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Tom Peters’ Health ( care ) Excellence ! Part I Leaders in Healthcare/Dubai/22January2006. Slides at … tompeters.com. Part I: Healthcare “Manifesto” Part II: Gettin g It Done !.
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Tom Peters’Health(care) Excellence!Part ILeaders in Healthcare/Dubai/22January2006
Health(care): Seven Main Messages1. Quality (Error reduction/ Evidence-based Medicine)2. “Healthcare” vs. “Health” (Wellness + Prevention)3. “Models of Excellence” available4. Life sciences (“Singularity”)5. Dubai as global/unique/“insanely great” “Center of Excellence”6. Avian flu7. Africa
TP’s Healing & Wellness Manifesto2006(1) Acute-care facilities are “killing fields.”(WE KNOW WHAT TO DO.)(2) Shift the “community” focus 90 degrees (not 180, but not 25) from “fix it” to “prevent it.” (WE KNOW WHAT TO DO.)(3) There are three primary aims for “all this”: Wellness-Healing-Health. (WE KNOW WHAT TO DO.)(4) I’m mad as hell and I’m not going to take it anymore. (I KNOW WHAT TO DO.)
Tom’s Rant2006 • Hospital “quality control,” at least in the U.S.A., is a bad, bad joke: Depending on whose stats you believe, hospitals kill 100,000 or so of us a year—and wound many times that number.Finally, “they” are “getting around to” dealing with the issue. Well, thanks. And what is it we’ve been buying for our Trillion or so bucks a year? The fix is eminently do-able … which makes the condition even more intolerable. (“Disgrace” is far too kind a label for the “condition.” Who’s to blame? Just about everybody, starting with the docs who consider oversight from anyone other than fellow clan members to be unacceptable.) • 2.The “system”—training, docs, insurance incentives, “culture,” “patients” themselves—is hopelessly-mindlessly-insanely (as I see it) skewed toward fixing things (e.g. me) that are broken—not preventing the problem in the first place and providing the Maintenance Tools necessary for a healthy lifestyle.Sure, bio-medicine will soon allow us to understand and deal with individual genetic pre-dispositions. (And hooray!) But take it from this 63-year old, decades of physical and psychological self-abuse can literally be reversedin relatively short order by an encompassing approach to life that can only be described as a “Passion for Wellness (and Well-being).” Patients—like me—are catching on in record numbers; but “the system” is highly resistant. (Again, the doctors are among the biggest sinners—no surprise, following years of acculturation as the “man-with-the-white-coat-who-will-now-miraculously-dispense-fix it-pills-and-surgical-incisions-for-you-the-unwashed.” (Come to think of it, maybe I’ll start wearing a White Coat to my doctor’s office—after all, I am the Professional-in-Charge when it comes to my Body & Soul. Right?)
“When I climb Mount Rainier I face less risk of death than I’ll face on the operating table.”—Don Berwick, “Six Keys to Safer Hospitals: A Set of Simple Precautions Could Prevent 100,000 Needless Deaths Every Year,” Newsweek (1212.2005)
CDC 1998: 90,000 killed and 2,000,000 injuredfrom hospital-caused drug errors & infections
HealthGrades/Denver: 195,000hospital deaths per year in the U.S., 2000-2002 = 390 full jumbos/747s in the drink per year.Comments: “This should give you pause when you go to the hospital.”—Dr. Kenneth Kizer, National Quality Forum.“There is little evidence that patient safety has improved in the last five years.”—Dr. Samantha CollierSource: Boston Globe/07.27.04
1,000,000“serious medication errors per year” … “illegible handwriting, misplaced decimal points, and missed drug interactions and allergies.”Source: Wall Street Journal/Institute of Medicine
YE GADS!New England Journal of Medicine/ Harvard Medical Practice Study: 4% error rate (1 of 4 negligence). “Subsequent investigations around the country have confirmed the ubiquity of error.” “In one small study of how clinicians perform when patients have a sudden cardiac arrest, 27 of 30 clinicians made an error in using the defibrillator.” Mistakes in administering drugs (1995 study) “average once every hospital admission.” “Lucian Leape, medicine’s leading expert on error, points out that many other industries—whether the task is manufacturing semiconductors or serving customers at the Ritz Carlton—simply wouldn’t countenance error rates like those in hospitals.”—Complications, Atul Gawande
RAND (1998): 50%, appropriate preventive care. 60%, recommended treatment, per medical studies, for chronic conditions. 20% chronic care treatment that is wrong. 30% acute care treatment that is wrong.
