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Improving and Reforming Health
Care: Rediscovering the Basics
Steven Levenson, MD, CMD
September 21, 2010
1
“Reform”

“Reform” is in the air


But just what does “reform” aim to fix?
Reform


Improve by alteration or correction of errors or
defects and put into a better condition
Make changes for improvement in order to correct
abuses

Source:
http://www.google.com/search?hl=en&q=define%3A+refo
rm&btnG=Google+Search&aq=f&oq=
2
Reform Hurdles

“AMA to White House: Don't Dictate
Care” [3/9/09]


http://www.healthleadersmedia.com/content/229394
/topic/WS_HLM2_HR/AMA-to-White-House-DontDictate-Care.html
“Any attempts by federal government to
use evidence-based medicine to dictate
how physicians provide individualized
care would be a deal breaker”
3
Reform Hurdles


It isn’t just patients and doctors
Health care reflects and impacts all major
social institutions


Education, government, economics / commerce,
families, law
Oversight, attempts to change performance,
enforcement all reflect and influence health
care

Reflect beliefs and methods; for example, how to
investigate, draw conclusions, define truth,
identify correct actions, attribute cause and effect
4
Who Can Reform What?



Limitations of legislatures and political processes in
bringing about true reform
Many of us are having trouble changing our thinking
and actions
Non-therapeutic substitution

“In American culture, prescriptions and procedures have become
surrogates for real health care and real dialogue,” Dr. Newman
said. “We need doctors and patients to conceive of medicine and
health in a totally different way than they have been taught in the
last 20 to 30 years.”

Source:
http://www.nytimes.com/2009/03/03/health/03well.html?scp=14&sq=
health%20care&st=cse
5
Reform Efforts


How much do current efforts really
being about meaningful change and set
appropriate expectations?
Not surprisingly, current approaches are




Often uncoordinated
Sometimes self-contradictory
Don’t consistently result in good care
May not define issues correctly or identify
root causes
6
Reform: Prerequisites

To reform something effectively, it helps to
understand what we are trying to improve

Clear issue statement



Causes of imperfections and problems
What it should look like when done




Nature and components
What should be changed or strengthened
Options for changing things
Obstacles to implementing reform
Options for overcoming obstacles
7
Our Subject Matter

What will it take to do this right?






A cohesive strategy and a meaningful plan
Understand and apply biological foundation
Reconsider current improvement and
reform efforts
Challenge the conventional wisdom
Widespread, consistent accountability
Rethink the research agenda
8
Our Subject Matter

What will it take to do this right?

Focus attention on basic care principles
and processes





Promote desired performance and practice
Suppress reductionism and jurisdiction
Reconsider notions of competency and
expertise
Change approaches to assessing and trying
to improve quality
Develop biologically sound reimbursement 9
What Can We Each Do?
10
Solution is Straightforward
11
Mostly Self-Evident
12
Logically Consistent
13
Little Changes Add Up
14
Key Principles
What constitutes biologically
sound care?
15
16
The Three Human Dimensions
PSYCHOSOCIAL
FUNCTIONAL
PHYSICAL
17
Homeostasis

A key biological principle


Adequately functioning organ systems adjust
to compensate for stresses


An organism maintains relative stability through
constant internal adjustment
Including imbalances and impairments
Disease and organ failure may


Cause or exacerbate imbalances
Impair physiological reserve capacity
18
Homeostasis: Water Balance

Maintaining water balance
19
Homeostasis: Blood Sugar

Blood sugar regulation
20
Personal and Psychological
Homeostasis


Similar to physiological homeostasis
Individuals strive for psychological
balance and adequate function


To thrive in personal and social setting
Personal and psychological homeostasis
require adequate physical homeostasis

Example: function and mood may decline
when major medical illness causes physical
instability
21
Health, Illness, and
Impairment

Health can be defined as “a state of complete
physical, mental and social well-being and not
merely the absence of disease or infirmity” World Health Organization (WHO)


http://www.who.int/about/definition/en/print.html
Limits of health care in producing complete
well-being (i.e., health)

However, can have profound effects, for better or
worse
22
Key Biological Principles:
When Things Go Astray

Symptoms and risk factors have causes


Often combined effects of multiple issues
Causes and consequences have various
relationships

