Safe and High Quality Health Care

so please join me in welcoming to the distinctive voices podium dr. Harvey Fineberg I know that when you come to our vine and to Newport Beach that the proper attire is resort casual but I want you to know this is what passes for resort casual in Washington DC so here I am I'm going to be talking tonight with you about a subject that most doctors for most of their lives have not wanted to talk very much about and that is the question about errors in medical care and the quality of health care it's something that touches each of our lives at one time or another and for some of us almost as a daily or regular experience I want to begin by asking you all a question how many of you in your families are with a close friend know of an experience where you believe there was an error in the medical care of that person how many of you had that experience okay it's well over half I would say it's about 80% in fact it's almost 80% of virtually any audience I ask and if you begin to think about this for a moment if most of us have in our families or friends experienced a medical error it must be pretty common and yet for most of the time of the last half century most doctors haven't really thought directly about this problem the problem of medical errors and the question was always lurking in the background of avoiding even facing up to errors that were clear because of the worry about malpractice mainly and also just a sense of professional pride and a deep conviction that well errors might happen to others but not really to me and not to my patients but systematic surveys that began to be done in the 1980s particularly look very carefully at the experience of patients in hospitals retrospectively reviewing the patient charts found that there were quite a few errors in fact one in six patients one in seven in some studies in the course of their hospitalization would experience some type of error and of course errors aren't limited just in the hospital can happen as an outpatient it happens in nursing homes in fact when you added up all of the studies that had been done up through the 1990s and figured out how frequently do errors occur how frequently do those errors result in complications how frequently do those complications actually lead to the death of a patient an Institute of Medicine panel in the late 1990s examining all of this information came to the conclusion that every year in the United States tens of thousands of patients lose their lives because of an error in their medical care in fact the panel said if you listed medical errors among the top causes of death in the United States it would rank in the top ten it would be more than die on the highways it would be more people than die even from relatively serious diseases often errors intervene between care and recovery and deflect the patient's outcome in a tragic way now recognizing the problem is only the beginning of trying to deal with that problem the two studies that came out right around the year 2000 that really set the stage for this from the Institute of Medicine first was the study to err is human that's the one that analyzed all of this research and came to the conclusion about the tens of thousands of deaths and the other was called crossing the quality chasm in healthcare because the flipside of avoiding errors in medical care is having a system of care that provides high quality so we ask the two questions where do errors originate and secondly how do we move from error to high quality and that's what I want to talk with you about tonight there are at least six different ways to try to get your arms around this problem of medical errors on the one side and shortcomings in health quality on the other the first is what I describe as structural deficiencies in fact this was often the first instinct of many doctors and thinking about what is the problem that produces errors it is that we don't have the best equipment so we don't have the right things to work with or we don't have the right numbers of personnel or we don't have sufficiently sophisticated up-to-date hospitals or we don't have the necessary ways in which we can see patients efficiently it's something about the structure of the system that is a problem you can almost think of this as the architects conception of the problem where the builders conception of the problem we've got to build more proper infrastructure a second concept starts from a very different premise it says basically if only the doctor and the nurse cared enough fulfilled their responsibilities lived up to their duty to their patients listened carefully enough spent enough time if only they would do that be worthy of the profession then they would not make mistakes errors would not occur this is if you will the philosophical understanding of the problem it's that we need to select for training and reinforce in our training of health professionals a very high ethical standard a very high standard of responsibility for the patient a third way of thinking about the problem is you know doctors and nurses and other health professionals they're human beings like everyone else they respond to incentives and disincentives just like everyone else and so if you want doctors to make fewer errors and deliver higher quality care well pay them for better quality punish them for making errors have a stricter system of malpractice that discourages mistakes and figure out a way to reward and recognize outstanding performance and high quality and avoidance of error this is a if you will an economist conception of where does the problem come from and how do we deal with it a fourth is limitations of the human capacity to think to reason to judge cognitive limitations psychological limitations medical care often is delivered in in circumstances a very high emotion very great tension a lot of stress information overload thousands