“In a disturbing 1991 study, 110 nurses of varying experience levels took a written test of their ability to calculate medication doses. Eight out of 10 made calculation mistakes at least 10% of the time, while four out of 10 made mistakes 30% of the time.”Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson
20%: not get prescriptions filled50%: use meds inconsistentlySource: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation
“In health care,geography is destiny.”Source: Dartmouth Medical School 1996 report
Geography Is Destiny“Often all one must do to acquire a disease is to enter a country where a disease is recognized—leaving the country will either curethe malady or turn it into something else.… Blood pressure considered treatably high in the United States might be considered normal in England; and the low blood pressure treated with 85 drugs as well as hydrotherapy and spa treatments in Germany would entitle its sufferer to lower life insurance rates in the United States.”– Lynn Payer, Medicine & Culture
“A healthcare delivery system characterized by idiosyncratic and often ill-informed judgments must be restructured according to evidence-based medical practice.”Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson
“Without being disrespectful, I consider the U.S. healthcare delivery system the largest cottage industry in the world.There are virtually no performance measurements and no standards.Trying to measure performance … is the next revolution in healthcare.”Richard Huber, former CEO, Aetna
“Practice variation is not caused by ‘bad’ or ‘ignorant’ doctors. Rather, it is a natural consequence of a system that systematically tracks neither its processes nor its outcomes, preferring to presume that good facilities, good intentions and good training lead automatically to good results. Providers remain more comfortable with the habits of a guild, where each craftsman trusts his fellows, than with the demands of the information age.”Michael Millenson, Demanding Medical Excellence
“As unsettling as the prevalence of inappropriate care is the enormous amount of what can only be called ignorant care.A surprising 85% of everyday medical treatments have never been scientifically validated.… For instance, when family practitioners in Washington State were queried about treating a simple urinary tract infection, 82 physicians came up with an extraordinary 137 strategies.”Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson
“Most physicians believe that diagnosis can’t be reduced to a set of generalizations—to a ‘cookbook.’ … How often does my intuition lead me astray?The radical implication of the Swedish study is that the individualized, intuitive approach that lies at the center of modern medicine is flawed—it causes more mistakes than it prevents.”—Atul Gawande, Complications
Deep Blue Redux*: 2,240 EKGs … 1,120 heart attacks. Hans Ohlin (50 yr old chief of coronary care, Univ of Lund/SW) : 620. Lars Edenbrandt’s software: 738.*Only this time it matters!
Dr Larry Weed/POMR (“problem-oriented medical record”)/Etc: “It’s impossible to keep up with the avalanche of knowledge. Therefore it’s essential to use a valid diagnostic-decision aid like Larry’s” —Neil de Crescenzo, VP Global Healthcare/IBM Consulting“There is no other profession that tries to operate in the fashion we do. We go on hallucinating about what we can do.”—Dr Charles Burger (using Weed’s software for 20 years)
PARADOX:Many, many formal case reviews … failure to systematically/ systemically/ statistically look at and act on evidence.Source: Complications, Atul Gawande
Leapfrog Group:CPOE/Computerized Physician Order Entry*ICU staffing by trained intensivists**EHR/Evidence-based Hospital Referral***Source: HealthLeaders
The Benefits of …FOCUSED EXCELLENCE Shouldice/Hernia Repair: 30-45 min, 1% recurrence. Avg: 90 min, 10%-15% recurrence.Source: Complications, Atul Gawande
About Time!100,000 Lives Campaign**Don Berwick/Institute for Healthcare Improvement
Hospitals Pay AppropriateAttention To Medical ErrorsYes ………………………………. 1%Aware and Trying Hard ……... 8%Aware But Tepid Response … 22%No ………………………………... 25%An Inexcusable Tragedy …….. 44%Source: 12.2005 Poll/tompeters.com
“Some grocery stores have better technology than our hospitals and clinics.”—Tommy Thompson, HHS SecretarySource: Special Report on technology in healthcare, U.S. News & World Report (07.04)
Computerized Physician Order Entry/CPOE:5%of U.S. hospitalssource: HealthLeaders/06.02
“Our entire facility is digital. No paper, no film, no medical records. Nothing. And it’s all integrated—from the lab to X-ray to records to physician order entry. Patients don’t have to wait for anything. The information from the physician’s office is in registration and vice versa. The referring physician is immediately sent an email telling him his patient has shown up. … It’s wireless in-house. We have 800 notebook computers that are wireless. Physicians can walk around with a computer that’s pre-programmed. If the physician wants, we’ll go out and wire their house so they can sit on the couch and connect to the network. They can review a chart from 100 miles away.” —David Veillette, CEO, Indiana Heart Hospital (HealthLeaders/12.2002)
“Sanitary revolution”: mortality in major citiesdown55%between 1850 and 1915Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation
“Gwen [former healthcare exec] has wonderful health insurance and an abundance of healthcare. What Gwen does not have is health. And there is nothing our health system can do to give it to her.” “The battle cry is always health, but in fact the struggle has always been over healthcare.” “For all its inspiring, high-tech cures, medicine is just not very effective at curing our era’s major killers.” “Medicine doesn’t do much [for] chronic disease.” “When the most common killers of our era are mostly incurable and our preventive treatments pretty feeble, you have to wonder about medical care as a whole.” “There is a widely held view that medical care contributes little to health.”(John Bunker/Journal of the Royal College of Physicians)Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation
Smoking, drinking, exercise, diet: 40% of deathsSource: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation
“Our mistake is not that we value medical care—but that we have misunderstood what it can and cannot do.”Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation
“Curve Shifting”Source: Tom Farley & Deborah Cohen,Prescription for a Healthy Nation
“Bump into factor”: Extra-size portions, eat more. Higher % shelf space snacks, more obesity. More liquor stores, more crime. High vs low fat: Japanese who emigrate to U.S. suffer 3X increase in heart disease.Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation
Context Change: The Most Powerful Force (??)Wastebaskets: Japan v U.S.; Christchurch NZ v Sydney AUS**“Broken windows”
+10: Sardinians, Adventists, OkinawansDon’t smoke. Put family first. Be active every day. Keep socially engaged. Eat fruits, vegetables, whole grains.[Other: nuts, red wine, pecorino cheese, small portions.]Source: National Geographic (National Institute on Aging), November 2005
“The ‘curative model’ narrowly focuses on the goal of cure. … From many quarters comes evidence that the view of health should be expanded to encompass mental, social and spiritual well-being.”Institute for the Future