Defining those links is crucial to providing
safe, effective, and patient-centered care
23
Biologically Sound Care

“Quality of life” and “quality of care” are
inseparable in all settings


Effective care is based on linking each person’s
physical, functional, and psychosocial causes and
consequences
The essence of “individualized (personcentered) care”


Requires “context” of underlying causes and
consequences
Recognizes that interventions may be beneficial,
inconsequential, or harmful
24
Causes and Consequences
Consequences 
Causes
One
Multiple
One
Multiple
+/+
+ / ++++
++++ / + ++++ / ++++
25
Causes and Consequences



All consequences (e.g., impairments,
symptoms, complications) have causes
Causes and consequences occur in four
major patterns and relationships
Clarify links among causes and
consequences

Basis for providing care in any setting
26
Causes and Consequences
27
28
Causes and Consequences:
Examples

One cause  One consequence (1:1)



Fracture  impaired mobility until fracture
heals
Fatigue  headache for a few hours
One cause  multiple consequences
(1:Multiple)


Altered family processes mood disturbance 
social withdrawal and behavioral symptoms
COPD (advanced)  activity intolerance, altered
breathing patterns, impaired gas exchange, selfcare deficit
29
Causes and Consequences:
Examples

Multiple causes  one impairment
(Multiple:1)

Hydration or depression risks due to


CVA and dementia (neurological), chronic renal
failure (urinary), colitis related to antibiotic use
(gastrointestinal)
Multiple causes  Multiple impairments
(Multiple: Multiple)

[New stroke + diabetes + ischemic heart disease
+ chronic renal failure + medication side effects +
mood disorder]  [impaired mobility + pain +
social withdrawal + altered nutritional status +
risk of altered skin integrity]
30
Linking Causes and
Consequences

Four essential steps before interventions
1) Characterize the disabilities
2) Identify causal impairments
3) Determine specific diseases underlying identified
causal impairments
4) Discover any contributing factors

Hoenig H, Nusbaum N, Brummel-Smith K. Geriatric
rehabilitation: State of the Art. J Am Geriatr Soc
45:1371-1381, 1997
31
32
Biologically Sound Care: Key
Underlying Principles


Impairments may often be prevented or
improved by treating underlying causes
Important to




Identify all causes of impairments, to extent
possible
Determine which ones can be addressed and to
what extent
Choose interventions in the context of the whole
situation, not just one symptom or risk factor
Try to optimize—not undermine—physical
condition
33
Biologically Sound Care: Key
Underlying Principles

Interventions may prevent or correct
physical impairment by





Resolving underlying cause(s)
Improving homoeostatic balance
Maintaining or improving physiological
reserve capacity
Reverse impairments
Lessen severity or help reduce progression
to disability
34
Care in Context

Coordinated and integrated care of
people


Especially those with multiple issues
Consistent with biology because it

Takes each symptom, condition, risk, or
problem in context



Including sequence of events
Identifies proper combinations of cause-specific
and symptomatic interventions
Promotes care that optimizes physical,
functional, and psychosocial homeostasis
35
Care in Context

Fragmented or uncoordinated care

Biologically unsound because it




Approaches issues as distinct entities
Fails to identify root causes
Fails to address causes and consequences in
proper context
May cause new or additional complications
while trying to address issues in isolation
36
Biologically Sound and
Unsound Care

Sound

Care of person with [Condition A + Condition B +
Condition C + Condition D + Condition E]
≠

Unsound

[Care of Condition A] + [Care of Condition B] +
[Care of Condition C] + [Care of Condition D] +
[Care of Condition E]
37
38
Patient History and Context

What are the likely differences in cause,
approach, and context if someone



Gets delirium and then gets anorexia
Gets anorexia and then gets delirium
Has a significant condition change with
change in mental function and anorexia at
the same time
39
Health Care Role
What is the role of health care in
providing biologically sound care?
40
Implications for Care Provision

Key goal of all health care


Effectively integrate interventions and
services related to physical, functional, and
psychosocial dimensions
Key goal of medical care

Help individuals attain and preserve
enough physiological function to enable the
greatest possible personal and
psychosocial function