of relevant pieces of data that are very hard to assimilate into take account of in a real time when it's needed so there are psychological limits to how many things you can expect the doctor to do or the nurse to be able to execute properly and so the solution for this problem is that you figure out ways to support decision making you figure out ways to limit the hours that residents are on duty you figure out ways to limit the strain and stress that applies in emergent especially urgent care situations difficult complex patient care and that may be a solution here from the psychologists point of view and a fifth would say you know all of this stands on an educational foundation we're not training our doctor and our nurses sufficiently to be able to practice medical care in a consistently high quality and error-free way we've got to do more in training maybe we've got to use more robotic training maybe we need more hands-on practice sessions maybe we need more real team-based training maybe we need other ways of educating and reinforcing good clinical practices that we're not adequately doing now in our professional schools and in our residency and other clinical training experiences so this is the educators solution now I would maintain that all of these perspectives have some relevance and some validity but the Institute of Medicine committee that looked at the problem and tried to understand all of the attributes of the problem came to a slightly different perspective and basically they said the fundamental problem if we want to understand it and get our arms around it is a problem of systems design and operation it's the processes of care it's not the individuals being careless it's the whole system in which individuals practice patients experience and and errors get made and the core idea behind a systems approach to understanding how this occurs is to recognize that health care and the outcomes of care are the result of a tremendous number of intersecting forces partly related to the clinical judgments that are made partly related to the hospital capacities often inpatient partly related to the patient and the patient's role partly related to the available resources partly related to the ways in which people are prepared and educated but all of these working together in an interacting way to produce the results that we have and here's the key concept instead of thinking about our system of healthcare as being fundamentally great and occasionally allowing an error through we should think of our healthcare system as being perfectly designed to produce exactly the results that it produces if we have one in seven errors in a patient's experience in hospital our system is designed to produce one in seven errors and the key idea is not to design a system in which it's possible to practice high-quality error-free care it's how do you design a system where it's virtually impossible to allow the error actually to affect the patient that's the key concept a story to illustrate the point dates back to the time when you'll remember Japan was the economy that was going to overtake the United States remember that in the 1980s when Japan was on the rise and Japan had introduced some remarkably successful Quality Assurance mechanisms and there's a story about the American company that ordered a place in order with a Japanese company by telephone over the transatlantic cable at the time to request 1000-year mechanisms and they that was a rather sizable order for the company and and the person placing the order said there cannot be only there can only be two – that won't be properly working so the person on the other side said let me understand this correctly it's – he said yes – so six weeks later when the order comes and they unpacked the crate they're unpacking them they're they're 998 gear mechanisms and there's a little box when they open the bar neatly wrap and it says these are the two that don't work now that is a system perfectly designed to produce exactly the number of errors that you want so we have to think about healthcare and the strategies that will intrude on the systems of care to prevent them from occurring by the way just incidentally do you know what the most common type of error relates to in medicine the most common relates to medications the most common is medication because think about it you know with medication you have to get the right drug to the right person in the right dose through the right route at the right time that's a lot of Rights any one of those can go wrong each and every time you deliver a medication and that is the most frequent source of error and that's something we may come back to now you may wonder does good design of a system matter this is one of my favorite illustrations it's it's called coffee pot for masochists there are some mornings when I think I could probably use it without thinking but the point of this illustration is that every design everything that we even take for granted has an effect on its quality and safety we don't even think about most of the things that we use every day we don't think about the chairs typically we don't think about the tools that we pick up and use the pens and pencils but if you begin to reflect on everyday things you can see how the design really does matter and does affect sometimes the safety now safe design the idea of safe design which is a core engineering principle and by the way this whole notion of systems design is essentially the engineering philosophy and approach which is so fitting for us when we're in the Beckman center to be thinking about because if anything dr. Beckman was the problem solver par excellence but here systems that are what are called complex tightly coupled system this means a system that has a lot of parts and the parts are highly interdependent a spaceship is a complex tightly coupled system things that can go wrong in one