Page 1
The Global Perspective on Improving Health
The Welsh Public Health Conference 2015
United in Improving Health:
A Healthier Happier, and Fairer Wales
Cardiff, Wales – November 2, 2015
Donald M. Berwick, MD
President Emeritus and Senior Fellow
Institute for Healthcare Improvement
Page 2
Story #1…
“If you haven’t counted the cells,
they have not been counted.”
2
Page 3
Story #2…
“I’m the doctor, and you will get
penicillin when I say you will get
penicillin.”
3
Page 4
Eliot Freidson:
Profession of Medicine
“A profession is a work group that reserves to
itself the right to judge the quality of its own
work.”
• Technical Knowledge
• Beneficence
• Self-Regulation Freidson E. Profession of Medicine:
A Study of the Sociology of Applied Knowledge.
(New York: Dodd, Mead & Company, 1975)
4
Page 5
A Brief History of Health Care Quality and Safety
Pre-1910: Craftsmen and Apprentices
1910: Scientific Foundations
1970: Studies of System Performance
Page 6
Variations in Spending Across Regions
(Elliott Fisher and Jack Wennberg)
Source: The Dartmouth Atlas of Health Care 2005
$8,580 to $14,360 (61)
$7,820 to < $8,580 (62)
$7,190 to < $7,820 (60)
$6,620 to < $7,190 (62)
$5,280 to < $6,620 (61)
Not Populated
Page 7
Variations in Spending Across Regions
(Elliott Fisher and Jack Wennberg)
Source: The Dartmouth Atlas of Health Care 2005
$8,580 to $14,360 (61)
$7,820 to < $8,580 (62)
$7,190 to < $7,820 (60)
$6,620 to < $7,190 (62)
$5,280 to < $6,620 (61)
Not Populated
The Care You Get Depends on
Where You Live,
Not What You Need
Page 8
Institute of Medicine –
1999 & 2001
44,000 – 98,000 Deaths per Year
6 AIMS FOR IMPROVEMENT • Safety • Effectiveness • Patient-Centeredness • Timeliness • Efficiency • Equity
Page 9
A Brief History of Health Care Quality and Safety
Pre-1910: Craftsmen and Apprentices
1910: Scientific Foundations
1970: Studies of System Performance
1990: Costs
2000: Accountability and Transparency
Page 10
The Global Health Care Context
Complexity in Production
Aging and Chronic Disease
Prevention Weak
External Scrutiny - Measurement
Politicization of Health Care
Dominant Focus on Cost
10
Page 11
$0
$2,000,000,000
$4,000,000,000
$6,000,000,000
$8,000,000,000
$10,000,000,000
$12,000,000,000
$14,000,000,000
$16,000,000,000
$18,000,000,000
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15
Fiscal Year
Education
Environment & Recreation
Health Care
Human Services
Infrastructure, Housing & Economic Development
Law & Public Safety
Local Aid
Other
Source: Massachusetts Budget and Policy Center
Massachusetts Budget FY 2001 - 15
Page 12
Waste Category Annual Estimates
12
Category Cost to US Healthcare (2011 $B)
Overtreatment $158 to $226 Failures to Coordinate Care $25 to $45
Failures in Care Delivery $102 to $154 Excess Administrative Costs $107 to $389 Excessive Health Care Prices $84 to $178
Fraud and Abuse $82 to $272
2011 Total Waste $558 to $1263
% of Total Spending 21% to 47% (MED = 34%) 12
Page 13
A Face Behind the Need: Gorje
Sanchez
13
Page 14
14 Health Care Expenditures and
Life Expectancy - 2013
Page 15
Population
Health
Experience
of Care
Per Capita
Cost
The Triple Aim
15
Page 16
New Context Meets History: Collision
This all has birthed a vast mismatch
between traditional professional
self-definitions and the evolving
social need.
16
Page 17
Freidson: “Profession of Medicine”
“While the profession’s autonomy seems to have
facilitated the improvement of scientific knowledge
about disease and its treatment, it seems to have
impeded the improvement of the social modes of
applying that knowledge.”
Freidson E. Profession of Medicine:
A Study of the Sociology of Applied Knowledge.