Within limits of what’s reversible / preventable 41
Reform and Improvement
How and why do these principles
affect efforts to improve health
care?
42
Reform and Improvement

Meaningful efforts to improve and
reform health care must


1) be consistent with, or at least not
contradict, aforementioned key principles
2) promote, or at least not undermine,
adherence to those principles
43
Health Care Reform
Problem Definition and Cause
Identification
44
Essential Support for Reform


Mutual influence between health care and all
other social institutions
Other social institutions and public policy
must



Reflect and respect underlying biology
Understand what they are alleging to try to
improve and reform
Promoting “individualized” care means much
more than just functional and psychosocial
interventions
45
Essential Support for Reform

Less helpful efforts


Promote interventions out of context
Focus on fragments of the care delivery
process


For example, care planning or treatment
Are too focused on artificial distinctions

Such as “medical” and “social” models of care
46
Approach to Health Care
Reform

IF biologically sound care is required in order
to meet key quality attributes



Safe, effective, efficient, timely, equitable, patientcentered
AND only some of the care is biologically
sound
THEN

We must focus on improving the biological
soundness of all care, in all settings
47
Approach to Health Care
Reform



IF the three human dimensions are closely
related
AND health care only partially reflects that
reality
THEN


We must focus on properly integrating and
coordinating services in all settings
We must suppress and reverse excesses of
thinking about “medical” and “social” models
48
Approach to Health Care
Reform



IF human beings have mechanisms to
maintain physical, functional, and
psychosocial stability despite change
AND health care only partially reflects
that reality
THEN

We must ensure that care in all settings
respects and reflects—and does not impair
or damage—those balances
49
Approach to Health Care
Reform



IF biologically sound care provides
treatment in context and as a means to
an end, instead of an end in itself
AND health care only partially reflects
this understanding
THEN

We must try to get care in all settings to be
given in the proper context
50
Approach to Health Care
Reform



IF causes and consequences have
identifiable relationships, and those
links are important to identifying care
AND health care only partially reflects
this understanding
THEN

We must try to get care in all settings to be
based on identifying and linking causes
and connecting causes and consequences 51
Foundation For Subsequent
Reforms

Further tinkering is inadequate because




Resources are limited
Waste is problematic
Results count more than ever
Important to consider reasons for
success or failure of previous efforts
52
Recommendations to Improve &
Reform Health Care: Summary





Reconsider current improvement and
reform efforts
Challenge the conventional wisdom
Vigorously subdue “political
correctness”
Rethink the research agenda
Focus attention on basic care principles
and processes
53
Recommendations to Improve &
Reform Long-Term: Summary




Suppress reductionism and jurisdiction
over care
Reconsider notions of competency and
expertise
Change approaches to assessing and
trying to improve quality
Develop biologically sound
reimbursement
54
Reconsider Current
Improvement and Reform
Efforts
55
Sources of Efforts to Improve
and Reform Health Care

Various sources






Governmental
Industry groups and coalitions
Public and consumer initiatives
Physician initiatives
Insurance initiatives
Non-industry organizations and
associations
56
Types of Efforts Targeting
Reform

Various types







Laws and regulations
Assessment tools
Workforce initiatives
Quality-improvement strategies
Work groups
Campaigns
Consumer initiatives (e.g., “culture
change”)
57
Problems and Solutions

Current reform initiatives



A potpourri of approaches
Still lacks a comprehensive problem
statement and cohesive strategies
Inadequate to just aggregate multiple
“solutions” and reform agendas, e.g.

