Recommended Reading: The Best Practice by Charles Kennedy
While this book is almost 5 years old and long since in paperback, I recently reread it for my own purposes. It never would have occurred for me to review it here because I had assumed that most Americans--all the way from those highly initiated healthcare to those pretty ignorant of it--would agree it is pretty messed up these days. HOWEVER, this past weekend I had a somewhat disturbing conversation with a good friend, who happens to be smart and a highly successful entrepreneur and businessman, which made me question my assumption and to rush this review onto the site to address what I fear are some widely held beliefs out there, which I find to be both unsupported by the facts and dangerous, re the state of healthcare in this country. Hang on…
John F. Kennedy famously and correctly said that “too many people enjoy the comfort of opinion without the discomfort of thought.” Sadly true. Almost a quarter century ago I had a discomforting “conversation” with (more accurately described as an a..chewing by) a senior colleague who had been a 4-Star General and head of the SAC in his life prior to the RR. He offered me some unsolicited advice, which I have tried to follow ever since: “don’t ever mistake opinion for fact.” With these two pieces of historical wisdom on the table, I offer the following question--Fact or Opinion: Healthcare in America is the “best in the world?” Before you answer, consider the following facts and conclusions from them detailed in The Best Practice, in no particular order:
“Americans, --regardless of race, ethnicity or socioeconomic status—receive the right care (the consensus scientific care for their condition) only about half the time.” (The RAND Corporation); “In the past two decades, health care has gone from being a source of national pride to being one of America’s preeminent threats.” (Michael Porter and Elizabeth Olmstead Teisberg, two of America’s leading scholars on healthcare in their book Redefining Health Care); “Millions of patients who would benefit from widely recognized and available treatments do not get those treatments…and millions more receive medications or treatments known to have no effective impact.” (The Institute of Medicine “IOM”); “Crucial reports from disciplined review boards document…[that] between the healthcare we have and the healthcare we COULD have lies not just a gap, but a chasm.” (Crossing the Quality Chasm from IOM); “Diabetic patients receive half of the care they need, and hypertension patients get less than 65% of care recommended for their illness….To substantially improve the quality of healthcare in America available to all patients, we need to focus on large-scale, systemwide changes” (RAND); “Among the 30 developed nations that make up the Organization for Economic Cooperation and Development, the U.S. ranks near the bottom of most standard measures of healthcare.” (New England Journal of Medicine); In a “measure comparing countries throughout the world the U.S. ranks 42nd in infant mortality and 46th in life expectancy.” (Ibid.); “Healthcare defects occur 10 to 20% of the time [while] with airlines and nuclear power plants, the defect rate is 1 in 10,000.” (the Institute for Healthcare Improvement). “Every year an estimated 1.7 million Americans are victims of hospital-acquired infections—4600 per day!” Finally for now, “There are 15 MILLION instances of medical harm in the U.S. each year.” (Institute for Healthcare Improvement).
And make no mistake, The Best Practice contains many other, sadly similarly, facts from which stark conclusions re the state of healthcare in America may be drawn. The author of The Best Practice makes no bones that, as of 2005, his opinion and the opinion of many quality leaders in healthcare at the time, is that most measureable indicators suggested the factual answer to my question in paragraph one above is a firm “NO,” America is nowhere NEAR the best in healthcare! And some of these opinions come from sources you might not expect. Take for example, the Forward for the book, entitled A Call to Action, which was written by the then-Chairman and CEO of Blue Cross Blue Shield of Massachusetts, who offers a 9-point Manifesto of demands all Americans are entitled to make of its leaders in order to help America achieve the health care system we want [deserve and need, but DON’T have]. He concludes that “the facts speak for themselves. For example, we are uncertain about the clinical benefit of almost half the care we provide in our country…In fact, only about 20% has been scientifically tested. It has been estimated and a quarter of all new drug prescriptions contain errors. Even more disturbing is that the United States ranks only 23rd among industrialized nations in infant mortality, yet we spend about 16 % of our GDP on healthcare.” “[W]e experience as many as 98,000 preventable patient deaths in the U.S. health care system every year…Would any other system, industry or enterprise in the U.S. accept, or be allowed such answers?”
