Transforming medicine and saving lives

This week, Don Berwick will announce the results of the 5 Million Lives Campaign
before thousands of people in Nashville attending the National Forum on Quality Improvement in Health Care.

Twenty years ago, it was almost heretical to question the quality of American health care. The common refrain being that it was unarguably the best in the world.

Decades of work by Berwick and others, however, have dispelled that myth, and the underlying belief that medical errors and hospital acquired infections are simply an artifact of the business. These quality champions deem it unacceptable that as many as 98,000 Americans die annually from preventable medical errors, and that most Americans receive the recommended care only half the time. They’ve spent years building their case, and in turn created a social movement around their cause.

In the book, "The Best Practice," Charles Kenney chronicles this long march toward a culture within American health care that demands continuous quality improvement.

The book was published in July. I finally finished it a month ago and just now getting around to writing about it, but I guess my timing works well with the Institute for Healthcare Improvement upcoming convention.

"The Best Practice" is an amazingly readable book. My amazement is not a reflection on Kenney’s writing, but rather that he managed to make health care quality interesting for nearly 300 pages.

He succeeded by introducing readers to characters. There’s heroism and tragedy at the forefront, and the science, research and business cases are woven into the background.

The heroes include, but are not limited to, Berwick, Paul Bataldan, Lucian Leape, Rick Shannon, Paul O’Neill and Peter Pronovost. These leaders took on "the establishment," learned from other industries and rejected the notion that medical errors weren’t preventable. Then, they spread their enthusiasm and mission to others.

We also meet the victims of tragic errors, such as Boston journalist Betsy Lehman, who died from a chemo overdose at the Dana Farber Cancer Institute, and toddler Josie King, who died of dehydration at Johns Hopkins Hospital. The reader quickly learns that if such errors can occur at these prestigious institutions, surely they must not be anomalies.

Five chapters are essentially case studies of specific efforts at Virginia Mason Medical Center, the Pittsburgh Regional Health Initiative, the Cincinnati Children’s Hospital, Kaiser Permanente and Jonkoping County, Sweden. Each case makes a distinct point.

With the Kaiser example, for instance, Kenney points out the importance and opportunity that integrated systems and linked electronic medical records have for improving quality.

Kenney takes us to a county in Sweden, where the people are already healthier than most others in the world, but whose leaders continue working hard and innovating to further improve the quality of health care.

Throughout the book, Kenney weaves in the seminal research that provides the foundation
for the quality movement: The Institute of Medicine’s "To Err is Human"
which estimated up to 98,000 people die annually from preventable
medical mistakes; and its subsequent report, "Crossing the Quality

Kenney also introduces readers to the work of Elizabeth McGlynn, of RAND Health, whose frequently cited studies calculated that Americans receive the recommended care only about half the time.

He quotes McGlynn describing her findings to Congress: "Overuse occurs when a patient is given an intervention for which the expected risks substantially exceed the expected benefits. Underuse is the failure to provide services when the expected benefits are greater than the expected risks. Errors are mistakes in the provision of services that have the potential to result in serious adverse consequences for the patient."

My main criticism is that Kenney so narrowly focuses on the quality movement within the hospital and structural health care system. If we truly want to do something about the fact that Americans receive the recommended care only half the time, we must look at underlying factors that go well beyond whether a hospital system can model itself after Toyota.

The Institute for Healthcare Improvement has recognized a need to expand its mission and focus on improving health care at the population level. In the last few pages, Kenney mentions IHI’s new mission called the Triple Aim. The three simultaneous aims are guaranteeing high quality care for individuals, improving health of the population and reducing the cost of health care per capita.

"The Best Practice" reminds us that a philosophy of quality improvement is about people. It’s about the patients who become victims of errors. It’s about the doctors and nurses working to innovate and improve care. It’s about the hospital administrator who is dedicated to full transparency despite the risk of a public black eye. And it’s about the janitor who recognizes a faulty cleaning process.

Quality improvement, Kenney tells us, is about teams of people working together to establish systems that protect patients, protect clinicians and reward progress.

5 replies »

  1. Matthew,
    I haven’t read those books, though I thought about asking Michael Millenson’s opinion and then forgot.
    Best Practice reminded me of a cross between Shannon Brownlee’s “Overtreated” and Tracy Kidder’s “Mountain Beyond Mountains.” In the latter, Kidder makes Paul Farmer sound like a public health god. Farmer certainly deserves recognition, but he’s not without his critics.
    Here, Kenney follows a similar pattern of making Berwick and the quality folks look infallible. He also mostly ignores the negatives of the quality movement … but I don’t really know what those are so I can’t comment.
    What I did appreciate about the book was that it gave a newcomer to the subject area, like me, a thorough background and made it interesting.

  2. Neimon your responding to comment spam. Sorry-I took it out
    Sarah–nice piece (glad you read the book even if I didnt!). Did you think that Kenney got a little too close (fawnish) to Berwick to be objective? I’d heard that tidbit? It was certainly the case in the Seltzer/Berry book about “Management Lessons from the Mayo Clinic” that I read (and didn’t review on THCB) which essentially just a long infomercial — albeit about a terrific institution. http://www.amazon.com/Management-Lessons-Mayo-Clinic-Organizations/dp/0071590730
    Finally, have you read Demanding Medical Excellence by our very own lad Michael Millenson? Written in the mid 1990s about similar topics…. give it a try http://www.amazon.com/review/product/0226525880/ref=cm_cr_dp_all_helpful?_encoding=UTF8&coliid=&showViewpoints=1&colid=&sortBy=bySubmissionDateDescending

  3. “Yes. Every person is accountable for his actions,even if he is a doctor.”
    Really? Even if he’s forced at gunpoint into a camp where he’s put to work as slave labor?
    Even when, through dire economic circumstances beyond his control, he is forced to skip a house payment because he simply doesn’t have the money?
    I do believe in accountability, but I don’t believe in blanket statements. The trick is that if everyone is solely accountable for their actions, it leaves out a person’s effect on someone else. I can hit someone with a stick and plausibly claim it’s that person’s fault for being in the way of the stick.

  4. We have been advocating the same..but our definition of quality goes beyond the error reduction. While just the medical errors have large impact on healhcare business, we beileve we need to look at the quality of doctors (as in ethics), business management process, prescription, equiment being utilized, and so on.
    A total healthcare transformation is a must and that would require: policy, legislative, information technology, ethics, business management, assets, etc, all to work in sync. We need to go from cure to wellness.
    We offer services in healthcare transfomration and work with the clients to structure the engagement to suit their needs: from daily to profit sharing as the need may be.

  5. The drive towards best practices and quality improvement will become fully operational in healthcare when the following ideas are fully integrated into the process:
    1. Every adverse event begins with a patient complaint that is not heard.
    2. At their core, disparities in health and health care outcomes for minority groups are evidence of inattention to group complaints that are not fully recognized by researchers.
    The one size fits all approach promoted by the U.S. Task Force for Preventive Services fails to take into account regional difference in populations and the contribution this makes to appropriate differences in medical practice.
    Recommendations for best practices need to be flexible enough to accomodate the combined effects of geography and group membership.