[Agenda A] + [Idea B] + [Campaign C] +
[Proposal D] + [Notion E]
58
Reform Efforts: Desirable and
Problematic
Desirable Efforts
Problematic Efforts
- Cohesive and compatible
- Fragmented, piecemeal,
uncoordinated, inconsistent,
incompatible
- Arise from thoughtful
discourse
- Based on inadequate
understanding of problems and
underlying causes
- Respect precedent
- Tend to reinvent the wheel
- Biologically sound
- Biologically unsound
- Promote all essential
elements
- Overly complicated; missing
key elements
59
Reform Efforts: Desirable and
Problematic
Desirable Efforts
- Promote full care delivery
process
Problematic Efforts
- Do not emphasize all care
delivery process components
- Emphasize empirical methods - Underemphasize rational
for clinical problem solving
clinical problem solving
- Emphasize good outcomes
- Emphasize good intentions
- Assess both results and
related processes
- Unbalanced emphases
- Valid approaches to
identifying care quality
- Inadequate approaches to
identify care quality
60
Reform Efforts: Desirable and
Problematic
Desirable Efforts
Problematic Efforts
- Focus on underlying care as
well as treating specific
conditions
- Overemphasize treatment of
specific conditions at expense
of underlying concepts
- Promote balanced care and
treatment in “context”
- Promote unbalanced or
superficial care
- Avoid false “medical / social”
model dichotomies
- Unbalanced emphasis on
“medical” or “social” models
- Balanced approaches to
regulatory compliance
- Excessive preoccupation with
regulatory compliance
- Promote vital management
role in effective care
- Downplay or overlook key
management role
61
Strategies: Reconsider Current
Improvement & Reform Efforts



“The chief cause of problems is
solutions” –Eric Sevareid (CBS News
Reporter / Commentator, 1939-1977)
Evaluate compatibility of reform efforts
with key principles
Focus more on defining issues correctly
and identifying root causes

Restrain tendencies to try to “do
something” in vague hope it works
62
63
Challenge the Conventional
Wisdom
64
Challenging the Conventional
Wisdom

Genuine reform and improvement
requires rethinking and undoing much
of the conventional wisdom



Many common practices in health care are
unfounded
Many beliefs about health care are
incorrect or misleading
Current CW often prevails because it
serves diverse agendas
65
Conventional Wisdom: The
Other Side
Conventional Wisdom
Unconventional Viewpoint
- Reformers are above
reproach
- Reformers deserve scrutiny
- Reformers may be blocking
legitimate solutions
- More laws and regulations
are needed
- Laws and regulations need a
biologically sound basis
- All settings need to measure
performance
- Measurement has limits in
improving performance
- Stronger enforcement is
needed
- Accountability needs to be
consistent and evidence-based
66
Conventional Wisdom: The
Other Side
Conventional Wisdom
Unconventional Viewpoint
- More research is needed to
solve these big issues
- Implementation of existing
knowledge is vital
- Interdisciplinary teams are
essential
- IDTs must function properly
and know their limits
- The more care that is given,
the better the quality
- More care may simply be
irrelevant or hazardous
- Quality measurement
measures care quality
- Relevance of some current
quality measurement is unclear
67
Strategy: Challenge the
Conventional Wisdom

Seek and use available evidence to
assess conventional wisdom


Regardless of its source
Identify and contest common practices
that have questionable basis

Including undesirable de facto “standards”
of care, despite incompatibility with
evidence
68
Conventional Wisdom and
Accountability

Major obstacles to health care reform
today include





Insurance companies
Food and Drug Administration (FDA)
Drug companies
Doctors
To some extent, these and other
challenges are pertinent
69
Unconventional Wisdom

Major obstacles to health care reform
today include


Failures of accountability
The “Defensive Triad”




Rationalization
Projection
Denial
At all levels, in all settings
70
The Defensive Front

Rationalization




Projection


I had to do it because. . .
I had to do it this way (instead of another way) because. . .
It was beyond my control / I couldn’t help it
It’s someone else’s problem, not mine
Denial



I don’t have a problem
I didn’t do it
I am not responsible for what happened
71
Defenses and the Brain




Defenses are the brain’s way of protecting us
from too much anxiety
“I know the answer before I even hear the
question”
More automatic, little cortical involvement
Defy reasoning, logic, or “common sense”

Reference: Jacobs C. Management Rewired. New
York:Penguin Group, 2009.
72
Accountability: The
Unconventional Wisdom


Definition: answerable for actions and
decisions
The means of attaining responsibility

By applying basic principles and tactics to
attain desired performance
73
Responsibility

Definitions





Having an obligation to do something, or having
control over or care for someone
Morally accountable for one's behavior
Capable of being trusted
[Of a job or position] Involving important duties or
decisions or control over others
[Responsible to] Having to report to and be
answerable to
74
Accountability and Alignment
75
Basic Principles: Different
Groups, Different Approaches
#3
#2
#1
#4
10%
30%
50%
10%
76
Different Schools of Amateur
Management






