CROSSING THE QUALITY CHASM: HEALTH CARE FOR THE 21ST … 1 - Sistem... · 2010-07-20 · have lies not just a gap but a chasm. • The problems come from poor systems…not bad people

© 2001 IHI

CROSSING THE QUALITY CHASM: HEALTH CARE FOR

THE 21ST CENTURY

May 10, 2002

Donald M. Berwick, M.D.President & CEO

Institute for Healthcare Improvement

© 2001 IHI

The Foundation• IOM Roundtable• President’s Advisory Commission• National Cancer Policy Board• IOM Program on Quality of Health Care in

America• IOM Committee on Quality of Health Care in

America– Subcommittee on Environment– Subcommittee on the 21st Century “Chassis”

© 2001 IHI

The IOM Roundtable• “…Serious and widespread quality problems

exist throughout American medicine. These problems….occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed as a result….”

© 2001 IHI

Roundtable’s Categories

• Overuse (of procedures that cannot help)

• Underuse (of procedures that can help)• Misuse (errors of execution)

© 2001 IHI

Roundtable’s Categories

• Overuse (of procedures that cannot help)

• Underuse (of procedures that can help)• Misuse (errors of execution)

© 2001 IHI

Health Care ExamplesOveruse

• 30% of children receive excessive antibiotics for ear infections

• 20% to 50% of many surgical operations are unnecessary

• 50% of X-rays in back pain patients are unnecessary

© 2001 IHI

Health Care ExamplesUnderuse

• 50% of elderly fail to receive pneumococcal vaccine

• 50% of heart attack victims fail to receive beta-blockers

© 2001 IHI

“Misuse”: Health Care Safety

• 7% of hospital patients experience a serious medication error

• 44,000-98,000 Americans die in hospitals each year due to injuries from care

© 2001 IHI

The Foundation• IOM Roundtable• President’s Advisory Commission• National Cancer Policy Board• IOM Program on Quality of Health Care in

America• IOM Committee on Quality of Health Care in

America– Subcommittee on 21st Century Health System– Subcommittee on Environment

© 2001 IHI

© 2001 IHI

What the IOM Said….

• The patient safety problem is large.• It (usually) isn’t the fault of health

care workers.• Most patient injuries are due to

system failures.

© 2001 IHI

How Hazardous Is Health Care?(Leape)

1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Number of encounters for each fatality

To

tal l

ives

lost

per

yea

r

REGULATEDDANGEROUS(>1/1000)

ULTRA-SAFE(<1/100K)

HealthCare

Mountain Climbing

Bungee Jumping

Driving

Chemical Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power

© 2001 IHI

What the IOM Said….

• The patient safety problem is large.• It (usually) isn’t the fault of health

care workers.• Most patient injuries are due to

system failures.

© 2001 IHI

Quality is a system property

© 2001 IHI

© 2001 IHI

“The First Law of Improvement”

Every system is perfectly designed to achieve exactly the results it gets.

© 2001 IHI

© 2001 IHI

Core Conclusions• There are serious problems in quality

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

• The problems come from poor systems…not bad people– In its current form, habits, and environment, American

health care is incapable of providing the public with the quality health care it expects and deserves.

• We can fix it… but it will require changes

© 2001 IHI

The Chain of Effect inImproving Health Care Quality

Patient and Patient and CommunityCommunity ExperienceExperience

AimsAims (safe, effective, patient(safe, effective, patient--centered, timely, efficient, centered, timely, efficient, equitable)equitable)

MicroMicro--systemsystem ProcessProcessSimple rules/Design Simple rules/Design ConceptsConcepts (knowledge(knowledge--based, based, customized, cooperative)customized, cooperative)

Organizational Organizational ContextContext

Facilitator ofFacilitator ofProcessesProcesses

Design ConceptsDesign Concepts (HR, IT, (HR, IT, finance, leadership)finance, leadership)

Facilitator ofFacilitator ofFacilitatorsFacilitators

Design ConceptsDesign Concepts(financing, regulation, (financing, regulation, accreditation, education)accreditation, education)

Environmental Environmental ContextContext

© 2001 IHI


Patient and Patient and CommunityCommunity

ExperienceExperienceAimsAims (safe, effective, patient(safe, effective, patient--centered, timely, efficient, centered, timely, efficient, equitable)equitable)








© 2001 IHI

The Overarching Aim

• The purpose of the health care system is to reduce continually the burden of illness, injury, and disability, and to improve the health status and function of the people of the United States.

