Crossing the Quality Chasm:A Systems Approach

Richard J. Schuster, MD, MMM

Boonshoft Chair and Director

Health Systems Management

Wright State University

Chasm …

Grand Canyon

Grand Canyon

South Rim

Grand CanyonNorth Rim

A Double Oxymoron…..

Health

Systems

Management

Why ???

The History of AmericanMedicine is One of

Organizational Autonomy

Doctors Hospitals

Hospital

System

Doctor

Doctor

Doctor

Doctor

It’s Been Nearly Impossible to Establish a Health System

Doctor

Best Practice Analysis:Best Practice Analysis:Can all of these physicians be doingCan all of these physicians be doing

the Best Practice ???the Best Practice ???

Outlier

? Benchmark2 SD

StatisticalNoise ?

Unexplained Clinical VariationMust be Reduced…

� Explained ClinicalVariation

� Unexplained ClinicalVariation

David Nash

(W. Edwards Demming)

How Do You Create a HealthSystem?

� Collaboration� Interdisciplinary Teams� Human Factors Analysis and

Design� Aligned Financial Incentives

� Physicians� Hospitals� Insurers / Employers

Cultural

Change

Educational

Change

How Do You Create a HealthSystem?

� Information Systems

� Rapid Adoption of Best Practices� Not 17 years from research to practice

� Acceptance of practice guidelines &clinical pathways as a means to reducevariation and improve quality

� Evidence Based Practice

� Data Driven Outcomes Analysis

Cultural

Change

Educational

Change

Key Points

� Aims� Rules

Institute of Medicine, Crossing the Quality Chasm, National Academy Press, 2001

Aims for the 21st-CenturyHealth Care System

� Safe – avoiding injuries to patients from the carethat is intended to help them.

� Effective – providing services based on scientificknowledge to all who could benefit and refrainingfrom providing services to those not likely tobenefit (avoiding underuse and overuse,respectively).

� Patient-centered – providing care that isrespectful of and responsive to individual patientpreferences, needs, and values and ensuring thatpatient values guide all clinical decisions.

Institute of Medicine, Crossing the Quality Chasm, National Academy Press, 2001

Aims for the 21st-CenturyHealth Care System

� Timely – reducing waits and sometimes harmfuldelays for both those who receive and those whogive care.

� Efficient – avoiding waste, including waste ofequipment, supplies, ideas, and energy.

� Equitable – providing care that does not vary inquality because of personal characteristics such asgender, ethnicity, geographic location, and socio-economic status.

Institute of Medicine, Crossing the Quality Chasm, National Academy Press, 2001

Ten Rules� Care based on continuous healing relationships

Patients should receive care whenever they need itand in many forms, not just face-to-face visits.

� Customization based on patient need and values

� The system of care should be designed to meetthe most common types of needs.

� Have the capability to respond to individualpatient choices and preferences

Institute of Medicine, Crossing the Quality Chasm, National Academy Press, 2001

Ten Rules

� The patient as the source of control. Patients shouldbe given the necessary information and the opportunityto exercise the degree of control they choose overhealth care decisions that affect them.

� Shared knowledge and the free flow of information.

� Patients should have unfettered access to their ownmedical information and to clinical knowledge

� Clinicians and patients should communicateeffectively and share information

Institute of Medicine, Crossing the Quality Chasm, National Academy Press, 2001

Ten Rules� Evidence-based decision making.

� Patients should receive care based on the bestavailable scientific knowledge

� Care should not vary illogically from clinicianto clinician or from place to place.

� Safety as a system property. Reducing risk andensuring safety require greater attention to systemsthat help prevent and mitigate errors.

Institute of Medicine, Crossing the Quality Chasm, National Academy Press, 2001

Ten Rules� The need for transparency. Make information

available to patients and families allowinginformed decisions selecting health plans,hospitals, or clinical practices, or choosing amongalternative treatments. This should includeinformation describing the system’s performanceon safety, evidenced-based practice, and patientsatisfaction.

� Anticipation of needs. The health system shouldanticipate patient needs, rather than simplyreacting to events.

Institute of Medicine, Crossing the Quality Chasm, National Academy Press, 2001

Ten Rules� Continuous decrease in waste. The health

system should not waste resources or patient time.

� Cooperation among clinicians. Clinicians andinstitutions should actively collaborate andcommunicate.

Institute of Medicine, Crossing the Quality Chasm, National Academy Press, 2001

Grand Canyon

Health Care in the Future:Systems Promoting Quality & Efficiency

Crossing the Quality Chasm:A Systems Approach

Richard J. Schuster, MD, MMMBoonshoft Chair and Director

Health Systems ManagementWright State University