Can’t everyone just get along?
They are adults
They have a license
Hard to find good people
Where’s their critical thinking?
You can’t change personalities
77
78
Defending Against Defenses

Effective manager / leader




Accepts personal responsibility
Uses defenses / makes or accepts excuses < 5%
of the time
Demands / fosters accountability
Ineffective manager / leader




Denies personal responsibility
Makes / accepts excuses much of the time
Rationalizes other people’s poor performance
Much like dysfunctional staff they supervise
79
Problematic Health Care
Professionals in LTC

Don’t know what they should do






Don’t agree it is their responsibility
Don’t know why they should do it
Don’t know how to do it properly
Fear negative consequences for doing or not
doing something
Have few positive consequences for acting in
desired manner
Have no negative consequences for
inappropriate, undesired performance
80
The “ABCs”


Bi = f i (A,C)
Individual behavior (B) is a function of
antecedents (A) but – more
importantly— consequences (C)
81
Antecedents and
Consequences

Antecedents - Things That Precede
Performance




Slogans and pep talks
Policies and procedures
Training
Consequences - Things That Follow
Performance


Things that increase performance frequency
Things that decrease performance frequency
82
Vital Management Activities





Make sure they know what to do
Make sure they know why they should do it
Make sure they know how to do it
Check their performance
If performance still inadequate

Systematically review and address other reasons
for non-performance until



Performance satisfactory OR
Consequences unimportant OR
Individual no longer involved
83
Some Core Management
Functions






Identify expectations, and explain their basis
Explain how to fulfill those expectations
Identify criteria for satisfactory fulfillment of
expectations
Determine whether those expectations are be
met
Provide feedback to individuals about how
well they are meeting those expectations
Help individuals refine performance to meet
84
expectations better
Realization


“Management is an intervention more
like bridge building than rain dancing”
Management is a concrete, identifiable
intervention


Like cake baking or orchestra conducting to
lead towards a desired outcome
Best ingredients or best musicians alone do
not guarantee a good cake or concert
85
Management As Intervention

Preventive management is like preventive
maintenance



Manipulate elements to get predicted outcome
that would not have happened otherwise
Convert management philosophies and
theories into things to influence performance
Misdiagnosis by a manager may lead to
treating symptoms or wrong causes

Less likely to correct performance problems
86
Vigorously Subdue Political
Correctness
87
Vigorously Subdue Political
Correctness

Politics



The means by which societies try to
accommodate and reconcile diverse needs,
desires, and perspectives.
Politics can be constructive or
problematic
Presently, some serious imbalances
88
Political Correctness

“Political correctness” (PC)



Operates at all levels


Promote or expect certain beliefs, words,
attitudes, or actions
Avoid, sanction, or fail to even consider others
Within social institutions, facilities, organizations
Often merely a rationalization for


Gaining personal advantage
Avoiding accountability
89
Genuine Reform: Subdue
Political Correctness

Genuine improvement and reform
require more open and balanced public
dialogue about

Responsibility for inadequate performance



In all settings, at all levels, in all social
institutions
Appropriateness of proposed “solutions”
from diverse sources
Alleged “expertise”
90
Strategies: Subdue “Political
Correctness”

Broaden dialogue about



Reinforce accountability at all levels


Virtues and weaknesses of various settings
Proposals to improve and reform care
Stop excusing inappropriate performance
and practice
Contest incorrect and misleading advice

Regardless of the sources
91
Rethink the Research Agenda
92
Knowledge and Its Effective
Implementation



Many contributions from decades of
research
Huge gap between knowledge and its
effective application
Research is a means to an end


Not an end in itself
An evidence basis for care does not
necessarily improve that care
93
Respecting Precedent

Desirable improvement and reform
activities respect existing knowledge


Consider effectiveness of applying existing
knowledge
Emphasize enduring and universal clinical
and management principles

For example, problem solving and linking
causes and consequences
94
Example: Medications


For example, issues related to
medications have been identified for
decades
Researchers keep studying the topic


Conclusions not remarkably different from
the past
Problem of adverse medication
consequences remains widespread

Perhaps worse than ever
95
Meaningful Research
Hypotheses: Examples

What is impact of proper and improper care
process and clinical problem solving and
decision making on outcomes?