part can reverberate through the system and there's sometimes catastrophic results a university nearby or any university is a complex loosely coupled system things can go absolutely disastrously in one department and most of the university hardly notices so it's loosely coupled but it's a very complex place and engineers and designers who've thought about the problem have come up with a set of principles that help us to think about systems that are designed for safety for example that all of the elements are visible there's nothing hidden that it's as simple as possible that it has what are called affordances affordances is when you see a door with a push bar you know to push it have you ever come up to those glass doors with you can't tell whether you push or pull and you know usually it's the wrong way first and then you figure it out well affordances would prevent you from making the first error because it would tell you naturally which one you push now a natural mapping we're all familiar with this on a on a stove the burners now how are your controls laid out relative to the burners are they laid out the same way that the burners are laid out or are they all in a row in the front and then you sometimes forget which one is for the back burner which is for the front so a natural mapping tells you more accurately which way things apply when you move them we had a house once in New England with a an electrician honestly who had no concept of natural mapping you could throw a switch in that house and you had no idea what light was going to go on or off because it had no relationship to where things were now that was that was for the four years that we lived there a constant source of error no natural mapping forcing functions forcing functions means that the oxygen tube will not connect to anything except the valve that produces oxygen it just won't fit anything else you can't connect it to the wrong input that's a forcing function reversibility means that it's not final when you make a mistake you can get out of it you can back out and standardization is very very important we're going to come back to that when we have an example a little bit later what's happened in the field of anesthesia over the years so these are some of the core basic ideas and the question was well what do they have to do with healthcare and this means thinking about healthcare in a system's way and always putting the patient at the center of the system but thinking about the way what happens to the patient involves a care team may involve a larger organization and may involve a of Surround it's the clinicians it's the hospital it's what happens around it with supplies and suppliers and everything else that ultimately impinges on the patient now let me give you some examples of places that have tried to take very systematic approaches to improving care and the things that they have accomplished ascension healthcare is a system of hospitals about eleven hospitals and they went back to their fundamental processes of patient care and they looked at strategies systematically where errors could occur how do they reduce them and how do they avoid some common complications and what they were able to accomplish in the space of just a couple of years was to reduce compared to national averages bloodstream infections in the hospitalized patients by 43 percent birth traumas by 65 percent neonatal mortality death of the neonate by eighty nine percent below the national average and pressure ulcers and pressure ulcers occur really as a result of poor nursing care it's nursing care that determines whether a patient will develop pressure ulcers and that they were able to reduce 94 percent below the national average now I made a brief allusion to the field of anesthesiology because it's such a telling and excellent example for me during my professional life time of the changes that have been made moving toward a much safer health system in parts when I was in training and early in practice anesthesia was actually considered a pretty risky proposition just from anesthesia alone about one in 10,000 patients would die in surgery because of some mistake related to anesthesia and today that number has been reduced to where it's less than in two hundred thousand surgeries that's more than an order of magnitude reduction and the anesthesiologists have benefited tremendously their malpractice judgments their fees the number of claims that are aimed at anesthesiologists have declined as shown on the slide and the proportion of malpractice claims that are closed with payment went down from roughly 64 percent in the 1970s to 45 percent so not only were the claims fewer but the settlements were less so the anesthesiologists have benefited but that's nothing compared to how patients have benefited how did they do it it was a combination of things first and most importantly they acknowledge the problem and they faced up to it they established an anesthesia Safety Foundation whose whole purpose was to examine errors figure out what happened figure out how to prevent them and get those new procedures practices in place and they brought everybody into the act they brought the anesthesiologist they brought the regulator's they brought the manufacturers they brought the patient's representatives they had regular communication through the profession throughout the country they invested in research that would enhance safety per se and new technology made a tremendous contribution I can remember as a resident in the hospital if you had a very sick patient and you needed to know what the oxygen level they were getting in their bloodstream was it was a major production you had to alert the laboratory you had to get a bucket with ice because the transportation of the sample had to be kept cold by the time it would reach the laboratory or else the oxygen tension would change because of the temperature