROVING OUTCOMES IN CARDIAC SURGERY
REDUCING UNDERUSE OF EFFECTIVE TREATMENT FOR ASTHMA
REDUCING MEDICAL ERRORS AND IMPROVING PATIENT SAFETY
IMPROVING SERVICE CHARACTERISTICS IN HEALTH CARE
ADDING IT UP: HOW GOOD COULD AMERICAN HEALTH CARE GET?

EXECUTIVE SUMMARY

By many technical standards, American medicine is the best in the world. But it is plagued by serious and significant quality defects. These quality problems include overuse of treatments that on scientific grounds cannot benefit patients; misuse of services such as hospital treatment errors that harm patients; and underuse of treatments that would benefit patients. These problems exist in managed care and fee-for-service systems, across all health providers, in large and small communities and in all parts of the country. Scientific evidence favors the strong conclusion that improvements in American health care are both feasible and can contribute to substantial, double-digit reductions in the total costs of care. Even with modest assumptions about defect rates in health care, total cost reductions of nearly 30 percent below current levels should be attainable while improving the overall quality of care.

The opportunities for improvement of American health care are vast, and are closely linked to the social need for greater efficiency and value in health care. For many forms of defect, including overuse, error, and many forms of service failure, deficiencies in care lead to excess costs of care.

The stakes are high; in intensive care units, efforts to improve through reduction of waste and excess have yielded reductions in cost of 30 percent in a few months, without harming patients, and in many cases making patients safer and better off in the bargain. Over an eight-year period, Green Bay, Wisconsin’s cesarean section rate fell by 30 percent to under 12 percent overall. If the current national C-section rate of over 24 percent could be moved half-way toward Green Bay’s rate, there would be 250,000 fewer C-sections each year in the U.S., with decreased pain and surgical complications for mothers, shorter lengths of stay in hospitals, decreased subsequent repeat C-sections in later pregnancies, and probable financial savings of over $3000 per delivery, or a total of $750,000,000 nationally per year.

Leading researchers on hospital errors recently published an estimate of $4000 per drug as the health care cost of recovery from its own damage. Scaled up the American health care system as a whole, it suggests savings of billions of dollars per year if we were to reduce only one form of error (medication error) by only 50 percent.

Millions of people do not receive care they need and suffer needless complications that add to health care costs and reduce productivity. The underuse of simple forms of antibiotics for simple infections and of effective forms of prevention such as pneumococcal vaccine in clinical practice or the use of bicycle helmets at the community level cause millions of dollars in care of the conditions that could have been prevented, but were not.

Examples of quality improvements, with the attendant cost reductions, are in hand, through the work of many practitioners and health care managers who have found a way to make these needed improvements in local settings. As of yet, however, these case-by-case improvements have not yet summed up to what is now needed in American health care: a breakthrough example of system-level performance of unprecedented quality at affordable cost. This is what Toyota and other Japanese manufacturers of automobiles did for American industry: alert them not just to the theoretic possibility but to the fact that quality improvement and marketplace success go hand in hand.

Obstacles stand in our way to quality improvement and replicating success stories. First is the fear of the truth. Health care leaders must not regard quality problems as sources of embarrassment or as indications of bad faith, but as opportunities for improvement. The second barrier is the problem of finding alternatives to the status quo. We need new models that can build confidence in the feasibility of improvement. The third barrier is that health care is missing a comprehensive example of breakthrough performance – a model for all to emulate.

What is needed is a compilation of the very best practices and features, which are embodied in organized delivery systems that:

  • Use safety science techniques to drive error rates continually lower;
  • Practice and promote prevention seriously;
  • Create a seamless, timely delivery of care flow for all patients;
  • Involve patients and families fully in their own care and offer patients increasing control over decisions that affect them;
  • Break down the walls of intimidation and misunderstanding among professionals, patients and families;
  • Perform no scientifically groundless treatments; and
  • Formally search for effective, proven care practices, and assure that patients benefit reliably from such appropriate care.

Recent attention to creating a Patient Bill of Rights is welcome, and badly needed as a form of reassurance to a worried American public. But a Patient Bill of Rights is not nearly enough to address the overall need for improvement of health care nationwide. That need is broad, deep, and pervasive — far beyond mere protection of rights.

It is time for American health care, through its leaders, to devote itself to achieving for the public the breakthroughs in performance – defect reduction, patient safety, improvements in appropriateness, service enhancements, and waste reduction – which will lead us at last to believe that Americans can have the care they deserve at a cost well within their means to afford. The plausibility of this accomplishment is no longer in question. Our nation urgently needs the most serious form of dedication to improvement, starting at the top of American health care organizations which is expected and demanded by the American public at large.

INTRODUCTION

It’s a paradox. American medicine is the best in the world, but it is plagued by defects. A blue ribbon report this year from the Institute of Medicine (IOM) of the National Academy of Sciences documents three types of serious problem in technical care: underuse, overuse, and misuse.

