Healthcare ’ s Challenging Trio: Quality, Safety and Complexity

1. Healthcare’s Challenging Trio: Quality, Safety and Complexity John L. Haughom, MD March 2014

2. Healthcare: The Way It Should Be • Section One– Forces Driving Transformation • Chapter One – Forces Defining and Shaping the Current State of U.S. Healthcare • Chapter Two – Present and Future Challenges Facing U.S. Healthcare • Section Two– Laying the Foundation for Improvement and Sustainable Change • What will it take to successfully ride the transformational wave? • Section Three– Looking into the Future • What will it take to successfully ride the transformational wave?

3. Seminal IOM Publications November 1, 1999: The Institute of Medicine Committee on Quality of Health Care in America announces its first report: To Err is Human: Building a Safer Health System Health care in the United States is not as safe as it should be and can be. “ 44,000 to 98,000 deaths annually!

4. Patient Safety: A known problem… Prevalence of adverse events is a known problem…Given the existence of undesired circumstances, there is no insulation against error! • 1964 – Schimmel et. al. (Ann. Int. Med.) • 20% of University Hospital admissions result in injury with 20% fatality rate • 1981 – Steel et. al. (NEJM) • 36% of Teaching Hospital admissions result in injury with 25% of such injuries being serious • 1989 – Gopher et. al. (Proc. Human Factors Society) • 1.7 errors/day/patient with 29% that are potentially serious • See Table for more studies…

5. Reaching the Public’s Attention

6. Adverse Events: Lethal & Expensive Medical errors are costly in terms ofhuman suffering and in real dollar terms • Adverse events are the8th leadingcause of death • Total cost of preventable adverse events =$19-29 billion annually • Cost of preventable medication errors = $16.4 billion annually • Cost of preventable readmissions =$17 billion annually Medical Errors estimate is midrange of IOM figures of 44,000-98,000

7. And the Problem Extends to the Outpatient World… For Every: 1000 patients coming in for outpatient care1 1000 patients who are taking a prescription drug2 1000 prescriptions written3 1000 women with a marginally abnormal mammogram4 1000 referrals5 1000 patients who qualified for secondary prevention of high cholesterol6 There Appear to Be: 14 patients with life-threatening or serious ADEs 90 who seek medical attention because of drug complications 40 with significant medical errors 360 who will not receive appropriate follow-up care 250 referring physicians who have not received follow-up information in 4 weeks 380 will not have a LDL-C, within 3 years, on record (1) Gandhi T et al. Adverse drug events in primary care, under review, NEJM. (2) Gandhi T et al. Drug complications in outpatient settings J Gen Int Med 2000. (3) Gandhi TK et al. Adverse drug events in primary care, under review, NEJM. (4) Poon E, et. al. Failure to follow mammographers recommendations on marginally abnormal mammograms: determination of associated factors [abstract]. J Gen Intern Med 2001. (5) Gandhi T et. al. Communication breakdown in the outpatient referral process J Gen Intern Med 2000. (6) Maviglia SM, et.al. Using an electronic medical record to identify opportunities to improve compliance with cholesterol guidelines J Gen Intern Med 2001

8. Seminal IOM Publications March 1, 2001: The Institute of Medicine Committee on Quality of Health Care in America announces its second report: Crossing the Quality Chasm: A New Health System for the 21st Century Between the health care we have and the care we could have lies not just a gap, but a chasm. “

9. How Good is American Healthcare? • Only50% of Americans receive recommended preventive care • Patients with acute illness: • 70% received recommended treatments • 30% received contraindicated treatments • Patients with chronic illness: • 60% received recommended treatments • 20% received contraindicated treatments Schuster MA, McGlynn EA, Brook RH. How good is the quality of healthcare in the United States? MillbankQuarterly.