change you then had to locate an artery you had to have a glass syringe you took a blood specimen from the artery into the glass syringe you had to hold that artery for at least five minutes so that it would not bleed while someone else would race to the laboratory with the syringe and a half hour later you would get your answer which would be with plus or minus 10% accurate today you have a little thing that sticks on the end of your finger if you all had that and it's an instant readout it's continuous it's painless it works by looking at the color of your capillaries believe it or not it's such an ingenious invention now if you can constantly measure the oxygen and another wonderful invention was to measure carbon dioxide the cap nama tree so-called and if you are in the operating room and your anesthesiologists can tell that you're getting good oxygenation and that you're producing carbon dioxide you can be pretty certain at the endotracheal tube which was placed is actually in the trachea not in the esophagus going to the stomach which you don't want which was the cause of many horrible tragedies from time to time in the past so these technological advances have also made an enormous difference for anesthesiology but even more has been the fact that the manufacturers and the trainer's work to simplify and standardize the equipment so the same controls were in the same places in every surgery and that made a very great difference in terms of your ability as an anesthesiologist to do your job they say anesthesiology is a field of boredom punctuated by panic from time to time and when that panic arises you've got to be able to push the right button at the right moment now one of the things that is definitely going to be making an increasing contribution to both safety and quality is the advent and the expansion and distribution of Technology in information technology for the use of doctors and patients how many of you use a home computer for anything related to your own health I'm just curious well it's a it's quite a few I would say it's about half here your doctors are starting to use computers too I've even taken to wearing a little device that measures my exercise during the day and records it automatically to my computer I can't cheat anymore on the page I used to keep track of there's no cheating just like your your scale now can report your weight and your blood pressure directly to your computer or to your doctor and these techniques and ability to monitor and to keep up to date just can make an enormous difference when they're coupled with health systems designed to help people get the care they need where and when they need it in their home and to be monitored properly so if you have a chronic condition if you have diabetes if you have chronic lung disease if you have congestive heart failure you can be monitored and when you start gaining weight with congestive heart failure it doesn't have to reach a crisis before you go to the emergency room the nurse monitoring in your clinicians office will be able to followup with you and with the diabetic care the same thing including home based monitoring and maintenance so information technology in so many ways is going to be playing a role increasingly in safety in peer-to-peer and patient to doctors support and in many other ways to make a difference for the quality and safety of health care now I want to give an example of where a hospital system has taken information technology and coupled it with guidelines for good care and put it all together in a visible and very recognizable monitoring system called a dashboard to enhance the quality of patient care in the example I'm going to take us from Vanderbilt University where they had the goal of cutting down ventilator associated pneumonia sphere a very serious complication in intent of care and also had a second study that I'll just allude to on optimizing the tests that would be done for bone marrow biopsy now this very busy slide is a picture of what shows up on the monitor all over the intensive care unit at Vanderbilt hospital and what this basically has is a list of patients and with each patient an identified set of regular procedures mainly nursing procedures that should be done in the care of that patient in order to prevent ventilator associated pneumonia its proper nursing care in a timely way and this dashboard has a marker when something is done on time it's green when it's due but has not yet been done or at least not yet recorded as done it's yellow and if it's past due it's red this is visible to the families to the patient to every nurse and every doctor who enters to care for the patients in the intensive care if you're responsible for these patients you do not want red on your chart and it's very interesting what happened at Vanderbilt when they started this back in 2005 they introduced the system where they just had those standard orders those eight steps that you ought to do and that was a fairly effective it dropped things down a bit you know from 21.5 ventilator-associated pneumonia x' down to seventeen point nine not bad but not great when they added the dashboard the visible feedback the standardized method the simple monitoring system look what happened it went all the way down to four point six a reduction of more than eighty percent they estimated that in that time of that five years they avoided seventy five des in their own Hospital alone from this one technique and saved an estimated of 20 million dollars in care costs that are otherwise associated with caring for the patients who get the complication in the hospital I for one would much rather be in this group of patients than in this group another example of what they did which shows that high quality of care doesn't always mean doing less sometimes it means doing more when you get when you have certain types of cancer and and the clinicians do a bone