“Underuse” refers to the failure to offer patients diagnostic tests and treatments that are proven scientifically to improve their outcomes. As Professor Mark Chassin (Chair of the IOMís National Roundtable on Health Care Quality) puts it, “…(U)nderuse of proven, effective interventions is ubiquitous in U.S. medicine.” Examples from the IOM report and elsewhere include the following:

  • Simple, inexpensive medications, including aspirin and beta-blocker drugs, can significantly reduce the likelihood of dying from heart attacks. Yet one recent study of elderly heart attack victims showed that only one in five of the eligible patients was receiving the appropriate medications.
  • Inhaled steroid medications can prevent disability and complications in many asthmatic patients. Nationally published expert guidelines for the care of asthma now specify how these medicines should be used, and yet fewer than one-third of eligible asthma patients receive the correct treatment.
  • Breast-conserving surgery (lumpectomy), combined with radio therapy, has been proven in well-designed randomized trials to be effective and safe treatment for most women with early- stage breast cancer, and yet evidence published in the Dartmouth Atlas of Health Care shows a 30-fold variation from hospital to hospital around the United States in the rate of use of this approach, compared with more radical, and scientifically unnecessary, surgery.
  • Depression is a common and treatable disorder, but primary care doctors fail to diagnose it, and therefore fail to treat it, in almost half of the victims of depression in their patient panels.
  • Bicycle helmets save lives; they reduce the risk of head injury in bicycle accidents by 85% at a cost of under $20 per child. The city of Seattle, Washington, has dramatically reduced head injuries in children through a city-wide program that has raised childhood bicycle helmet use to over 60%. Yet nationally only 12% of children wear helmets when they ride.

“Overuse” involves subjecting patients to tests, procedures, and medications that, on scientific grounds, cannot help them, or, in the most egregious cases, are known to cause harm. Why overuse occurs is a matter of debate in the medical community, but its frequency is well-proven.

  • Over 1,000,000 cesarean sections are performed in the United States each year – almost 25% of all births are surgical. Using the best available scientific evidence, and drawing on the experience of countries like Ireland and the Netherlands, where cesarean section rates are less than one-third of the U.S. rate, the American College of Obstetrics and Gynecology and the World Health Organization have determined that cesarean section rates below 15% can be safely achieved. By this standard, over 400,000 cesarean sections in the U.S. each year are unnecessary.
  • Over the past 15 years, researchers from the RAND Corporation and elsewhere have conducted a series of well-designed studies of the appropriateness of various types of surgery and invasive diagnostic tests and found “inappropriateness” rates (not “close calls,” but frankly unnecessary procedures) with the following frequency, for example: 32% of carotid endarterectomies; 16% of hysterectomies; 17% of upper gastrointestinal endoscopies; and 17% of coronary angiograms. In a recent meta-analysis study conducted on behalf of the National Coalition on Health Care, RAND estimated that 30 percent of acute care is inappropriate.
  • Excessive use of powerful antibiotics is common, leading to extra costs, higher rates of toxic side-effects, and encouragement of the emergence of antibiotic-resistant strains of bacteria. One recent study in the Colorado Medicaid program of the treatment of 12,000 children with their first episodes of middle ear infection found that 30% of the children were treated with new, broad-spectrum, expensive, and potentially unsafe antibiotics despite national research and expert guidelines urging the use of simple, inexpensive antibiotics as far better initial treatment.
  • The second U.S. Preventive Services Task Force spent over five years reviewing well over 6000 published research articles on the effectiveness of clinical preventive practices, such as screening tests, counseling, and immunizations. The Task Force found good evidence behind many forms of prevention, but it also found that many allegedly preventive practices, such as screening urinalyses in well populations, ultrasound tests in normal pregnancies, and screening electrocardiograms, had no scientific support and in some cases lead to harm from meddlesome and unnecessary followup procedures. And yet many of these wasteful practices remain in widespread use.
  • Well-designed, randomized studies of new-onset low back pain, the third or fourth most common complaint in all of ambulatory medical care, show that two days of bed rest produces just as much relief as a week or more; that early, supported return to work encourages healing; and that expensive diagnostic tests (like MRI scans) in the first few weeks of back pain almost never yield any useful information compared with “watchful waiting” for this usually self-limited problem. And yet physicians frequently prescribe long periods of bed rest, advise patients to remain out of work much longer than necessary, and order MRIís and other tests much earlier than they should.

“Misuse” is the term the IOM uses to refer to poorly executed tests and procedures – mixups, errors, and flaws – whether or not the test or procedure was appropriate in the first place. The American public has become familiar with egregious, tragic errors in care through newspaper headlines about a wrong leg amputated or a fatally high dose of a chemotherapy agent. Less familiar is the longstanding and large body of evidence health care researchers have accumulated on the prevalence of errors in care overall – some lethal, but many more merely wasteful, inconvenient, or transiently disabling.

  • The Harvard Medical Practice Study of over 30,000 hospitalizations in New York State found serious complications from care, harming over 3 percent of patients, and placing many more at risk. Based on this study and others, the Harvard researchers estimated that 180,000 die each year as a result of adverse medical events. Two-thirds of these deaths, or 120,000 each year, are considered preventable. The Harvard team concluded that medical injuries and deaths due to errors constitute the nationís “hidden epidemic.”
  • Careful reviews in two outstanding teaching hospitals found serious or potentially serious medication errors in almost 7 patients for every 100 admissions.

Understandably, given the source, the IOM panel focused on overuse, underuse, and misuse of technical medical care – the devices, tests, drugs, and treatments that doctors use. Patients, families, and health care managers know that other categories of performance in health care suffer equally from high defect rates. These categories, including service, waiting times, access, and costs, are “qualities” of care, as well.

  • Waiting times in almost all health care settings are excessive, especially when compared to waits in other service industries. Emergency room patients other than the most seriously ill often wait hours to be seen, and can be held in the ER for even longer periods between the decision to admit them and their actual transportation to their hospital bed. Delays in start times for scheduled surgery in hospitals average an hour or more. Inpatients commonly report slow response times to their requests for pain medications.
  • Americans spend almost 40% more dollars per capita on health care than citizens of any other nation on earth, and yet the results of that investment are by no means the best in the world according to several important measures. For example, twenty-one nations in the world have a lower infant mortality rate than the U.S.
  • Forty-two million Americans (16%) lack health insurance at least some time during the year; and a male black baby born in the U.S. today has a life expectancy eight years shorter than a male white baby.
  • Operating inefficiencies occur in American health care systems that simply would not be tolerated in other industries. Clinics with long waiting lists close at 5 p.m., failing to meet the needs of working parents and others. Extremely costly diagnostic machines remain idle on evening and weekends, even while long waiting lists build up for their use in daytime hours. Sometimes, systems and schedules seem built more for the convenience of the clinicians than for the needs and desires of the patients and families who depend on them. More often, both clinicians and patients share a feeling of frustration and helplessness in the face of systems full of delays, fragmentation, and other obstacles.