Proper care delivery process task performance
essential to high-quality care
Lapses in care delivery process-related task
performance underlie care / quality issues
Failures of cause identification are major source of
avoidable negative outcomes
96
Meaningful Research
Hypotheses: Examples

Do treatment and care decisions
have a valid clinical rationale?
Valid rationale often missing or
incompatible with patient-specific
evidence
 Too much care is based on guesswork
and rote interventions

97
Meaningful Research
Hypotheses: Examples

To what extent do organizational and
operational issues impact care quality
and outcomes?

Facility management and care systems
profoundly influence


Care delivery process
Provision of appropriate, safe, and effective
care
98
Strategies: Rethink the
Research Agenda

Shift balance towards implementing
existing knowledge




Analyze failures in implementation
Recognize precedents, including
existing knowledge
Consider more pragmatic approaches to
influencing and improving performance
Broaden scope of research hypotheses
99
and questions
Strategies: Rethink the
Research Agenda

Redirect funding more towards
rethinking traditional approaches



Reduce repetition of conventional wisdom
Reexamine conflicts of interest that
impede free inquiry and dialogue
Focus much more attention on basic
care principles and processes
100
Focus Attention on Basic Care
Principles and Processes
101
Focus Attention on Basic Care
Principles and Processes



Good care results from painstaking
detective work
All settings need more individuals with
basic generic competencies
All settings need


A return to the roots of primary care
medicine and nursing
Faithful adherence to the care delivery
process
102
Strategies: Focus on Basic
Care Principles and Processes

Focus on




Strengthening care delivery process
Minimizing diagnostic fallacies and avoid
treating the chief complaint
Addressing challenges to providing safe
and effective care
Strengthening clinical problem solving and
decision making to help compensate for
these challenges
103
Suppress Reductionism and
Jurisdiction Over Care
104
Suppress Reductionism and
Jurisdiction Over Care


Time to reverse the trend to excessive
reductionism and jurisdiction in health
care
Reductionism


Misconception that aggregating pieces of
care = managing the whole patient
Jurisdiction

Giving various disciplines or settings rights
of supremacy to diagnose and treat
105
Suppress Reductionism and
Jurisdiction


Shortages of qualified staff and
practitioners do not justify inappropriate
practices with adverse consequences
“Political correctness” must not inhibit
accountability for performance and
practices

Including setting appropriate limits on
clinical decision making prerogatives
106
Strategies: Suppress
Reductionism and Jurisdiction




Apply evidence and manage issues in
the proper context (phronesis)
Ensure that care is consistent with basic
physiological principles
Inhibit claims of primary or exclusive
rights to diagnose and treat specific
problems and body parts
Faithfully implement correct
107
interdisciplinary team approach
Reconsider Notions of
Competency and Expertise
108
Critical Generic Workforce
Competencies







Make, report, document observations
Collect and organize information
Examine evidence
Provide a chronological story of events
Reason inductively and deductively
Formulate hypotheses
Draw conclusions

Providing rationale for those conclusions
109
Critical Generic Workforce
Competencies






Solve problems
Seek and identify causation
Give detailed answers to questions
Deal with multiple simultaneous causes
and consequences
Follow instructions and procedures
Abide by limits of personal knowledge
and skills
110
Reasons For Variable
Performance

Diverse reasons for desirable and
inadequate performance; for example




Inadequate knowledge
Failure to apply knowledge
Deficient clinical problem solving and
decision making skills
Effective reform efforts must address
these diverse issues and root causes
111
Strategies: Workforce
Functions and Competencies

Rethink key strategies about what
constitutes competency and “expertise”



Topical knowledge is important
Each topic must be applied in the proper
context
Knowledge about a topic does not
guarantee expertise in clinical problem
solving and patient management
112
The Cascade of Competent
Performance and Practice

Collect and analyze information
in order to perform
- Accurate problem definition & cause identification
resulting in
- Effective clinical problem solving and decision
making
leading to
- Evidence-based, individualized care
113
Strategies: Reconsider Notions
of Competency and Expertise



Reconsider notion of expertise and
criteria for determining who is an expert
Distinguish genuine clinical and
management expertise
Rethink strategies and core
competencies for training work force
114
Strategies: Reconsider Notions
of Competency and Expertise



