Right there all along

The tools required to remake the beleaguered U.S. healthcare system into one that's safe, cost-effective and patient-centered are available right now. So said the Institute of Medicine in a 382-page, catchall report that provided a comprehensive road map for such transformation.

Authored by an 18-member expert committee that included Helen Darling, president of the Washington-based National Business Group on Health, and Dr. Gary Kaplan, chairman and CEO of Virginia Mason Health System, Seattle, the Sept. 6 report stressed the need to leverage information technology infrastructure, management science, teamwork and other strategies to bolster improvement efforts.

“Missed opportunities for better healthcare have real human and economic impacts,” the committee said in the report. “If the care in every state were of the quality delivered by the highest-performing state, an estimated 75,000 fewer deaths would have occurred across the country in 2005. Current waste diverts resources from productive use, resulting in an estimated $750 billion loss in 2009.”

The report, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, comes more than a decade after the release of To Err is Human and Crossing the Quality Chasm, companion reports from the IOM that many say marked a watershed moment in the quality and safety movement.

But in the years since those two reports were released, costs have ballooned, rates of preventable harm have remained high, and racial, ethnic and geographic disparities have persisted.

“Medical care is growing more and more complex each day, and the amount of available data and evidence is growing, too,” said Dr. Mark Smith, president and CEO of the Oakland-based California HealthCare Foundation and chairman of the committee that produced the report. “But that kind of complexity—both biomedical and organizational—is just not compatible with our current system. Our whole ethos is rooted on an obsolete understanding of what we can and need to do.”

Just last month, researchers from Johns Hopkins University's Armstrong Institute for Patient Safety and Quality released a study concluding that more than 40,000 intensive-care patients die each year with an undiagnosed condition that might have caused or contributed to their deaths. Another study, published in the September issue of the Journal of the American College of Surgeons, found that 11.3% of general surgery patients were readmitted within 30 days of discharge.

Moving the needle has proved difficult, Smith said, because of a host of obstacles, including uneven use of available evidence, poor communication among clinicians and patients, and a lack of financial incentives for good care.

“New payment models are crucial,” Smith said. “In healthcare, people are basically paid to admit people, to do procedures and to have office visits. We have to get to a system where payment is based on value and not the number of times the turnstile is turned.”

Those poorly aligned incentives prevent most CEOs from implementing proven improvement strategies, according to Dr. Brent James, chief quality officer at Intermountain Healthcare, Salt Lake City, who also served on the IOM committee. “In most cases, you'll be financially punished,” James said. Intermountain lost $9 million in revenue, for instance, after a highly successful initiative to curb early elective deliveries before 39 weeks. “You need to align payment to see this system transition.”

To give some perspective, the committee contrasted healthcare with other consumer-oriented industries. If those industries operated like the healthcare system, the committee said in the report, airline pilots would design their own pre-flight safety checks and grocery stores wouldn't post their prices.

“If banking were like healthcare, automated teller machine (ATM) transactions would take not seconds but perhaps days or even longer as a result of unavailable or misplaced records,” according to the report. “If home building were like healthcare, carpenters, electricians and plumbers would work with different blueprints, with very little coordination.”

But Smith said the committee's framework for “a learning healthcare system,” developed during the past year and half, can change that.

One component emphasized repeatedly throughout the report is the importance of systems engineering and other management strategies for redesigning flawed processes. Those can be as simple as a short checklist, or more complex approaches—often borrowed from other industries—such as Lean and Six Sigma.

Such process improvements can make measurable effects on quality and can also result in significant savings, said Eugene Litvak, president and CEO of the Institute for Healthcare Optimization, Newton, Mass., and a member of the IOM committee.

The Institute for Healthcare Optimization, which specializes in operations management—specifically smoothing patient flow—has worked with a long list of well-known healthcare organizations, including Johns Hopkins Medicine, Baltimore, and the Mayo Clinic's satellite in Jacksonville, Fla.

Litvak argues that it's the peaks and valleys in bed occupancy that contribute to a host of problems, including high readmission rates, increased risk of mortality and nurse burnout. And despite average bed occupancy rates that hover around 65%, hospitals are plagued by overcrowded emergency departments and related problems like premature discharge, he said.