The litany of health care quality problems invites negative reaction, both from patients and payers, who have reasons to feel let down, and from doctors and other caregivers, who feel accused and personally criticized, even though the vast majority of them are trying hard to do a good job and care deeply about their calling. The paradox of American health care goes deeper than the apparent combination of “the best of care and the worst of care.” A reality check must lead any knowledgeable observer of care – anyone who really knows what goes on inside the system – to conclude that these flaws – overuse, underuse, misuse, waste, and poor service – continue to abound despite the hard work and best efforts of the people who work in the health care system. Good people….bad problems.

The negative reactions can become full-fledged rage and lead sometimes to misguided attempts at remedy. The theme of “accountability” is a strong one in America – not just in health care, and accountability, without doubt, can focus energies and guide behavior. Accountability requires measurement, and health care has invested heavily, with good results, in its own capacity to measure the effects of its work. Indeed, our enormous progress in measurement of health care outcomes, patient satisfaction, functional status, and appropriateness of care is the very reason that we now know so much more about our quality problems than we ever did before.

But herein lies a fallacy – the fallacy that measurement alone will produce the improvements we need. Measurement can help, in such forms as published “report cards” on the quality of care, or extensive accreditation and inspection procedures, such as the surveillance of the Joint Commission on Accreditation of Health Care Organizations or the National Committee on Quality Assurance. But measurement and public accountability for the quality of care are ineffective – indeed, they are wasteful and merely induce games and bad feeling – unless they are linked to changes in care itself. Measuring my time in the 400-yard dash may help motivate me to do better (especially if I have asked for the information), but it does not make me able to run the slightest bit faster. To run faster, I need to change the way I run.

Many in health care lack conviction that they can run any faster in the future than they do today. They feel helpless to improve; and they grow angry at patients, communities, and payers who continue to expect better care. Often loyal to their own doctors and hospitals, patients and communities look elsewhere to fix blame. They have come to believe that the problems come from outsiders – those who do not give care – avaricious insurance companies, venal managed care organizations, or bureaucratic governments. “If only they left the doctors alone,” they conclude, “the care would get better.” The doctors and hospitals agree.

But they are all wrong. Insurance companies and straight-jacket managed care systems can aggravate the problems, of course, but the way out for health care – the route to what the American public ought to have in health care quality, safety, reliability, service, and efficiency – cannot be found merely by peeling layers of inspection and cost-containment off the backs of caregivers. Improvement will not come from defense of any status quo; it will come from aspiration and bold changes in the ways that we give care.

How do we know that? Because it has been done. For every single problem listed in the IOM’s long review of deficiencies in care, and for every defect in service, cost, waste, and access that health care researchers and critics have documented, we now have strong, compelling, often inspirational examples of what “better” looks like. Excessive cesarean section rates are common, but they are not universal. Many physicians overuse expensive antibiotics, but some do not. Waiting times are long almost everywhere in health care, but there are clinics and physician office practices that have driven waits nearly to zero. Most American children ride their bicycles without helmets, but not in Seattle.

It is time to learn from success, even while we face the reality of our quality problems directly. Three primary barriers stand in our way.

First: fear of the truth. So long as health care leaders and the patients and communities they serve regard quality problems primarily as sources of embarrassment and as indications of bad faith and carelessness, the patients will accuse and the caregivers will defend themselves. That is only human. All improvement begins with the intention to improve – with the whole-hearted admission that a gap exists between what is and what should be. But, identifying a gap does not necessarily require fixing blame. It is equally possible to admit a need to improve, without blame, and then to begin the never-ending process of learning how to do things better. We do that every day in our schools, our hobbies, and our daily lives. The “quality improvement” slogan goes: Every defect is a treasure. Health care is loaded with treasures.

The second barrier – once we overcome the fear of the truth – is the problem of finding plausible alternatives to the status quo, examples that can build confidence in the feasibility of improvement and that give us ideas for approaching tasks differently. Better ways. Best practices.

The third barrier is more subtle: health care is missing a comprehensive example of breakthrough performance – a model for all to emulate. Even though, case-by-case, problem-by-problem, excellent examples exist of success by health care providers for almost every quality problem we have, no one – no one at all – in health care has ever yet “put it all together.” It was different in automobile manufacturing. When Detroit began to awake in the mid-1970s to the global competitive threat, American automobile manufacturers had no difficulty developing a comprehensive image of the overall quality they lacked. They could buy the evidence on how good a car could be; it was called a Toyota. The performance of the Japanese automobile – the whole automobile, in almost all dimensions of performance – was so far superior to the American automobile that the need for global change could not be ignored. The Japanese gave American automobile manufacturers a “two-fer” – both a threat to survival and a vision of what was possible – both a wake-up call and breakfast. Perhaps the former, alone, would not have been enough.

