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Why Best Practices Haven’t Fixed Health Care

In 1999, the Institute of Medicine reported that American health care was decidedly dangerous for patients. One in every few hundred was hurt, and one in every few thousand was killed by medical misadventures. The cause was not malfeasant individuals; it was inadequately designed and operated systems of care delivery.

Since then, health care providers have invested in a variety of initiatives aimed at improving safety: Electronic order entry to minimize medication mistakes, “kaizen blitzes” and other improvement projects to “lean out” unwieldy processes, checklists to ensure instruments aren’t forgotten inside patients, and countless patient safety conferences.

According to findings published recently in The New England Journal of Medicine, things have not improved. Researchers looked at performance changes in North Carolina hospitals supposedly doing the right things and therefore assumed to be representative of organizations on the cutting edge in improving quality and safety. Their findings: The needle on patient well-being had moved insignificantly.

The only reasonable explanation for this disparity between effort and outcome is that health care leaders are not investing in the right operational changes to achieve excellence in safety, affordability, and capacity.

This conclusion is based on my 10 years of experience helping providers improve care delivery and the documented fact that some select providers have generated profound, across-the-board benefits. They have eliminated complications like ventilator pneumonia and central-line infections, increased capacity, and reduced their costs.

These disparities in outcome are directly attributable to differences in approach.

Unfortunately, many health care organizations continue to cling to the view that improvement can be achieved by purchasing one-off interventions. Their thinking: If they implement enough best-practice bundles here or there to remove the problem and hire enough outsiders to lead improvement projects, things should get good enough. But the sad reality is while this approach will generate improvements, they will not be significant and sustainable.

Why not?

Providing care is complex work requiring well-integrated involvement of people spanning multiple disciplines. Even seemingly “simple” primary-care visits involve administrative staff, doctors, nurses, medical assistants, and technicians. Managing chronic illness, urgent and intensive care, and surgery involve even larger casts. Not only does the number of people make managing care delivery challenging, so do the interdependencies what one person does affecting and being affected by what many others do.

In short, system complexity is the essential challenge. As a result, those responsible for managing the delivery of care need a methodical approach for designing systems; they can’t manage the individual specialties and expect the whole to come together serendipitously. They also need a methodical approach for making things better a reliable approach for generating improvement and innovation.

The very best deliberately create end-to-end “service lines,” manage them across the disciplinary boundaries that often lead to the fragmentation of care, and train themselves and their colleagues to recognize when something is amiss: sterilized equipment that cannot be located, medications that are easy to confuse, orders which are ambiguous, or a patient whose condition is drifting unexpectedly. When they see these abnormalities, they swarm them both to prevent problems from propagating and to understand why they occurred so their recurrence can be prevented. More often than not, there aren’t silver-bullet solutions. Rather, the whole of the cumulative effect is far greater than the sum of many adaptations.

What does this mean? Health care leaders have to realize that safety cannot be bought like a new diagnostic tool; it has to be earned by engaging health care professionals broadly in seeing and solving problems and incorporating new learning as part of their daily work. (See the HBR articles “Fixing Health Care from the Inside, Today” and “Fixing Health Care on the Front Lines” for what this looks like in practice.) For most, this is a profoundly different approach, which requires a new style of leadership. Those most senior have to lead the charge and cannot delegate the responsibility to a continuous-improvement staff. Hopefully, more will, so when the next study is done, we’ll find that health care has improved in quality, access, and affordability.

Date: April 11, 2014

Medical Malpractice

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