CROSSING THE QUALITY CHASM: HEALTH CARE FOR THE 21 ST CENTURY

CROSSING THE QUALITY CHASM: HEALTH CARE FOR THE 21 ST CENTURY May 10, 2002 Donald M. Berwick, M.D. President & CEO Institute for Healthcare Improvement

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 21 st Century Chassis

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.

Roundtable s Categories Overuse (of procedures that cannot help) Underuse (of procedures that can help) Misuse (errors of execution)

Health Care Examples Overuse 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

Health Care Examples Underuse 50% of elderly fail to receive pneumococcal vaccine 50% of heart attack victims fail to receive beta-blockers

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

IOM Roundtable The Foundation 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

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.

Total lives lost per year 100,000 10,000 1,000 100 10 1 How Hazardous Is Health Care? DANGEROUS (>1/1000) HealthCare Mountain Climbing Bungee Jumping (Leape) REGULATED Driving Chemical Manufacturing Chartered Flights ULTRA-SAFE (<1/100K) Scheduled Airlines European Railroads Nuclear Power 1 10 100 1,000 10,000 100,000 1,000,000 10,000,000 Number of encounters for each fatality

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.

Quality is a system property

The First Law of Improvement Every system is perfectly designed to achieve exactly the results it gets.

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

The Chain of Effect in Improving Health Care Quality Patient and Community Experience Aims (safe, effective, patient- centered, timely, efficient, equitable) Micro-system Process Simple rules/design Concepts (knowledge (knowledge-based, customized, cooperative) Organizational Context Facilitator of Processes Design Concepts (HR, IT, finance, leadership) Environmental Context Facilitator of Facilitators Design Concepts (financing, regulation, accreditation, education)

The Chain of Effect in Improving Health Care Quality Patient and Community Micro-system Experience Process Aims (safe, effective, patient- centered, timely, efficient, equitable) Simple rules/design Concepts (knowledge (knowledge-based, customized, cooperative) Organizational Context Facilitator of Processes Design Concepts (HR, IT, finance, leadership) Environmental Context Facilitator of Facilitators Design Concepts (financing, regulation, accreditation, education)

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.

Aims Safety Effectiveness Patient-centeredness Timeliness Efficiency Equity

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

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

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

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

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

Three Guiding Frameworks Knowledge-based Patient-centered System-minded

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

New Rules for Health Care Safety as a system property The need for transparency Anticipation of needs Continuous decrease in waste Cooperation

Breakthrough Series (6 to 13 month time frame) Participants Select Topic Planning Group Develop Framework & Changes Pre-work LS 1 P A S E-mail P D A D S LS 2 Supports Visits LS 3 Congress, Guides, Publication s, etc. Phone Assessments Senior Leader Reports

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: GHC Contact: David K. McCulloch, MD, FRCP Email: McCulloch.d@GHC.org

Results from Effective Improvement Efforts. Health Resources and Services Administration (HRSA) Chronic Disease Care Improvement Collaboratives

10 9.19 Phase 2 Diabetes I and II Average HbA1c's DC1_Avg DC2_Avg 9 Average 8 Goal 8.54 8.10 8.35 7 6 A-99 J-99 O-99 J-00 A-00 J-00 O-00 J-01 A-01 J-01 O-01 Reporting Month J-02 A-02 J-02 O-02 J-03 A-03 J-03 O-03 J-04 Number of Patients 45000 40000 35000 Phase 2 Diabetes I and II - Total Registry Size DC1 Total DC2 Total Both Collabs 38,410 30000 25000 20000 15000 10000 24,846 13,564 5000 0 A-99 J-99 O-99 J-00 A-00 J-00 O-00 J-01 A-01 J-01 O-01 Reporting Month J-02 A-02 J-02 O-02 J-03 A-03 J-03 O-03 J-04