Additional barriers to fundamental improvement are structured into the habits and environment of health care. The financing system often rewards fragmented, non-cooperative behaviors, instead of fostering reduced redundancy, complexity, and interruptions of the entire care experience from the patient’s viewpoint. A test done in a hospital is repeated unnecessarily in the nursing home, and then repeated again upon rehospitalization. A medical center opens a new cardiac surgery unit in already-oversupplied region. Lay health care executives, by tradition and training, often leave improvement of care vaguely up to physician staffs, rather than assuming full, corporate responsibility for improving overall performance. It is as if airline executives left airline safety up to pilots, rather than assuming primary responsibility for running a safe system. Health care also lacks well-developed infrastructures for transfer of best practices. The widespread adoption of sound system changes and programs is left to weak methods, like publication, rather than strong, carefully managed methods of deployment.

Too bad for health care. The wake-up call may be here, in the form of a disillusioned and angry public and a demoralized and dispirited work force. But, so far, health care has no Toyota to tell us all what we could have if we change enough. If we are to overcome the third barrier – to develop a vision of a new whole for American health care, functioning systemically at a total level never before seen – we will have to use some imagination. From the patches of excellence that can teach us how we might overcome piecemeal the hundreds of quality defects that plague us, we will have to make a quilt ourselves to understand just how good it could get for all of us: patients, families, communities, payers, and those who give and manage health care in America.

Let’s examine some cases of leading organizations and people in health care for whom the status quo was not good enough, leaders who identified performance gaps, and then closed them. Their stories, and their successes, give us a glimpse of how much better American health care could get if these became, not the exception to the status quo, but the rule.

REDUCING OVERUSE OF CESAREAN SECTIONS IN GREEN BAY

We have seen above how prevalent overuse is in America, including overuse of highly invasive forms of care. Cesarean section rates are one dramatic case in point. Between 1970 and 1998, the American cesarean section rate rose from 5% of all births to nearly 25%. Few experts believe, and none have sound data, that American mothers or infants are on the whole better off because of this change. The occasional reports of complications from delayed cesarean section, such as uterine rupture or fetal distress, make more headlines than the much more common, but harder-to-assess complications – pain, anaesthesia risks, post-operative infections, and blood loss, for example – from hundreds of thousands of cesarean sections that simply did not need to be done.

Obstetricians and others offer lots of explanations for the climbing C-section rates, including the threat of malpractice suits, reimbursement systems that pay more for a C-section than for a normal delivery, the demands of patients who want to avoid labor, and the demands of doctors and hospital staff who want to complete their work at convenient times of the day. But, despite the explanations, none, or almost none, of the experts believe that the American C-section rate is anything near appropriate in medical terms.

Obstetricians in Green Bay, Wisconsin, set a goal of reducing C-section rates by 25%, while maintaining or improving maternal and infant outcomes. In 1986, the average C-section rate across all obstetricians in Green Bay was 16.3%, but rates varied widely from doctor to doctor. For example, in treating nulliparous patients (those having their first childbirth), the obstetrician-specific cesarean section rate varied from 4.3% to 12.3%. No differences were found in outcomes for mothers or infants, but doctors differed dramatically in their approaches to managing labor. For example, obstetricians with lower rates of cesarean section avoided inductions of labor, augmented labor with oxytocin only after the cervix was beginning to dilate, used oxytocin for longer periods and at higher doses, permitted longer second stages of labor without intervention, and used therapeutic rest for women with slow progress.

Dr. Robert DeMott, an obstetrician, became a community leader in developing approaches to safe reductions in cesarean rates, and helped to share information on practices and results with all of the obstetricians in the community. Over an eight-year period, Green Bay’s cesarean section rate fell by 30% (to under 12% overall), while the national cesarean rate continued to rise to over 24%. In Dr. DeMottís own practice, the rate is 6.1%, and the rate in vaginal birth after cesarean section (VBAC rate) is 60%. (The national VBAC rate, by contrast, is well under 30%.) In 1995, Green Bay’s cesarean section rate was 11.1%, with excellent maternal and infant outcomes.

If the current national cesarean section rate of over 24% could be moved half-way toward Green Bay’s rate, there would be 250,000 fewer cesarean sections each year in the U.S., with decreased pain and surgical complications for mothers, shorter lengths of stay in hospitals, decreased subsequent repeat cesarean sections in later pregnancies, and probable financial savings of over $3000 per delivery, or a total of $750,000,000 nationally.

REDUCING COSTS WHILE IMPROVING OUTCOMES IN INTENSIVE CARE UNITS

Intensive care units are high-risk and high-cost environments in which mistakes and delays can have tragic and wasteful consequences. Conversely, improvements in ICU effectiveness and efficiency can produce immediate and dramatic gains for patients and caregivers. Traditional ICU improvements come in technological packages – new drugs, devices, and procedures. These help, but greater leverage lies in redesign of ICU practices as a whole – systemic improvements that require better teamwork, better flow of information, and a focus, not on snazzy bells and whistles, but on meeting the real needs of patients and families.

At Nash Health Systems in Rocky Mount, North Carolina, unnecessary ICU days for patients whose illnesses do not require intensive care have been reduced by over 90%. This means less disorientation for patients, less intimidation and anxiety for families, and much more efficient use of one of the hospital’s most expensive resources. When Nash started its work, over 40% of ICU beds at any given time were being occupied by patients who could have received care just as well outside the ICU. A clogged ICU system – with two out of every five ICU days wasted – is characteristic of the majority of American hospitals, and yet Nash solved the problem within a few months. Length of stay for patients on respirators in Nashís ICU has fallen by over 50%.

Drug costs continue to skyrocket in all areas of medical care, but especially so in ICUs. Wasteful, scientifically unnecessary sedatives account for a surprisingly large portion of the new, higher cost drugs, and ICU experts around the nation strongly advise that many older, less expensive medications are often wiser choices. Taking this seriously, the ICU team at Phoebe Putney Memorial Hospital, in Albany, Georgia, adopted strong, scientifically grounded protocols for sedation and other forms of medication use, and, through these and other changes, reduced the cost of an average ICU day by over 20% in less than three months, without harming a single patient.