(New York: Dodd, Mead & Company, 1975) p. 371
Page 18
Choluteca River Bridge 1938…
Page 19
19
Hurricane Mitch - 1995
Page 20
But, the River Moved…
Page 21
Model I: Bad Apples
The
Problem
Quality
Frequency
Page 22
Model I: Bad Apples
The
Problem
Quality
Frequency
“Reliance on Inspection to Improve”
Page 23
The Cycle of Fear
Increase
Fear
Micromanage Kill the
Messenger
Filter the
Information
Page 24
Some Consequences of Reliance on
Inspection
Measurement Gone Wild – Adds massive
costs; Distracts from what matters; Objectifies
the crucial subjective
Accountability – Chills dialogue and authentic
exchange; Loses upward information flow
“Skin in the Game” – Afflicts the
disadvantaged; Lacks any evidence base
Standardization – Chills innovation;
Disconnects care from individual patients
Markets – Drives oversupply; Chills exchange 24
Page 25
“The First Law of Improvement”
Every system is
perfectly designed to
achieve exactly the
results it gets.
Page 26
Examples of National Initiatives
England
Scotland
Denmark
Sweden
China
Singapore
… And Wales!!
26
Page 27
National Initiatives: England
Five year forward view
Mid-Staffordshire and culture of safety
Cost overruns
Improvement
– Special measures
– Academic health center networks
– Vanguards
27
Page 28
NHS England’s “Five Year Forward View”
Radical Upgrade in Prevention and Public Health
Great Patient Control over Their Own Care
Better Joining-Up… – GP’s and Hospitals
– Physical and Mental Health
– Health and Social Care
Local Innovation – “Radical New Care Delivery Options” – Multispecialty Community Provider (MCP)
– Primary and Acute Care Systems (PACS)
– A&E, Smaller Hospitals, Midwifery, etc.
Strengthen List-Based Primary Care
Coherent National Leadership
Close the £30B Gap – Demand (Prevention, Out-of-Hospital Care, Carer Support, etc.)
– Efficiency (>2% per year)
– Funding
28
Page 29
Population
Health
Experience
of Care
Per Capita
Cost
Five Year View and Triple Aim
29
• Chronic Disease
Coordination
• Sepsis
• Kidney Damage
• Mental Health Care
• A&E
• “Radical Upgrade in
Prevention and
Public Health”
• Diabetes Prevention
• NHS Staff Well-
Being
• Demand
• Efficiency
• Revenue
Page 30
National Initiatives: Scotland
System-wide planning, avoiding markets
as solution
Scottish Patient Safety Program
Early Years Collaborative and community
health
Strong continual improvement support
systems
30
Page 31
National Initiatives: Denmark
National patient safety campaign
“Citizen-Centered Health Care System”
Elimination of Joint Commission-type
accreditation processes
31
Page 32
National Initiatives: Sweden
Very high-performing system – county-
level funding
Jönköping County – “Hospital” to
“Procedure Home”
Strong structure of registries
Triple Aim goals – completely integrated
care
“Esther Project”
32
Page 33
National Initiatives: China
Five-Year Plan and World Bank project
Expansion of insurance, facilities
Person Centered Health Care
Need to rebalance to primary care
Vast overuse of medications and
hospitalization
Need to reorient to quality as strategy
Need to reorient to prevention 33
Page 34
National Initiatives: Singapore
The Silver Tsunami – Agency for
Integrated Care
SHINE collaborative
Mental health initiative
Long-term care
Hospital construction – environmentalism,
teamwork
34
Page 35
New Rules for Radical
Redesign in Health Care
Page 36
Radical Redesign Principles –
IHI Leadership Alliance
1. Change the Balance of Power
2. Standardize What Makes Sense
3. Customize to the Individual
4. Promote Wellbeing
5. Create Joy in Work
6. Make It Easy
7. Move Knowledge, Not People
8. Collaborate/Cooperate
9. Assume Abundance
10. Return the Money 36
Page 37
Alaska Native People Shaping Health Care • SCF - 2011 Baldrige Winner • CEO 2004 McArthur Genius Winner
Copyright © 2011 Southcentral Foundation. All Rights Reserved.
NOTICE: Unless otherwise indicated, this work represents copyrighted material protected by United States and international law.
This work may not be used, reproduced, downloaded, disseminated, published, transferred or transmitted, in whole or in part, in any form or by
any means, electronic or mechanical, including photocopying, recording or information storage and retrieval, except with the express written permission of
the publisher. This work may not be edited, altered, or otherwise modified, in whole or in part, except with the express written permission of the publisher.