10. Types of Quality Problems • Several types of quality problems in healthcare have been documented by the IOM: • Variation in services • Underuse of services • Overuse of services • Misuse of services • Disparities in quality

11. How Good is American Health Care? Major teaching Minor teaching Nonteaching 100 90 80 91.2 86.4 70 81.4 60 % "ideal patients" receiving 63.7 50 60.0 58.9 58.0 55.5 55.2 40 48.8 30 40.3 36.4 20 10 0 Aspirin ACE inhibitors Beta-blockers Reperfusion Medication Allison JJ et al. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI. JAMA 2000; 284(10):1256-62 (Sep 13)

12. Practice Variation in the U.S. The Dartmouth Atlas of Healthcare is available at: http://www.dartmouthatlas.org

13. 55.0 100.0 50.0 80.0 45.0 40.0 60.0 35.0 % Admitted to ICU % Receiving Beta Blockers 30.0 40.0 25.0 20.0 20.0 15.0 10.0 0.0 Practice Variation in the U.S. Red Dots Indicate HRRs Served by U.S. News 50 Best Hospitals for Cardiovascular Care Red Dots Indicate HRRs Served by U.S. News 50 Best Hospitals for Geriatric Care The Dartmouth Atlas of Healthcare is available at: http://www.dartmouthatlas.org

14. Unwarranted & Warranted Sources of Practice Variation Unwarranted Warranted • Clinical differences among patients • Variable risk attitudes • Variable preferences among health outcomes • Variable willingness to make time trade-offs • Variable tolerance for decision responsibility • Variable coping styles • Variable access to resources and expertise • Insufficient research • Unfounded enthusiasm • Parochial perspectives • Faulty interpretation • Poor information flow • Poor communication • Role confusion Knowledge-Based Patient-Centered

15. Extensive research has made it veryclear… …inappropriate variation… …harmspatients, leads to poorquality, and results inwaste…

16. Reasons for Practice Variation • Inadequate levels of safety and inconsistent quality result from clinical uncertaintywhich in turn results from: • An increasingly complex healthcare environment • Rapidly exploding medical knowledge • Lack of valid clinical knowledge (poor evidence) • Over reliance on subjective judgment

17. Human Limitations Miller, G.A. The magic number isseven, plus or minus two: limits on our capacity for processing information. • Psychological Review 1956; 63(2):81-97

18. Medical Progress Over Half a Century Care circa 1960… Care circa 2011… The complexity of modern American medicine exceeds the capacity of the unaided human mind. - David Eddy, MD, PhD “

19. The Evidence Base is Expanding 12000 12000 First RCT published: 1952 First five years (66-70): 1% of all RCTs published from 1966 to 1995 Last five years (91-95): 49% of all RCTs published from 1966-1995 10000 10000 8000 8000 Number of RCTs 6000 6000 4000 4000 2000 2000 0 0 1991 1992 1971 1993 1968 1970 1972 1973 1982 1969 1974 1979 1986 1988 1989 1990 1966 1976 1981 1984 1985 1987 1978 1980 1983 1994 1995 1975 1977 1967 Year

20. Rapidly Exploding Medical Knowledge • In 2004, the U.S. National Library of Medicine added • almost 11,000new articles per week to its on-line archives • That represented about 40% of all articles published, • world-wide, in biomedical and clinical journals. • (1,500 – 3,500 completed references per day, 5 days a week) • To maintain current knowledge, a general internist would need to read: • 20 articles per day, • 365 days of the year This is an impossible task… Current estimates are this has grown to 1 article every 1.29 minutes in 2009!

21. The Science of Medicine • Of what we do in routine medical practice, what proportion has a basis (for best practice) in published scientific research? • Williamson (1979): < 10% • OTA (1985): 10- 20% • OMAR (1990): < 20% • The rest is opinion • That doesn't mean that it's wrong – much of it probably works • But, it may not represent the best patient care Williamson et al. Medical Practice Information Demonstration Project: Final Report. Office of the Asst. Secretary of Health, DHEW, Contract #282-77-0068GS. Baltimore, MD: Policy Research Inc., 1979). Institute of Medicine. Assessing Medical Technologies. Washington, D.C.: National Academy Press, 1985:5. Ferguson JH. Forward. Research on the delivery of medical care using hospital firms. Proceedings of a workshop. April 30 and May 1, 1990, Bethesda, Maryland. Med Care 1991; 29(7 Suppl):JS1-2 (July).