Phoebe Putney Hospitalís carefully documented achievement of more than 20% reduction in ICU cost is fully within the reach of any ICU that today operates at an average level of efficiency, and Dr. William Brock, head of Phoebe Putney’s ICU, believes that they may have only scratched the surface of safe, prudent, improvements in efficiency. Dr. Terry Clemmer, Director of Critical Care Services at LDS Hospital in Salt Lake City, Utah, agrees. In cooperation with nurses and specialists there, his unit has reduced unnecessary ICU expenses by over $2 million per year.

With similar commitment, inpatient physicians and nurses at Sarasota Memorial Hospital in Florida totaled up the cost of their use of an intravenous fluid, albumen suspension, which has been shown in sound research to have almost no advantage over far cheaper and more available electrolyte solutions. To their surprise, they found an albumen bill of over $217,000 per year. They stopped it, achieving a 93% reduction in the use of the useless solution in a little over three months, saving the hospital over $202,000 per year that year and every year thereafter.

These local gains of intensive care units are striking, and they grapple directly with forms of overuse of ineffective care and underuse of effective care, as classified by the IOM. Even more striking, however, is the failure of these successes to spread quickly and deliberately throughout the health care system, even when it comes to the relatively well-circumscribed multi-hospital systems of which these leaders are a part. For health care, it has proven very difficult indeed to make the best known practice, like St. Mary’s ventilator management described below or Sarasotaís switch away from albumen, the standard (or the default) practice. Having discovered these nuggets of gold in the health care riverbed, we seem almost never to begin panning for the rest. Instead, health care organizations preserve the status quo as the default, favoring the familiar present over the best possible future.

FOCUSING ON PATIENTS’ NEEDS, REDUCING COSTS, AND IMPROVING OUTCOMES IN CARDIAC SURGERY

Cardiac surgery is costly, risky, and anxiety-provoking for patients and their loved ones. Because the stakes are so high, improvements in cardiac surgery can have enormous payoffs, as progressive cardiac care departments, focused on breakthroughs, have found.

When asked what they disliked most about their experiences of care, patients recovering from heart surgery commonly mention the pain and restriction caused by the various “tubes” that penetrate their bodies in the post-operative period – mainly the endotracheal tubes in their windpipes, through which respirators help them breathe, and the chest drainage tubes that keep their injured lungs expanded and allow internal bleeding to be monitored and relieved. On average, an American patient who undergoes a successful, uncomplicated coronary artery bypass graft operation will spend about 18 hours on a respirator machine post-operatively before his or her endotracheal tube is removed – 18 hours of high risk, high cost, and, often, significant discomfort.

But not at St. Mary’s Hospital in Madison, Wisconsin. There, a cross-functional team of doctors, nurses, and others systematically have reduced post-operative ventilator time to a median of six hours, and an increasing percentage of their patients are having their respirator tubes removed safely and routinely immediately after their surgery ends. They spend no time at all on a respirator machine post-operatively. At Sentara Norfolk Hospital in Virginia, a similar cardiac surgery team has also reduced ventilator time post-operatively to under six hours.

The implications are profound, and they echo both in cost and in outcomes. By shortening post-operative ventilator time, Sentara Norfolk Hospital helped achieve reductions in total length of stay, since time on a respirator delays rehabilitation, requires the use of disabling sedatives, and introduces risks of complications such as ventilator-induced pneumonia and lung collapse (pneumothorax), which themselves may require prolonged treatment. (It is no accident that Nash Health System has reduced ventilator-induced pneumonia cases nearly to zero. That is in part a side-effect of their work on early, appropriate extubation.)

At Loma Linda University Medical Center in California, cardiac surgeon Steve Gundry leads a unit, characterized by innovation and a constant search for waste, which today can do safe and effective coronary artery bypass surgery for an average of $8000 per case, compared to the national average cost of $18,000 per case. Rochester (New York) General Hospital’s cardiac surgery unit, led by Dr. Ron Kirschner, has developed approaches to multidisciplinary teamwork and continuous flow processes that allows it to use its own operating rooms with nearly three times the efficiency of the average cardiac surgery unit, thereby conserving resources and improving the experience of patients at the same time. In addition, Rochester General’s readmission rate for heart surgery patients (a measure of safe discharge) fell 50% in one year.

Responsibly pursued, these enormous savings in cost and waste are not accomplished at the expense of safety or patient service. Indeed, usually the opposite is true. Inefficiencies lead to dangerous and inconvenient waits for patients and families. Patients extubated in six hours have much less discomfort than those extubated in 18 hours. Older, familiar sedatives have proven track records and are often less risky and easier to handle than the latest fad drug. Safely shortened lengths of stay get patients home sooner to familiar, healing environments, and reduce their exposure to the resistant bacteria and medication errors that lie within the hospital’s walls. As its efficiency has improved through better management of its surgery processes, Rochester General Hospital’s use of blood products in cardiac surgery has been cut in half, and its readmission rate (one measure of outcomes) has fallen 50%. The hazards of cost-containment, that the public justifiably fears at the hands of blunt, sometime blind, insurance rules and managed care policies, come from lack of wisdom or information, not from lack of opportunity. Safer, more effective, less expensive care is feasible, as the pioneers are proving, but only by basing changes on sound knowledge and clearly documented best practices.