Design: Cooperate
Page 38
“NUKA” CARE SYSTEM
Southcentral Foundation
Anchorage, Alaska, USA
Page 39
Some Nuka Results
Urgent Care and ER Utilization = 50%
Hospital Admissions = 53%
Specialist Utilization = 65%
Primary Care Utilization = 20%
HEDIS Outcomes and Quality = 75-90%ile
Employee Turnover Rate < 12% per year
Customer and Staff Satisfaction > 90%
Page 40
NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G
Design: Move Knowledge, Not People
Project ECHO
Page 42
ECHO Treatment Outcomes:
Equal to University Medical Center
Hepatitis C Outcome ECHO UNMH P-value
N=261 N=146
Minority 68% 49% P<0.01
SVR (Cure) Genotype 1 50% 46% NS
SVR (Cure) Genotype 2/3 70% 71% NS
SVR=sustained viral response
Arora S, Thornton K, Murata G. NEJM 2011; 364:23
Page 43
PEEK:
Telemedicine
at Scale
Design: Move Knowledge, Not People
Page 44
PEEK: 10,000
Children Screened
per Week by
Teachers in Kenya
Design: Assume Abundance
Page 45
DHAT Program:
Could Meet All Dental Health
Needs in Alaska’s Villages
with 70 DHAT’s
Alaska Dental Health AideTherapists - “DHAT”
45 Design: Assume Abundance
Page 46
Question: What Creates Health?
Page 47
Question: What Creates Health?...
Answer: Not Health Care!!
Page 48
420 Students:
20% of pupils in deciles 1-3
35% of pupils in deciles 4-7
45% of pupils in deciles 8
and 10
St Ninian’s Primary
School
Stirling, Scotland
At the Start:
45% of Pupils
Were Overweight
Design: Promote Wellbeing
Page 49
“Fit to play, fit to learn”
St Ninians Primary
School
Stirling
Scotland
Ms Elaine Wyllie
[email protected]
“The Daily Mile”
Three years later,
and, of 57 Primary
One children, not
one is overweight
Page 50
What If? – A New Care System Team (Nuka)
Lean Production (Denver Health)
Technology (PEEK)
Expanding Scope of Practice (ECHO)
Telehealth at the Home
New Workforce (DHAT’s)
Using the Abundance of Patient and Community Capacity
You can’t say, “It can’t be done.” It can be done.
50
Page 51
The Future State –
Most Can Be Winners
51
BURDEN
TIME
CURRENT STATE
FUTURE STATE
Page 52
The Transition State:
Hard for All
52
BURDEN
TIME
CURRENT
STATE
FUTURE
STATE
TRANSITION
STATE
Page 53
A Disruptive Question for the
“Business of Health Care”
What would you do if an
empty bed were more
profitable than a full bed?
53
Page 54
What Were We Thinking?
Recovering the moral
vocabulary that is
foundational in the pursuit
of health and healing.
54
Page 56
My 2007 Advice
1. Declare patient injuries an enemy,
and establish patient safety as a
shared goal.
2. Cease blame. Substitute science.
3. Assess where you are starting.
4. Collaborate with other nations to
pursue “Shared Aims.”
56
Page 57
My 2007 Advice
5. Establish knowledge exchange, and
increase peer-to-peer learning
6. Foster a community of expertise –
Faculty for Quality Improvement
and “Health Care Improvement
Fellows”
7. Reconvene annually to review,
reflect, learn and celebrate.
57
Page 58
So… Where Next for Wales?
• “Constancy of Purpose for Improvement”
• Linkage of Improvement of Care to
Sustainable Cost – A Focus on “Muda”
• Broadening the Agenda – beyond Safety
to Embrace All Dimensions of “Goodness”
• Lead the World in Community-Wide
Design and Improvement
• Push the Boundaries of “Patient and
Family Centered Care” (PFCC)
Page 59
Design of Integrative Care
1. Place the Patient at the Center
2. Individualize
3. Welcome Family and Loved Ones
4. Maximize Healing Influences within Care
5. Maximize Healing Influences outside Care
6. Rely on Sophisticated, Disciplined Evidence
7. Use All Relevant Capacities – Waste Nothing
8. Connect Helping Influences with Each Other
Page 60
[email protected]
The IHI Open School for
Health Professions:
254,000 Students
72 Nations
760 Local Chapters
www.ihi.org
Page 61
Congratulations, Wales!
Prudent Health Care –
Lead the Way for the World
61