Compare Sweden, with 20 different self-administered county health systems, which cover every citizen from birth to death and are totally financed with tax dollars. Sweden spends 11 percent of its GDP on health care. Per person, Sweden spends $2825 per person vs. $6100 in the U.S. Less money spent AND better outcomes in Sweden and even it is not considered the best. Consider the following: Sweden ranks well ahead of the U.S. in key measures such as life expectancy and infant mortality rates, which are less than half the rate found in the U.S. Cancer deaths per 100,000 people are considerably lower in Sweden than in the U.S. In fact, one study found that ‘among 19 countries where deaths could have been prevented by access to timely and effective health care’ the U.S. ranked last and Sweden tied for 4th.” While 90 percent of doctors in Sweden rely on electronic medical records, which Kaiser Permanente contends is “the single most important thing that can be done to improve the quality, safety and efficiency of health care today,” only about a quarter of U.S. doctors use such technology.
Amazing—and “we’re # 1?” Hardly by any measure except hubris and reputation—urban myth at is best. BUT, “reputation is not measurement.” As Kaiser Premanente has found, the U.S. does NOT ‘“have the data necessary to track which providers or care teams have achieved the best [or worst] results for back surgery, knee surgery, or eye surgery. We don’t know which oncology group gives patients the longest survival time from Stage II lung cancer, or who does the best job of treating breast cancer and getting it into remission…How can the providers with the worst performance levels improve when they have no sense at all that [they are even below average]?”’ “The problem is that a clinician has no way of knowing whether he or she is performing near the top or the bottom of the pack. Many think they know. Many believe they are among the best; but, in fact, they have little [or no] statistical proof.” Sadly, according to one noted scholar and physician, “[T]he U.S. spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status…too many Americans do not receive [needed care], receive it too late, or receive poor quality care.” David Berwick, a Harvard trained physician and CEO of the Institute for Healthcare Improvement says that the “myth that America has the best healthcare in America is just that—a myth.” And he is BY NO MEANS alone.
The Best Practice concludes, like the the book “Unaccountable” (which is also reviewed on this site) and the countless other books and studies (cited throughout The Best Practice) by great doctors and other experts and change leaders everywhere who have devoted their professional lives to improving healthcare in America and beyond have similarly concluded—we need more technology, we need more measurement, we need more transparency and accountability before we could ever be considered to have the best when it comes to healthcare. And, if you are not yet convinced and still remain skeptical about the status of healthcare in the U.S., even in the face of the quality data that does exists, ask yourself 2 final questions: Forget who is #1, “does America have the healthcare system all of its people deserve or can we do a lot better with KNOWN quality tools?” Second, however you answered this last question, here is one more: “Is healthcare in this country too damn expensive for what we get?” Read on for what we can do about it…
The nine legitimate public demands formulated by the then-CEO and Chairman of Blue Cross Blue Shield of MA, who found all of these things missing in U.S. healthcare as of 2005, are as follows:
1) A system of “zero preventable harm” for all patients
2) Appropriate, evidenced-based care, whether preventive, acute or chronic conditions
3) A system that eliminates racial, cultural [and gender] disparities in access to and the delivery of healthcare
4) Compensation of caregivers based on objective performance measures related to clinical outcomes
5) Patients who receive what they need to make informed choices
6) Health system leaders, especially trustees and board members who are strong and consistent advocates of quality on behalf of those they serve
7) A system where new technologies and treatments are evaluated and compared to existing alternatives prior to their adoption
8) Patients, the public generally and healthcare providers who are fully informed about how and why we need to improve healthcare
9) A system where savings from safer, more evidenced-based and cost-effective health care are reinvested in a way that slows spiraling costs while improving the health of all our citizens.
A significant part of the quality problem in U.S. healthcare is that, unlike most critical industries that drive our society and its economy, and unlike how the participants are treated throughout their healthcare training, performance is rarely measured, even more rarely reported to the public or even current or prospective patients, and even more rarely is anything corrective done with the actual healthcare results when the path for improvement based on those results should be clear.