Phase 2 Diabetes I and II Average Percent of Patients with Two HbA1c's (at Least Three Months Apart) 100 90 Goal DC1_Avg DC2_Avg 80 70 60 Percent 50 40 30 20 10 26.6% 18.5% 42.4% 39.7% 0 A-99 J-99 O-99 J-00 A-00 J-00 O-00 J-01 A-01 J-01 O-01 J-02 A-02 J-02 O-02 J-03 A-03 J-03 O-03 J-04 Reporting Month October Data: 38,410 patients in diabetes registries. See previous slide for details about registry growth

100 90 80 70 60 50 40 30 20 10 0 Goal 37% CVD Collaborative 1 Average Percent of Patients with Two BP's in Last 12 Months 63% M-01 J-01 J-01 A-01 S-01 O-01 N-01 D-01 J-02 F-02 M-02 A-02 M-02 J-02 J-02 A-02 S-02 O-02 N-02 D-02 J-03 F-03 M-03 A-03 CVD_DM3 Collaborative - Total Number of CVD Patients in Registries 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 4720 LS1 M-01 J-01 J-01 A-01 S-01 O-01 N-01 D-01 J-02 F-02 M-02 A-02 M-02 J-02 J-02 A-02 S-02 O-02 N-02 D-02 J-03 F-03 M-03 A-03

100 90 80 70 60 50 40 30 20 10 0 Goal CVD Collaborative 1 Average Percent of Patients with BP < 140/90 45% M-01 J-01 J-01 A-01 S-01 O-01 N-01 D-01 J-02 F-02 M-02 A-02 M-02 J-02 J-02 A-02 S-02 O-02 N-02 D-02 J-03 F-03 M-03 A-03 CVD_DM3 Collaborative - Total Number of CVD Patients in Registries 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 4720 LS1 M-01 J-01 J-01 A-01 S-01 O-01 N-01 D-01 J-02 F-02 M-02 A-02 M-02 J-02 J-02 A-02 S-02 O-02 N-02 D-02 J-03 F-03 M-03 A-03

10 Diabetes Collaborative 3 Average HbA1c's 9 8 7 8.6 Goal 8.2 6 M-01 J-01 J-01 A-01 S-01 O-01 N-01 D-01 J-02 F-02 M-02 A-02 M-02 J-02 J-02 A-02 S-02 O-02 N-02 D-02 J-03 F-03 M-03 A-03 Number of Patients 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 M-01 J-01 CVD_DM3 Collaborative - Total Number of DM Patients in Registries 8,159 J-01 A-01 S-01 O-01 N-01 D-01 J-02 F-02 M-02 A-02 M-02 Reporting Month J-02 J-02 A-02 S-02 O-02 N-02 D-02 J-03 F-03 M-03 A-03

Results from Effective Improvement Efforts. Veterans Health Administration Immunizations Treatment of Heart Attacks

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; 2/3 vaccinated 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.

Pneumococcal Vaccination Rates 100 Percent Vaccinated 80 60 40 20 0 FY 95 4th Qtr 97 4th Qtr 98 Cum 99 Cum 00 VHA Healthy People 2000 Iowa 99* * Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz

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...

Quality: Influenza Vaccination Rates 100 Annual Influenza Vaccine 80 60 40 20 0 FY 95 4th Qtr 97 4th Qtr 98 Cum 99 Cum 00 VHA Healthy People 2000 Iowa 99

Beta Blocker following AMI in VHA Medical Centers 100 Percent Eligible Pations 80 60 40 20 0 Improved Provision of Beta Blockers Has Saved Over 500 Lives since 1996 FY 95 4th Qtr 97 4th Qtr 98 Cum 99 Cum 00 VHA NCQA AHCPR (NJ) Non-Govt AHCPR: Soumerai et al. JAMA 1997;277(2):115-21 Non-Govt: Krumholz HM et al. Ann Int Med 1999;131(9):648-54

VA Results Compared to Others : Treating Heart Attacks 100 80 Percent Eligible Pts 60 40 20 VA AMC NT 0 ASA b-blk ACE Allison JJ et al, JAMA 2000;284:1256-1262

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)

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

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

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

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

What Congress Can Do Commission the development of standards for health care Information Technology Launch a national moon shot to develop a new medical record, available to all

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

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)