The Value Proposition
By William Bornstein
“Reliable process design” and “waste reduction” may not be as exciting as “brilliant scientific discovery,” but they mark the way to turn around a flagging U.S. health care system. Illustration by Dave Cutler
The tipping point for the “quality movement” in U.S. health care began in 1999. At that time, Americans generally referred to their health care system as “the best in the world.”
In truth, there was much to be proud of. Truly breathtaking advances had been achieved over the preceding decades. The human genome was on the verge of being completely sequenced. Remarkable advances had occurred in pharmaceuticals, imaging, and minimally invasive surgery as well as on many other fronts. U.S. health care had led the world in achieving the bulk of these advances. For most Americans, these advances were ample evidence of the extraordinary quality of American health care.
| William Bornstein is chief medical officer and chief quality officer of Emory Healthcare. An internist and endocrinologist, he continues to care for patients in addition to leading the quality efforts for Georgia’s most comprehensive health system. |
On the other hand, evidence had been quietly accumulating that all was not well with our health care system. A number of studies published prior to 1999 had begun to make the case that in the midst of these advances, problems of safety and quality were rampant. The Institute of Medicine (IOM) published a pivotal report, To Err is Human, in 1999. While most IOM reports are for the most part known only among those in scholarly circles with interest in a related area, this one turned out to be a blockbuster. By all accounts, it was so by explicit design. The headline, based on inferences from previously published studies, was that medical errors occurring in American hospitals were resulting in 44,000 to 98,000 deaths per year, making hospital errors the eighth leading cause of death in the United States. The IOM followed To Err is Human with Crossing the Quality Chasm in 2001, again making similar dramatic points about the unsatisfactory state of health care quality in this country. Both reports stressed that the issues that had been uncovered were not the result of a lack of highly motivated, highly qualified, highly trained, hard-working health care workers but rather were due to a lack of emphasis on systems design to achieve quality and safety. Moreover, these issues were more problematic in the United States than in most other developed countries.
So, how does one reconcile the apparent paradox of a health care system that has led the way in achieving remarkable advances that have improved the quality of life of millions around the world with major deficiencies in basic quality and safety? I think the issue can best be summarized by what I refer to as “the brilliant versus the routine.” In the process of achieving remarkable advances, our health care system had focused on innovation and individual excellence while failing to apply the same vigor to measuring and improving the more routine aspects of care (including the translation of innovations into standardized and reliably implemented processes of care). Some measure of this imbalance has been reflected in the staggering gap between the U.S. funding of basic biomedical research targeted at developing such innovations and the funding of “health services research,” which focuses on how to best deliver care—in other words, how to ensure that patients receive evidence-based care reliably and safely. We can see one crude estimate of this imbalance by comparing the funding of the Agency for Healthcare Research and Quality (AHRQ), which focuses on health care delivery, with that of the NIH, which emphasizes basic biomedical discovery. When To Err is Human was published, the predecessor of AHRQ was funded at a level of $171.055 million. That same year, the NIH’s budget was $15.6 billion. By 2011, the gap was narrower but still enormous, with President Obama’s budget for FY 2011 requesting $611 million for AHRQ and $32.2 billion for NIH.
Meanwhile, the costs of U.S. health care have been rising considerably faster than the gross domestic product and are adding to the present U.S. economic crisis and imperiling future American prosperity and competitiveness. While considerable progress has been made in improving many of the measures of quality and safety illuminated by the IOM and other reports, progress has not been fast enough—despite the staggering costs of U.S. health care and the unsustainable rate of increase of those costs. Since the work of collecting, analyzing, and reporting data and improving performance has added to the costs of care, one could wonder whether we can afford to continue to expand these activities, which currently are in many ways still rudimentary.
I think we have, indeed, reached a pivotal moment for our health care system. While the details will continue to be battled over in Washington and elsewhere, we can be confident that health care providers that thrive in the future will be those who can provide patients and their insurers with better outcomes for lower costs (loosely described as better “value” in health care reform lingo). This will be a sea change from our present system, which largely ignores outcomes and rewards interventions, whether effective or not and whether successful or not. Thriving—and indeed surviving—as health care providers will require a new expertise in reliable process design and waste reduction. The lament that health care is different because each patient is unique in no way diminishes the importance or feasibility of such approaches. Indeed, many industries unassociated with health care have achieved “mass customization” through targeted and selective standardization, which paradoxically facilitates appropriate individualization.
Health care came late to the party in recognizing that the “how” of designing and implementing reliable and efficient processes requires training and sophisticated expertise. So does knowing “what” care to implement, which has been the focus of traditional medical education and training. Going forward, modern improvement strategies such as Lean and Six Sigma will be essential components of the toolsets of health care providers.
Emory Healthcare (EHC) has made substantial commitments to improving quality over the past several years. Setting ambitious goals is perhaps the single most important step to achieving breakthrough improvements, and in 2006, the EHC board challenged leadership to achieve top 10 status by 2012, as judged by the University HealthSystem Consortium Quality & Accountability Scorecard (considered the best overall quality benchmarking system). The year that goal was set, Emory University Hospital (EUH) and EUH Midtown were in the bottom half of the pack in that scorecard. But in 2011, both met their goals, achieving 10th and 11th place rankings, respectively, out of 101 ranked hospitals.
So how did the EHC make the unparalleled tandem improvements to get to these ranks? It built on the cultural foundation of the EHC care transformation model, which puts patients and families at the center of care decisions along with the attributes of a fair and just culture, transparency, cultural competency and diversity, and shared decision-making. The model’s goal is to offer a promise of quality to patients that they will receive impeccable outcomes and excellent service. To do so, it also drew on the educational infrastructure of the EHC Quality Academy, which has received national recognition. And it made targeted investments in health care information technology, along with many other specific initiatives.
The challenge for the system now is accelerating these improvements even more while at the same time cutting costs. The Emory Clinically Integrated Network (CIN), which we are currently building, is a network of providers who share data sets to improve care. It will provide a platform for Emory providers to collaborate more effectively with community partners to achieve these quality goals. Health care information technology—leveraging the EHC Health Information Exchange (HIE)—will be an important asset for achieving these goals. The HIE will facilitate the sharing of electronic information between EHC and private practice physicians who participate in the CIN to provide data for improvements in quality and value. However, the most important ingredients will be having the commitment and confidence to set ambitious goals and then to relentlessly pursue those goals through the application of the most effective available tools.
U.S. health care providers, led by our academic medical centers, must continue to lead the world in the development of new diagnostic and therapeutic interventions. At the same time, we must apply the same intellect, talent, and spirit of innovation to the pressing problems of improving the reliable and safe delivery of care. By enhancing value, we can afford to provide care for all citizens without undermining national economic vigor. In fact, we can’t afford not to do it.