“At its core, this book is about how the [quality] movement is transforming the way we deliver and manage [healthcare]. This is a story of visionaries, mavericks, and revolutionaries with impeccable pedigrees and experience in some of the most prestigious hospitals in the world; the story of a small group of physicians and other scientists who see things others do not yet see; who believe what others have never imagined. At its core, this is the story of a small band of crusaders who have set out to change the medical world”—for ALL of our sakes!
This is a story of the birth of IHI—the Institute for Healthcare Improvement—an independent organization whose aim is to radically transform the level of healthcare in the U.S. This is also a story of Dr. Lucian Leape, the leading expert on errors in medicine and how when he began to tackle the medical error problem in the 1990s found NOTHING about medical errors even in print. He became an Edwards Deming disciple (the father of quality efforts since WW II, especially in Japanese industry, including in the automobile industry there and here in the U.S.) and began to, along with some of the early crusaders, apply basic quality principles to the medical arena. His seminal work in 1994, Error in Medicine, concluded with a simple proposition: “Systems that rely on error-free performance are doomed to fail…The primary objective of system design for safety is to make it difficult for individuals to err…Error prevention systems work brilliantly in various industries. If we adapt these systems in healthcare, we will reduce error, improve quality and save lives.” AND CUT COSTS TO BOOT!
The story continues with the Allegheny General Hospital and the Pittsburg Regional Health Initiative, a private working group working with hospitals to improve quality and safety, which just happened to have another Deming disciple, Paul O’Neill, then head of Alcoa, as its leader. Under O’Neill’s leadership, the announced goal of all 47 hospitals in the consortium became “perfect care for every patient.” Transparency and accountability became the touchstone of everything these hospitals did, and it was not always easy or easily accepted in the boardrooms of the hospitals. Quality can be scary stuff as these stories point out—it can also lead to incredible results as the stories also show. For example, it took a really difficult and divisive look inward for Cincinnati Children’s Hospital to go from thinking it was the best in its category, to realizing it was closer to the bottom, to then redoing almost everything to actually reach the best in class status, where it had for way too many years mistakenly believed it was.
Perhaps one of the book’s most telling stories is in the chapter dedicated to Virginia Mason Medical Center in Seattle, WA and its internal tug-of-war with quality processes developed and best applied at Toyota, where Mason took a number of its not-so-willing doctors and other staff to learn the Toyota Production System first hand in Japan. Through trial and error and lots of blood, sweat and tears, Mason was able to spread its simple yet revolutionary message to it staff—“This is not about you. This is not about the doctors and the nurses; it is about our patients and doing everything we can to keep our patients healthy and safe.” Too much to ask? ,or too many at Mason and elsewhere at great institutions across America, the answer remains an unacceptable “yes.” Yet, for all our sakes, the work goes on to ensure that all of medicine is patient-centered and error-free.
One particularly touching story contained in The Best Practice is that of Sorrel King, Mother of Josie and the author of Josie’s Story also reviewed on our website. The fact that this tragic story has had so much power in medical circles is due in part to 3 things: 1) Josie’s death was tragic because it was preventable and because she was so young; 2) the death happened at a prestigious hospital, which shocked many, as did the way Mayo’s leaders admirably handled the matter to its conclusion not only with the family but with its staff and on behalf of future patients and 3) the tenacity and tireless of Sorrel King to make sure Josie’s death was not in vain. It is all a good story of how to bring much good out of something so horrible.
I feel like I am now “beating the proverbial dead horse.” America’s system is broke—“Change is coming…based on the recognition of the reality rather than the myth of American healthcare…Incremental change will not cut it…this is a revolution.” (William Body, MD and then-head of Johns Hopkins University); while we have some great minds and groups trying to hasten this revolution and to reverse this sad and tragic state of affairs, they are not nearly enough to get things changed fast enough before we have all experienced some catastrophic medical error and its consequences for patient, family and society alike. Wake up American consumer, as we did in the late 80s when the Japanese taught us we could have better quality of cars and lower prices. We can have the same in healthcare and I for one believe it is FAR more important to our country and its future than an automobile was a quarter century ago.
For more on this crucial subject, check out our recommended books on this website, www.4ourelders.com. and get involved in the healthcare quality movement yourself—for all our sakes.