“We are one-third idle and we're overcrowded,” Litvak said. “Only in healthcare could you manage that. We should have enough beds for everyone if we use them properly.”

One of the tactics Litvak and his colleagues often use is smoothing out elective surgery schedules so procedures are not clustered on certain days of the week. Not surprisingly, that strategy has been met with plenty of pushback, he said. But it's also produced results.

At Cincinnati Children's Hospital Medical Center, for instance, they were able to increase bed occupancy rates to 91% from 76%. Additionally, the hospital saw $100 million in avoided capital costs and another $100 million in additional revenue following implementation of the institute's recommendations.

“I think it's very important for patients to know that when they sit for hours in the emergency room, it's not because everyone got sick at once,” Litvak added. “It's not a shortage of beds; it's a shortage of knowledge and leadership.”

He predicted a sea change in the use of process improvement strategies, propelled by new payment models that emphasize value. Accountable care organizations, in particular, he said, will drive organizations to look more closely at how their systems can be adjusted to make care better.

Health IT, interoperability and real-time access to data are also critical elements of a high-performing healthcare system, the committee said. “Once in place, these systems create the potential for advanced uses of clinical data to improve outcomes,” they said in the report. “For instance, they allow providers to analyze their patient populations and identify those who may benefit from preventive care or other proactive clinical services.”

After years spent lagging far behind other industries when it comes to adoption of IT systems, the stars are beginning to align, said Dr. Paul Tang, vice president and chief innovation and technology officer at the Palo Alto (Calif.) Medical Foundation.

HHS' National Quality Strategy and its Partnership for Patients initiative both explicitly call for increased use of health IT, said Tang, who was also a member of the IOM committee that produced the report. Even more significant, he says, has been the considerable uptick in adoption since the beginning of the federal government's EHR incentive programs.

“To Err is Human made visible the tremendous problem we had with medical errors, but back then very few systems had this kind of data infrastructure,” Tang said. “We're in a much different spot now.”

Like the Patient Care Program, a $500 million initiative launched Aug. 28 by the Gordon and Betty Moore Foundation, this latest IOM report places a great deal of emphasis on patient and family engagement and the need to include them in team-based strategies with clinicians.

Arthur Levin, director of the New York-based Center for Medical Consumers, served on the committee that produced To Err is Human and Crossing the Quality Chasm, as well as on the committee that authored this latest report.

The new report is different from previous ones, he said, because it brings together a range of disparate elements that have been shown to be successful and it puts them in one framework.

“There's no one place that's doing everything right,” Levin said. “But we do know what works. There are successes out there that tell us it can be done.”

He said that understanding of patient engagement has evolved during recent years to include learning from patients and their families and providing them with the electronic tools they can use to help manage their own care. “That's something that was not widely accepted before,” Levin said.

In the report, the committee argued that patients need better information about the benefits and risks associated with treatments, adequate instructions during thorny transitions of care, and care plans that take their goals and preferences into account.

Involvement by patients and families has been linked to reduced pain, improved health outcomes and lower utilization of services, they said. And the stakes for engaging patients are growing with the CMS' inclusion of patient-experience metrics in its hospital value-based purchasing program.

Patients and their families also can be a valuable asset in hospital improvement initiatives, the committee contended.

“Case studies have shown that by working on such councils, patients may participate in institutional quality improvement projects, help redesign service delivery processes, serve on search committees for new executives, and help develop educational programs for hospital staff,” they said in the report. “They also may aid the hospital in making its procedures more efficient and patient-centered and may participate in rounds, which can lead to new suggestions for improvement.”

The slew of changes advocated in the report—increased use of health IT, secure information exchange, point-of-care decision support, patient engagement, culture change, systems re-engineering—can seem daunting, but the general tone of the report is optimistic, Smith said.

“There's such a hunger by other organizations to learn about what the best ones have achieved,” he said, adding that leading systems like Denver Health have had to set up tour operations to accommodate visitors. “That's profoundly encouraging.”

TAKEAWAY: Healthcare executives need to review and then optimize their organizations' own internal systems to better control costs and improve the quality and safety of care.