By JOSEPH M. SMITH, MD

US Healthcare is sick and getting sicker, and while its chaotic complexity suggests to many that it will need to fail big before it can be rebuilt, some simple rules may help to get it back on track. As this the time of year when many of us prepare to send our children on grandchildren off to school in the hopes that they will learn what they need to succeed, I thought we could revisit the lessons of Kindergarten and their application to healthcare. The following list, initially from “ALL I REALLY NEED TO KNOW I LEARNED IN KINDERGARTEN” by Robert Fulghum.  has been adapted (read ‘man-handled’) for applicability to US healthcare. You’ll find the original list here:  http://www.robertfulghum.com/

• Share everything – In healthcare, this means share ALL the data, all the information, all the acquired wisdom. Interoperable systems are essential. Price transparency is the right side of history. Automated, coordinated, connected systems are essential.  Healthcare is too much of a team sport not to share all that we know, so that we can quickly understand what works, what doesn’t, and what it’s all going to cost.

• Play fair – It isn’t fair when decisions are made without a person’s input.  It isn’t fair that a patient should bear the risks, the pain, the scars and the costs without having unfettered access to all the relevant information. Shared decision making is part of playing fair in a world where healthcare is meant to happen for patients and with patients, but not to patients.

• Don’t hit people. – We must avoid ‘hitting’ patients with costs they can’t bear, or complications they didn’t know could happen. We should avoid ‘hitting’ clinicians with unsophisticated systems that complicate their lives and distract them from their patients. We need to stop ‘hitting’ innovators with unanticipated or needlessly complicated regulatory hurdles. And we need to work hard to have all of us avoid the ‘hit’ of a financially and logistically unsustainable healthcare system.

• Put things back where you found them. Except for things like an infected appendix or a malignant growth, this continues to make great sense.  And as we go about transforming healthcare, we must recognize that wholesale, sweeping changes are easier to envision than execute.  While progress requires change those changes that align with / enhance / expedite existing workflows will be easiest to achieve.

• Clean up your own mess – Healthcare is big enough that there are messes everywhere. We should favor local control over central planning. Patients must bear some responsibility for the consequences of their life-style choices that might be reflected in their insurance costs. Hospitals must monitor and manage their own quality metrics. Medical boards need to step up their efforts to spotlight and sanction professional inadequacy.  Our federal government must do a better job of limiting inappropriate payments in healthcare. If each of us cleans up after ourselves, things get better quickly.

• Don’t take things that aren’t yours. We must stop stealing money from families for tests and treatments that do not work, or work less well than less expensive alternatives.  We must stop stealing time from clinicians by imposing regulations and requirements that add to their administrative burden without aiding them in the care of their patients, or asking them to perform repetitive functions or complex tasks better left to smart devices). And we must stop stealing opportunity from all, and refuse to tolerate a status quo that has a disproportionate share of our national budget being spent on a sub-par healthcare system.

• Say you’re sorry when you hurt somebody. Lets admit that no part of the healthcare enterprise is perfect. Clinicians make mistakes, technology has inherent limitations, drugs have side-effects. We must acknowledge that risk is the price we pay for the innovation we desperately need. Defensive medicine, unwarranted malpractice claims, and expensive and lengthy product liability suits can all add friction to a process already struggling under its own weight.  While those harmed must be appropriately compensated, well-intentioned imperfection must be tolerated and not punished to the point where we frustrate needed progress.

• Wash your hands before you eat. Lets wash everything (hands, stethoscopes, elevator buttons) to avoid further challenging the sickest/weakest among us.

• Flush. – Oh, the things we should flush. Lets flush things like late-night advertisements (I-800-SUE THEM) that appeal to the angels of lessor mercies and exploit our tort system to further burden our healthcare system.  Lets flush the distortion resultant from a 24-hour news cycle and Catastrophic News Networks that so highlight tragedy and failure that we have a stilted view of our healthcare successes. Lets flush the amazing pricing variation for similar services in slightly different locations or practice settings, and lets flush the waste, fraud and abuse that contributes a full third of our already swollen and inflamed healthcare spending.

• Warm cookies and cold milk are good for you.  Comfort foods are their own incentives, and a national epidemic of diabesity proves that incentives work.  In healthcare, shouldn’t we align incentives with the desired behavior and make those things that are good also easy. Let’s use comparative effectiveness results and pursue value-based insurance design so that those things (tests, treatments) that are truly good for you are also financially attractive for you to use/receive.

• Live a balanced life – learn some and think some and draw and paint and sing and dance and play and work every day some. Lets instill balance in healthcare, and be sure to include the full gamut of human needs in the prescription – its not just about potent pills and high-tech devices to treat illnesses, its also about lifestyle choices and social needs. And lets remember that “healthy days at home” may mean more to patients than HEDIS measures or cost-effectiveness ratios.

• Take a nap every afternoon.  A nap is still good advice.  Lots of studies point to the value of good sleep (for everyone).

• When you go out in the world, watch out for traffic, hold hands and stick together.  While healthcare is a team sport, lets be clear that personal responsibility is essential, as it is personal choices that determine billions of dollars of healthcare spending. And shouldn’t we act more like a team and advance care coordination to reduce fragmentation and duplication of services whenever possible?  And as we look out for risky settings, lets be much more clear that simply being in a hospital is a very risky proposition.

• Be aware of wonder. Remember the little seed in the Styrofoam cup: the roots go down and the plant goes up and nobody really knows how or why, but we are all like that. Medicine is a cross between and art and a fledgling science.  Lets be clear that we know much less than we should, and that much of what we believe we “know” turns out to be wrong.  Lets always appropriately caveat our guidance with our uncertainty, admit that our understanding is substantially incomplete, and be willing to learn from each new encounter.

• Goldfish and hamsters and white mice and even the little seed in the Styrofoam cup – they all die. So do we.  Lets embrace the undeniable truth that death is not a medical defeat to be avoided at all costs, but an intensely personal closure that deserves thoughtful preparation with complete respect for patient and family values.
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• And then remember the Dick-and-Jane books and the first word you learned – the biggest word of all – LOOK.  Lets be aware that healthcare is on a journey, that we are all participants, and each has something to add to the story.  If we keep our eyes open, share what we know, take personal responsibility, play fair, and use hard-won lessons learned from other industries and in other countries, we can doubtlessly transform US healthcare delivery to a sustainable system of patient-centered excellence that we all want and deserve..