Focus public education on improving
key generic competencies
Shift health care professional education
to include key concepts
Shift approaches to training and
educating staff in all settings
115
Suppress Reductionism and
Jurisdiction

Capable staff and practitioners




Willingly explain evidence basis for their
conclusions and decisions
Take responsibility for results
Can analyze and recover from unexpected
or avoidable complications
Less capable individuals do not


Offer a valid basis for conclusions
Accept responsibility appropriately
116
Change Approaches to Assessing
and Improving Quality
117
Change Approaches to Trying
to Improve Quality


Rethink current approaches to assessing
and improving quality
Some current approaches are pertinent
and meaningful

Others may actually impede definitive
improvement
118
High Quality Care

High quality care has certain attributes


Safe, effective, efficient, person-centered,
equitable, timely
Attained by consistently doing the right
things in the right way

This approach may be most likely to attain
desirable results
119
Path to Quality Care
How Done 
What Is Done
Right Thing
Wrong Thing
Right Way
Wrong Way
+/+
+/-
-/+
-/-
120
Limits of Measurement




Numerous efforts to improve quality by
collecting and analyzing data
Not everything being measured is
meaningful
Only some meaningful things are being
measured
Quality measurement and quality
indicators are a means to an end
121
Balancing Outcome and
Process Emphasis



Care process compliance is not “paper”
compliance
Effective clinical problem solving and
decision making are vital for outcomes
Genuine reform requires better balance
between outcomes and care processes
as basis for assessing care quality
122
Limits of Impact of Measuring
Quality

Ultimately, quality measurement can
only improve performance somewhat


For example, giving more statistics to an
athlete does not necessarily produce
additional improvement
Also need capacity to improve and
proper guidance
123
Root Causes Are Vital

Addressing root causes may improve
multiple performance aspects


Not just finding more things to measure
For example


Identifying deficits in clinical problem solving
and decision making
Identifying inadequate accountability for
ineffective performance and clinical decision
making
124
Strategies: Change Approaches to
Assessing & Improving Quality




Balance assessing outcomes and
underlying processes and practices
Emphasize internal systems for
identifying and addressing quality issues
Recognize limits of using aggregate
outcomes to judge care quality for
individuals
Recognize limits of fixed data sets as
125
basis to evaluate quality
Develop Biologically Sound
Reimbursement
126
Develop Biologically Sound
Reimbursement

Incentives ultimately are a major
influence on human behavior



Money is a major incentive in many
societies
Reimbursement must be compatible
with—and not inhibit—desirable care
Physiology does not obey payment rules


Payment must be biologically sound
At present, it is only partially sound
127
Develop Biologically Sound
Reimbursement


Care is often reimbursed despite
incompatibility with key concepts,
practices, and processes
Payment sources still unduly influenced
by less significant things



Primary diagnoses / DRGs
Facility licensure or category
Treatments and services rendered
128
Root Causes of Wasteful Care


Much concern expressed about waste
and inefficiency in health care
“Reform” must identify and tackle key
root causes


For example, failures of the care delivery
process in diverse settings
Reimbursement must not distort care
approaches; for example,

Labeling patients based on treatment
129
Summary



Enduring improvement and reform
require focus on things not commonly
considered
Essential biological, medical, and
philosophical principles
Consider whether reform efforts


Reflect and promote desirable approaches
Avoid and inhibit undesirable approaches
130
Summary: General
Responsibilities For Reform

Better understanding by overseers and
reformers of




What they are trying to oversee and
improve
Their appropriate roles
Impact of social institutions and culture
on identifying and solving problems
Need for improvement in every
component of health care system
131
Summary: Reforming the
Reform Efforts

Respecting essential, enduring, and
universal concepts and approaches
typically brings desirable results


Need much more attention to the basics


Defying them brings perilous consequences
for health and well-being
Not inadequate workaround “solutions”
Need universal accountability
132
Summary: Applying the
Lessons


Lessons of efforts to reform health care apply
to all facets of the health care system
Reform and improvement are entirely possible


Only by respecting and applying key concepts and
approaches
Law of gravity is universal

Either respect it to our advantage or defy it at our
own risk
133
134