The total magnitude of achievable gain in both outcomes and efficiency in acute, inpatient settings is still a matter for speculation, at least until some health care Toyota manages to “put it all together.” But, experience such as that at Phoebe Putney, Sentara, Loma Linda, and Rochester General Hospital suggests that, overall, cost reductions of at least 30% in intensive inpatient settings, such as surgical units and ICUs, ought to be achievable through appropriate changes in care, while maintaining, and often improving, the experience and outcomes of patients and their loved ones.

REDUCING UNDERUSE OF EFFECTIVE TREATMENT FOR ASTHMA

Underuse of effective care is as costly in human terms, and may be as costly in long-run financial terms, as are overuse and errors. Medical science now knows, for example, highly effective approaches to the prevention and treatment of attacks in asthma patients. Proper use of safe and effective inhaled steroid medications, coupled with ongoing patient education and self-monitoring of patients’ breathing capacities, can cut asthma complication rates dramatically. One HMO-based study showed an 80% decrease in hospital days and emergency room visits for asthma care among patients trained to avoid asthma triggers, measure their own lung function, follow a consistent treatment plan, and make adjustments in their own medications at home. Similar approaches at Yale-New Haven Hospital’s Primary Care Center led to a 50% decrease in hospital admissions and emergency department visits for high-risk asthma patients. A demonstration project involving American Health Care Network and physicians in Kokomo, Indiana, reduced emergency department visits and hospitalizations for 350 asthmatics by over 95%.

These improvements did not depend on generating new scientific data; the science was already in hand and fully codified and published by the National Heart, Lung, and Blood Institute. The organizations that broke thorough to new performance levels simply put the science to work.

Asthma is one of the most common reasons for visits to primary care doctors and causes more hospitalization among children than any other medical condition. Making the best-known programs of asthma care the standard for all asthmatic children would cut pediatric visits and hospitalizations dramatically.

REDUCING MEDICAL ERRORS AND IMPROVING PATIENT SAFETY

The IOM’s third category of quality problem – “misuse” or errors in care – is as ripe for improvement as are overuse and underuse. The principles for improvement here come, in part, not from health care but from other industries where risk-reduction, error prevention, and recovery from errors have long been objects of concerted research and action. The hub of modern American scientific research on aeronautics, the NASA-Ames Research Laboratories near Palo Alto, California, has entire divisions devoted to the sciences that underlie the discovery, prevention, and mitigation of error and the improvement of safety. Today’s airplanes and space vehicles draw upon an immense library of theory, experiment, and experience in safety improvement, using principles from human factors engineering, operations research, statistics, and human and organizational psychology.

Health care has no NASA-Ames to improve its safety, having relied primarily, instead, on traditional, but intellectually almost bankrupt, notions of personal accountability, blame, and exhortation to seek safety. In aviation, pilots involved in “near miss” hazards are strongly supported to report the problem and are welcomed to become involved in uncovering causes and inventing solutions for the future. In health care, nurses involved in “incidents” know that they will probably have a black-mark report end up in their personnel file, and, in the worst cases, may be roasted by internal committees or outside regulators. Therefore, no surprise, most health care “near misses” never get reported at all.

But some hospitals and health systems have mustered the courage and the curiosity to tackle hazards the way they ought to be tackled – not with blame, but with study and principled redesign. At Fairview Health System in Minneapolis, a team of pharmacists, physicians, and others have capitalized on two major principles of human factors engineering – standardization and simplification – to reduce several types of serious medication errors by over 60%.

How do simplification and standardization help? Let’s examine one specific case: errors in heparin dosage. Of all drugs in inpatient care, one of the most hazardous is the anticoagulant, heparin, used for patients who have thrombophlebitis or atrial fibrillation, for example, and need prompt anticoagulation. Heparin comes in five concentrations such as: 1000 units per cubic centimeter (cc), 5000 units per cc, and 10,000 units per cc. Many hospitals stock multiple concentrations in their pharmacies or nursing units. By far the most common form of heparin error (causing either undercoagulation or, worse, bleeding due to too much heparin) is a wrong dose, caused by use of the wrong concentration. A nurse means to administer one cubic centimeter of the 1000 units per cc heparin, but accidentally picks up a 10,000 units per cc vial. One way to prevent such an error is to exhort nurses to be more careful, but no modern student of error would bet much on that solution. To err is human. The better way – the scientific way – is to standardize the system to make it error-proof. In simple terms: stock only one form of heparin (say, the 5000 unit per cc form), and throw away the rest. Poof – no mixups.

That is safety science at work. Unfortunately, even the simpler forms of modern approaches to system safety are virtually absent from health care organizations. The remedies are clear, but unused, and so patients live (or die) with rates of serious drug errors of 7 per 100 admissions.

In the past 30 years, air travel has become safer, measured in fatalities per passenger mile flown, by a factor of 20. Between 1950 and 1990, US airline fatalities in deaths per one million departures fell from 1.18 to 0.27, almost an 80% reduction, despite an enormous increase in the volume of air travel. Aviation safety has improved; safety in health care has not. And yet, if health care systems set about to become much safer, and harnessed the many sciences of safety to its service, order-of-magnitude improvements should be accessible, as they have been at Fairview. Using computer-assisted decision support, doctors at LDS Hospital in Salt Lake City reduced adverse drug events – complications – from antibiotics in hospitalized patients by 30%, while at the same time reducing the average antibiotic cost per treated patient from $123 to $52. Financial benefit should accrue along with the improvement of outcomes. Automated, computerized reminder systems at the Reigenstrief Institute in Indianapolis and at Group Health Cooperative of Puget Sound in Seattle have vastly increased the reliability of appropriate followup of abnormal laboratory tests and use of effective preventive practices, like immunizations in the elderly. Leading researchers on health care error from the Harvard School of Public Health, Brigham and Women’s Hospital and Massachusetts General Hospital recently published an estimate of $4000 per drug error as the health care cost of recovery from its own damage. Scaled up to the American health care system as a whole, this suggests savings of billions of dollars per year if we were to reduce only one form of error (medication error) by only 50%.