22. Variation in Expert Opinion Experts’ estimates of the chance of a spontaneous rupture of a silicone breast implant 0% 0.2% 0.5% 1% 1% 1% 1.5% 1.5% 2% 3% 3% 4% 5% 5% 5% 5% 5% 5% 5% 6% 6% 6% 8% 10% 10% 10% 10% 13% 13% 15% 15% 18% 20% 20% 20% 25% 25% 25% 30% 30% 40% 50% 50% 50% 62% 70% 73% 75% 75% 75% 75% 80% 80% 80% 80% 80% 80% 100% Courtesy of David Eddy, MD, PhD

23. 0 20 40 60 100 80 Variation in Expert Opinion The practitioners, all experts in the field, were then asked to write down their beliefs about the probability of the outcome ... "that would largely determine his or her belief about the proper use of the health practice, and the consequent recommendation to a patient." “ Eddy. A Manual for Assessing Health Practices & Designing Practice Policies: The Explicit Approach. Philadelphia, PA: The American College of Physicians, 1992; pg. 14.

24. You can find a physician who honestly believes (and will testify in court to) anything you want. • - David Eddy, MD “

25. Complexity Science • Complexity science is the study of complex adaptive systems, the relationships within them, how they are sustained, how they self-organize, and how outcomes result. • Complexity science is made up of a variety of theories and concepts. • It is a multidisciplinary field involving many different disciplines including biologists, mathematicians, anthropologists, economists, sociologists, management theorists, computer scientists, and many others.

26. Viewing Healthcare as a Complex Adaptive System • Complexity science is the study of complex adaptive systems, the relationships within them, how they are sustained, how they self-organize, and how outcomes result. • Complexity science is made up of a variety of theories and concepts. • It is a multidisciplinary field involving many different disciplines including biologists, mathematicians, anthropologists, economists, sociologists, management theorists, computer scientists, and many others. In complex situations, A + B ≠ C

27. Characteristics of Complex Adaptive Systems

28. Comparison of Leadership Styles

29. The Need for a Better System Insanity is doing the same thing over and over again and expecting a different result. – Albert Einstein “ “ Every system is perfectly designedto produce the resultsthat it does achieve. – Paul Bataldan, MD

30. In Summary… • The levels ofqualityand harm in modern clinical care are not acceptable • Inadequate levels of safety and inconsistent quality result largely from clinical uncertainty • Clinical uncertainty results from an increasingly complex healthcare environment, a rapidly expanding healthcare knowledge base, a lack of valid clinical knowledge for much of what we do, and an over reliance on expert opinion • Extensive research has made itvery clear that inappropriate variationharms patients, leads topoor quality, and results in high levels of waste • Healthcare can be viewed as acomplex adaptive system, and going forward complexity science will play an increasingly large role in the design of newcare delivery systemsand new care models

31. Healthcare: The Way It Should Be • Section One– Forces Driving Transformation • Chapter One – Forces Defining and Shaping the Current State of U.S. Healthcare • Chapter Two – Present and Future Challenges Facing U.S. Healthcare • Section Two– Laying the Foundation for Improvement and Sustainable Change • What will it take to successfully ride the transformational wave? • Section Three– Looking into the Future • What will it take to successfully ride the transformational wave?

32. Questions, discussion, etc… ? ? ? For Information Contact: John.Haughom@healthcatalyst.com Upcoming Webinars – register at www.healthcatalyst.com Placeholder, enter yourown text here The Top Trends that Matter in 2014 By Bobbi Brown, Vice President; Dan Burton, CEO; and Paul Horstmeier, Senior Vice President of Health Catalyst March 19th | 1-2 PM ET Transforming Healthcare: Data Alone is Not Sufficient By John Kenagy, MD, Physician Executive March 27th | 1-2 PM ET