© 2001 IHI

Aims

• Safety• Effectiveness• Patient-centeredness• Timeliness• Efficiency• Equity

© 2001 IHI

Clarifying National Aims for Improvement

• Safety -- As safe in health care as in our homes• Effectiveness -- Matching care to science; avoiding overuse

of ineffective care and underuse of effective care• Patient Centeredness -- Honoring the individual, and

respecting choice• Timeliness -- Less waiting for both patients and those who

give care• Efficiency -- Reducing waste• Equity -- Closing racial and ethnic gaps in health status

© 2001 IHI

Four Levels of Change Required

• Clarifying national aims for improvement• Changing the care, itself• Changing the organizations that deliver care• Changing the environment that affects

organizational and professional behavior

© 2001 IHI

Aims: Recommendations

• #1: Endorse the Statement of Purpose for the Health Care System

• #2: Endorse the Six Aims for Improvement (Safety, Effectiveness, Patient-centeredness, Timeliness, Efficiency, and Equity)

• #3: Link to Measurement and Annual Report to President and Congress on the State of Quality of Care in America

© 2001 IHI

What Congress Can Do…

§ Take the National Quality Report seriously§ “Receive it formally,” annually§ Set clear national aims for improvement§ Review and comment on progress over time

© 2001 IHI

What Congress Can Do…§ Reach the public to help build will for improvement§ Use the Six Aims from the IOM as your framework§ Expect annual plans from Federal agencies that

provide and fund care to improve on most or all of the Six Aims§ You represent the “customers” and have the right

to insist on a habit of excellence

© 2001 IHI











© 2001 IHI




© 2001 IHI

Three Guiding Frameworks

• Knowledge-based

• Patient-centered

• System-minded

© 2001 IHI

“New Rules” for Health Care

• Care based on continuous healing relationships

• Customization based on patient needs and values

• The patient as the source of control• Shared knowledge and the free flow of

information• Evidence-based decision making

© 2001 IHI

“New Rules” for Health Care

• Safety as a system property• The need for transparency• Anticipation of needs• Continuous decrease in waste• Cooperation

© 2001 IHI

Breakthrough Series(6 to 13 month time frame)

Select Topic

Planning Group

Develop Framework & Changes

Participants

Pre-work

LS 1

P

S

A DP

S

A D

LS 3LS 2

Supports

E-mail Visits

Phone Assessments

Senior Leader Reports

Congress,

Guides,

Publications,

etc.

UKPDS Glycemic Control

• A 1.0% reduction in HbA1c:– 17% reduction in mortality– 18% reduction in MI– 15% reduction in stroke– 35% reduction in cardiovascular endpoints– 18% reduction in cataract extraction

• Cost: $98.2 billion/year in the U.S.A.

Source: GHCContact: David K. McCulloch, MD, FRCPEmail: [email protected]

© 2001 IHI

Results from Effective Improvement Efforts….

Health Resources and Services Administration (HRSA)

Chronic Disease Care Improvement Collaboratives

© 2001 IHI

Phase 2 Diabetes I and II - Total Registry Size

13,564

24,846

38,410

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DC1 Total DC2 Total Both Collabs

Phase 2 Diabetes I and IIAverage HbA1c's

8.35

9.19

8.10

8.54

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Goal

© 2001 IHI

Phase 2 Diabetes I and IIAverage Percent of Patients with Two HbA1c's

(at Least Three Months Apart)

26.6%

42.4%39.7%

18.5%

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October Data: 38,410 patients in diabetes registries. See previous slide for details about registry growth

© 2001 IHI

CVD Collaborative 1 Average Percent of Patients with Two BP's in Last 12 Months

37%

63%

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CVD_DM3 Collaborative - Total Number of CVD Patients in Registries

4720

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© 2001 IHI

CVD Collaborative 1 Average Percent of Patients with BP < 140/90

45%

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CVD_DM3 Collaborative - Total Number of CVD Patients in Registries

4720

0500

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© 2001 IHI

Diabetes Collaborative 3Average HbA1c's

8.6

8.2

6

7

8

9

10M

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CVD_DM3 Collaborative - Total Number of DM Patients in Registries

8,159

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Reporting Month

Number of Patients

© 2001 IHI

Results from Effective Improvement Efforts….

Veterans Health Administration

ImmunizationsTreatment of Heart Attacks

© 2001 IHI

Vaccine Cuts Pneumonia Risk in High-Risk Patients

• 50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine.

– VAMC study of 1,900 elderly patients with chronic lung disease; 2/3vaccinated against pneumonia.