IMPROVING SERVICE CHARACTERISTICS IN HEALTH CARE

Taking primarily a technical view of quality of care, the IOM Roundtable group did not include service characteristics – such as convenience, dignity, ease of access, privacy, communication, comfort, patient involvement in decision-making, and promptness of care, for example – in its summary of quality levels. Had it done so, the IOM’s report on defects would have been even more expansive and disturbing, for the service levels of much of health care would frankly be an embarrassment in any other human service industry. Long waits, anonymity, isolation, embarrassment, confusion, non-response, physical discomfort, and infantilization are all common characteristics of health care settings from patients’ and families’ point of view, excused and permitted socially perhaps only because of durable and justified trust in the underlying samaritanism, skill, and professionalism of the people who work in those service-poor systems. In fact, patients more often sympathize with and excuse the doctors and nurses than blame them or complain.

It does not have to be that way. “Service” in all of the dimensions mentioned, and others, is a legitimate and important “quality” of health care, and, even more to the point, many dimensions of good service are empirically associated with better care outcomes in the “important” dimensions of health status, physical function, pain control, and even longevity. The Picker Institute, housed at Harvard Medical School, has carefully documented patient reports on their own care and has developed easy-to-administer and internationally normed questionnaires that can allow any health care organization to know precisely how it is doing in these dimensions of care (as the Picker Institute puts it) “through the patient’s eyes.”

Examples of breakthroughs in service performance are just as much in hand in health care as are technical advances in clinical care. Almost 20 years ago, for example, innovators in California developed the so-called “Planetree” patient care units, now established in several dozen hospitals throughout the United States. Planetree Units fully incorporate the philosophy of patient-centered care, and they seek every possible way to offer patients and their families control over and participation in their own care. If they wish, Planetree inpatients can dress in their street clothes, not hospital “johnnies”; they can read and write in their own medical records to increase communication between them and their caregivers; they administer their own medications in many cases, instead of waiting like children to have nurses give them pills from bottles that they could open just as well. Planetree Units have no “visiting hours,” since family members and loved ones are not “visitors” they are full partners in care, welcome all of the time; and the units have kitchens and snack bars in which patients and families can, if they wish, prepare their own meals when and how they choose to. One Planetree Unit now operates for cardiology patients at New York’s Mount Sinai Medical Center where families are trained to participate in care, including cardiac resuscitations. Ten minutes into a presentation by or a visit to a Planetree Unit, most observers, and most visiting doctors and nurses, ask the same question: “Why isn’t it like this everywhere?” The answer is not “because it costs too much.” Planetree Units operate with the same or lower staff-to-patient ratios as classical hospital wards. These service-oriented care systems are not more expensive than usual care; they are less expensive.

Among the most promising innovations in health care service today are methods to involve patients directly in their own technical care. Dr. Larry Staker, at LDS Hospital in Salt Lake City, has trained diabetic patients to monitor their own blood sugar levels and adjust their own insulin doses without Dr. Staker’s intervention, producing better blood sugar control, more satisfaction among patients, and lower costs of care. Innovators in asthma care in Kaiser-Permanente and the Harvard Pilgrim Health Care system have taught asthmatic patients to measure their own lung function, adjust their own medications, and administer at home to themselves treatments formerly available only in hospitals. The result: symptoms and complications rates fall, satisfaction improves, and costs fall. Dr. Richard Rockefeller, of the Health Commons Institute, and colleague physicians, like Dr. Charles Burger, of Bangor, Maine, are using computerized patient record systems and other forms of decision support to help patients participate more as equals in their own care. In health care as a whole, the era of patient control, self-care, and truly shared decision making is only dawning.

The waiting and delay so familiar to all in health care, both patients and providers, are not inevitable. Relatively simple changes in scheduling and information exchange, engineered by Dr. Mark Murray and Nurse Catherine Tantau at Kaiser-Permanenteís Rosemont Medical Center, have produced “same-day access” and nearly wait-free patient flow for ill patients, have reduced delays for routine appointments from over two months to one day, and done so without any expansion in staff at all. A team at Sewickley Valley Hospital in Pennsylvania reduced delays in start times for surgery (a chronic, costly, and annoying problem for surgeons, operating room staffs, patients, and their pacing families) in less than three months from an average of 80 minutes to less than 10 minutes, again with no changes in staffing. And the Pediatric and Adolescent Medicine Unit at Mayo Clinic in Rochester, Minnesota, cut waiting times for routine appointments from an average of over 30 days to less than five days. What each of these “delay-reducers” did was to apply in health care some simple rules and methods for profiling demand, scheduling services, and streamlining procedures – rules and methods that have been standard in many service industries other than health care for decades.

And yet, for most of health care, the innovations developed (and published) by Dr. Murray, Sewickley Valley Hospital, and Mayo Clinic remain poorly deployed – copied almost nowhere. The average clinical scheduling system operates with theories 30 years or more old, rather than with modern and better understandings of how to decrease or abolish waiting. Evidence from the best suggests that waiting time reductions of over 50% from the current averages should be relatively easy to achieve within current resource constraints, and that truly “world class” designs in clinics, offices, operating rooms, and emergency departments might reduce many chronic waits by 80% or more without raising costs a penny.

ADDING IT UP: HOW GOOD COULD HEALTH CARE GET?