marrow specimen they will send that specimen for tests in the laboratory but not every test is actually relevant to every patient with every type of cancer and so all they did at Vanderbilt was to have the order run through a information feedback system that would inform the doctor how their orders compared with the standard recommendations for patients with the diagnosis that the doctor reported and gave the doctor the possibility then of either reducing or adding to their order set they did miss some tests on average about a half a test per patient but they had almost a 1.3 too many that were unnecessary and the net effect was almost one test per bone sample that was done and when you add that up around the country believe it or not that's also millions and millions of dollars that could be saved and care improved because you're doing a more precisely prescribed set of tests for that patient now I want to refer to another basic engineering approach to improve the quality and efficiency of healthcare and it's almost embarrassingly simple it's it's the ideas operations research and the essential idea is that the problem of backups in hospital and overcrowding are often problems of scheduling and here's how it works typically you go into the emergency room a lot of you must have been at emergency rooms often times they're crowded and in fact sometimes they are really overcrowded sometimes hospitals even tell the ambulances don't bring us any more patients we can't handle them right now so when a hospital has a very crowded emergency room what is the typical response of the people responsible for the hospital the typical response is you know we need to build a bigger emergency room it's logical isn't it it's crowded build a bigger room that's a little bit like imagine you were collecting rain in a rain bucket and you had a small hose that was letting the water out and it was overflowing and your solution was to enlarge the bucket operations research says no look at the hose what is it that's blocking patients from going out oftentimes patients are in the emergency room need to be scheduled for surgery it turns out and so scheduling through surgery actually has a backup benefit for the emergency room what's wrong with surgical scheduling in hospitals well first most surgeons really don't like to operate on Fridays well because you know they could be bothered on the weekend and the hospital doesn't have the first team in place on the weekend sometime well hospitals have to be 24/7 another problem they like to have a room designated for their kind of surgery they want the surgery that they do in the same room to be there and what happens is that that's a very inefficient set of constraints on scheduling patients and by the way there's no overflow room so operations research very typically what they will do in analyzing the flows they will say to the hospital schedule every room for every doctor every surgeon schedule every day of the week where you can do surgery and set aside an overflow room seems so simple but it's very hard to persuade the doctor sometime that that's what should be done where it has succeeded it has succeeded remarkably this one example of st. John's Hospital in Springfield Missouri in which the capacity for emergency admissions by virtue of rescheduling surgery almost doubled from when it was before to after the the surgical change the volume of surgeries that they were doing increased by one third the capacity for inpatients increased by almost 60% without adding a single bed how is it hospitals are overcrowded when on average if you take the daily census in American hospitals one-third of the beds are empty its scheduling and the waiting time improved very dramatically in the afternoon because they had set aside the room another simple example Cincinnati Children's Hospital this is quite a remarkable story because their waiting time declined 28% while their volume increased 24% that's a pretty good combination there over time that they had to pay nurses because they hadn't scheduled in a regular way decreased by 57% within four months and the daily throughput the daily throughput per operating room was almost five percent more they saved building a hundred beds at a million dollars of bed simply by improving the way they scheduled and by the way this is higher quality care this means you're more often going to get to the bed in the hospital where the people are best trained to take care of the type of surgery that you have had this means that you're not going to be waiting so long that you get dehydrated and therefore more susceptible to complications in anesthesia or after surgery this is better in every way and it saves money now we have done a lot of work on malpractice which is a real problem in our country and it's something we might want to discuss if if you're interested afterward in the discussion period very simply our malpractice neither rewards most patients who get injured nor deters bad practices so it loses on two counts and I'm sure you all know most of the money does not go to the patients most of it goes for administrative and legal costs so this is a very very broken system there are lots of ways that have been tried to fix including some legislative ways in different states on on on setting different standards one of the simplest most fundamental approaches is to essentially begin to regard malpractice more like a workman's compensation type program in which you have adjudication of injury and damages quickly awarded and you also have systems that can weed out those occasionally really bad actors who are just not going to be able to provide level of care at the quality we need health literacy is a very important problem from the point of view of patients especially in a country that's as heterogeneous as ours with education levels with different languages one of my favorite examples of the problem