• Pneumococcal vaccination:– 43% reduction in hospitalizations for pneumonia and influenza, and a

29% reduction in the risk of death.

• Pneumonia and Influenza vaccination:– 72% reduction in hospitalizations for these two diseases and an

82% reduction in deaths from all causes.

• Pneumococcal vaccination saved an average of $294 per vaccine recipient over the 2-year period.

© 2001 IHI

Pneumococcal Vaccination Rates

0

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60

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FY 95 4th Qtr 97 4th Qtr 98 Cum 99 Cum 00

Per

cent

Vac

cina

ted

VHA Healthy People 2000 Iowa 99*

* Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz

© 2001 IHI

Extrapolating from Dr. Nichol’s study:

Between 1996 and 1998, Increased Rates of Pneumococcal Vaccination Averted 3914 Excess Deaths Nationally in VA Patients with Chronic Lung Disease . . .

© 2001 IHI

Quality:Influenza Vaccination Rates

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Ann

ual I

nflu

enza

Vac

cine

VHA Healthy People 2000 Iowa 99

© 2001 IHI

Beta Blocker following AMIin VHA Medical Centers

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Pe

rce

nt

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VHA NCQA AHCPR (NJ) Non-GovtAHCPR: Soumerai et al. JAMA 1997;277(2):115-21Non-Govt: Krumholz HM et al. Ann Int Med 1999;131(9):648-54

Improved Provision ofBeta Blockers Has SavedOver 500 Lives since 1996

© 2001 IHIAllison JJ et al, JAMA 2000;284:1256-1262

ASA b-BLK ACE0

20

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Per

cent

Elig

ible

Pts

VAAMCNT

VA Results Compared to Others’:Treating Heart Attacks

© 2001 IHI

The Care, Itself: Recommendations

• #4: Adopt the “New Rules” for care• #5: Focus on 15 priority conditions first• #6: Foster innovation - Health Care Quality

Innovation Fund ($1 billion)

© 2001 IHI


§ Encourage innovation and pursuit of excellence in Federal health systems§ VA§ DoD (Military Health Command)§ HRSA§ Indian Health Service

© 2001 IHI

What Congress Can Do…§ Ask staff to explore the “Ten Simple Rules” and

identify regulatory obstacles … then remove, or suspend, them§ Fund the spread of innovative ideas about care as

a public good …. (e.g., The “Agriculture Extension Service” for health care)§ “Billionize” the Agency for Healthcare Research

and Quality (AHRQ) as a support for better care

© 2001 IHI











© 2001 IHI




© 2001 IHI

Changing the Organizations that Deliver Care

• Redesign care based on best practices• Use information technology to improve access to

information and to support clinical decision-making• Improve workforce knowledge and skills• Develop effective teams• Coordinate care among services and settings• Measure performance and outcomes

© 2001 IHI

Changing Organizations: Recommendations

• # 7: Redesign:– Care Processes – Information Systems – Human Resource Development – Effective Teams – Coordination across Boundaries – Incorporating Measurement

• #8: Moving Science into Practice• #9: National Commitment to

Information Infrastructure

© 2001 IHI


§ Commission the development of standards for health care Information Technology§ Launch a national “moon shot” to develop a

new medical record, available to all

© 2001 IHI











© 2001 IHI




© 2001 IHI

Changing the Environment• #10: Reform payment (not more money, but

different ways to pay)– For chronic care– To encourage improvement in care– To move payment toward high quality– To encourage best practices, not variation– To increase cooperation and decrease fragmentation

• #11: Social experiments on payment• #12: Design new workforce requirements• #13: Start toward change of the tort system

© 2001 IHI

What Congress Can Do…§ Authorize CMS to conduct market-area

experiments on payment reform, focusing on paying for quality … same costs, more flexibility§ Request a Presidential Commission on the Future

of the Heath Care Workforce, including reforms in professional education§ Ask AHRQ, with the IOM, to design and supervise

one or more four-year regional or statewide experiments on tort reform – (No Fault, Enterprise Liability, Total Disclosure, Direct Compensation)

© 2001 IHI

Core Conclusions

• There are serious problems in quality– Between the health care we have and the care we could

have lies not just a gap but a chasm.

• The problems come from poor systems…not bad people– In its current form, habits, and environment, American

health care is incapable of providing the public with the quality health care it expects and deserves.

• We can fix it… but it will require changes

© 2001 IHI











Documents

CROSSING THE QUALITY CHASM: HEALTH CARE FOR THE 21ST … 1 - Sistem... · 2010-07-20 · have lies not just a gap but a chasm. • The problems come from poor systems…not bad people