So, what does this all add up to: a quilt, or just a mess? At the moment, it’s the latter. The good news is that health care in America contains a treasure trove of gem-like breakthroughs in performance. For almost every example of poor quality – overuse, underuse, and misuse – that the IOM’s Roundtable laments, a search uncovers an example of one or more practitioner or clinic that has buckled down, made scientifically grounded changes, and knocked the socks off the problem. Broaden the search to international terrain, and the likelihood of finding a thrilling counter-example approaches certainty.

The bad news is that the treasure-trove is undeveloped by those, especially leaders, who ought to be using that wealth to build a future. Not only do the particles of excellence lie lonely, unduplicated, not spread, but not even one organization has yet had the ability, or perhaps the courage, to collect these many, exciting innovations into a new whole – a care system consisting throughout of the very best known and thereby performing at levels of quality, service, and low cost so far unimagined in the mainstream of American health care.

How good could it get? Imagine that someone – maybe even a smart investor – convened the leading-edge innovators in improvement along all of the lines covered in the IOM’s review, and added in innovations in the service dimensions of quality as well and found a way to link them in a common system of care operating everywhere at the “best known” or “best currently achievable” performance level. Such an organization in modern jargon might be called an “Integrated Delivery System” (IDS), putting under one managerial umbrella, in just the right proportions, hospitals, outpatient offices, specialty referral centers, nursing homes, home care, and all of the other major components of care needed to serve a population. But, unlike the run-of-the-mill IDS of today, which assembles average performers to create, at best, an average whole, this IDS would be a compilation of the best:

  • It performs no scientifically groundless surgery and administers no scientifically groundless medications (following examples like Dr. Bill Brock at Phoebe Putney and the team at Sarasota). In its commitment to evidence-based care, it eschews both wasted costs and avoidable hazards.
  • It formally searches for effective, proven care practices and assures that patients benefit reliably from such appropriate care. With 100% reliability, patients at this organization receive the influenza immunizations they need, get beta-blockers and aspirin at appropriate phases in care of their heart disease, and follow well-proven guidelines for diagnosis and treatment of asthma (as in the Yale Emergency Department and Kokomo, Indiana, projects). The medical record system supports the selection of the right antibiotics (as at LDS Hospital in Salt Lake City) and acts as a “tickler” system when patients who could benefit from a preventive treatment fail to receive it (as in the Reigenstrief Institute in Indianapolis and parts of Group Health Cooperative of Puget Sound).
  • It is the safest health care organization ever known in the modern, technical era of health care. It uses simplification, standardization, and safety sciences such as human factors engineering to drive error rates continually lower and to mitigate the effects of the errors that do occur (as the team at Fairview did), and it systematically reduces its use of risky, invasive forms of care by developing and spreading safer, equally effective alternatives (following the example of the early extubation projects at St. Maryís Hospital, Sentara, and Loma Linda). The frequency of medication errors is not 7 per 100 admissions as in most American hospitals, but 1 per 1000 admissions, and headed lower.
  • It does not always wait for trouble. This organization takes prevention seriously, and follows where the evidence leads. It has built on Seattle’s experience to drive bicycle helmet use to 90% in children and has followed the example of a Oklahoma City experiment on smoke detector use to reduce burn injuries in its patients by over 50%.
  • It is free of waiting (as Kaiser’s Dr. Mark Murray and Rochester General Hospital’s Dr. Ron Kirschner could help design it). All patients and staff experience smooth and seamless flow through the various parts of the system, not rushed, but stopping only when they wish to, and otherwise knowing that the health care system fully respects their time.
  • It involves patients and families fully in their own care, giving them control over decisions (as Dr. Jack Wennberg has designed) and teaching them to diagnose and treat themselves safely, if they wish (as Dr. Larry Staker does for diabetes patients and Kaiser Permanente’s Dr. Guillermo Mendoza and the Harvard Pilgrim’s Health Care Plan Asthma Program do for asthmatics), achieving better outcomes, more satisfaction, and generally lower costs. Women with familiar symptoms of urinary tract infection diagnose and treat themselves safely, with out wasteful visits or delays (as they do at Dartmouthís Hitchcock Clinic). Computerized patient record systems and other forms of decision support have converted patients and doctors from passive-active models into teams of joint problem-solvers (as in the medical practices of Dr. Charles Burger and Dr. Richard Rockefeller).
  • It is an open health care organization, breaking down the walls of intimidation and misunderstanding among professionals, patients, and families. Families, especially, are welcomed as respected participants and full partners, continually oriented, and involved, if they wish, in the care of their loved ones (as demonstrated by Dr. Terry Clemmer in his ICU and by the Planetree Units throughout the country). Patients read and write in their own medical records, improving communication, accuracy, and the patientsí knowledge of their own illnesses. There are no “visiting hours” here; patients and their loved ones are together whenever, and for as long as, they please.

It does not yet exist, but this organization need not remain a dream. All its elements of excellence, and many more, exist either in reality somewhere already, or are firmly supported by sound, scientific evidence. The aggregate can be an American health care organization that operates at a total cost per capita 30% lower than that spent on the average Americanís health care today; with health status outcomes for specific acute and chronic illness at or above the very best known profile of outcomes; trimmed of hazardous, costly excess and waste in ineffective medical procedures, drugs, diagnostic tests, supplies, and equipment; reinvesting those savings in forms of care, service, and prevention currently unaffordable; involving patients and families totally in their own care, with the fullest possible control (to the extent they want it) over the decisions and circumstances under which they receive that care; characterized by levels of service, smooth flow, dignity, responsiveness, clarity, and optimism that we today associate only with world-class service organizations; and 100 times safer than the health care of today.

Blue sky? Not at all. This performance is within reach, if we believe it, study it, and demand it, and if we are willing to change far enough and fast enough.

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