if if some doctor says to a patient who's spanish-speaking this pill you won't you should take it once daily ONC e Spanish 11 right that's not once that's 11 that's a that's a serious miscommunication how many times have you been in your doctor's office and when you're ready to leave the doctor says do you now tell me back what I just told you tell me in your own words what I what I instructed you to do that doesn't happen too often that wouldn't take that much longer and it would be a lot of reassurance that you actually at that moment at least understood what the instructions were now I want to point out finally in conclusion of a program that I recommend to you if you're interested in this whole area of quality and safety in health care that has been championed by the American Board of Internal Medicine foundation mobilizing medical professional societies all over the country in an initial foray nine different professional societies joined with the board of internal medicine Consumer Reports is is promulgating these messages through its publications and a number of other consumer related organizations have gotten on board the name of this program is choosing wisely and if you look it up if you google choose choosing wisely it will take you to this website and the essential idea from each of these nine initial professional societies eight more to come out in the fall is they've identified five common practices which they think deserve a second thought before you just go ahead and do it as a patient as a doctor so for example when do you need antibiotics for sinusitis how many people have ever gone to the doctor for sinusitis for an inflammation of science how many people got a prescription most everybody who went got a prescription it turns out almost all sinusitis is viral it's not bacterial and so the antibiotics really don't do you any good all they do is occasionally sitter and probably you didn't take them all because it may have gone away before the antibiotics were exhausted and so they sit around in your shelf and they get outdated or you pour them down a drain and they enter into the into the environment and then it it's not good for our resistance of antimicrobials in the future but it's it's not a very good practice and so what they're saying is think twice about prescribing and in my problems it's about 1/2 of 1% that will need it but it's not for most cases of sinusitis bone density tests this is a DEXA test its tests it's that's commonly using anybody under age 65 ever get this test well unless you had a real indication the family medicine folks are telling you think twice think twice it's probably not going to tell you much that you need except maybe you'll then be prescribed a drug that you actually also don't need and so think twice about that when you need imaging tests for lower back pain how many have been to the doctor for lower back pain most all of us it's the fifth most common reason why people go to the doctor lower back pain and you know what a CT or an MRI with contrast costs today anybody know $100 200 closer to a thousand for MRI with contrast on average around the country I don't know what it is locally but that's the that's the average do you need that when you first go in well the orthopedist SAR the family physicians here are telling us unless it's been neurologically symptomatic that's progressing so you're wheat you get more weakness more pain instead of gradually improving which most lower back pain does and unless it's gone on more than six weeks they don't think that it's actually needed when you need a Pap test well men doesn't apply to you you never need it but if you're a woman when when do you need a pap to us turns out the family physicians again say if you're under age 21 it's probably not a very useful test because the risk of cancer is extremely low and the risk of various dysplasias and other things is actually pretty high which then leads to colposcopy or other tests which are unmeet unnecessary but reassuring once you learn you had some problem in the first exam and so these things just compound and add up to a lot of money when you need an imaging test for a headache you've been to the doctor for headache some complicated headache well unless you've had neurologic symptoms with it some some other symptoms or it was extremely different from any other headache you ever had or it came on with great intensity or some other really distinguishing feature an imaging test is really not going to help in differentiating and in treating and what about heartburn and what's called gastro esophageal reflux I can remember when the first purple pill ads came out on television anybody else remember the purple pill ads you remember that I what I remember most is I had no idea what they were for but I knew I needed them because I mean they were in the most beautiful places once you took that pill it was green lush countryside that you were immediately transported to so well that's one of the that's one of the pills but if unless you have severe heartburn several times a week for several weeks in a row you probably don't need any of the expensive pills and if you do take the pills the recommendations from the gastroenterologist is to get yourself down to the lowest possible dose that will control your symptoms which also coincidentally would save you money even if it doesn't make more money for the manufacturers but that's not your main purpose so what is it that we can conclude from all of this we do have a serious problem of quality and safety in medical care it is fundamentally a challenge in the design and processes of our systems of care doctors hospitals nurses and patients are all parts of that system and we can all play our part to make our health care safer and higher quality which is exactly the care that you deserve thank you all very much

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