(Hat-tip to Modern Healthcare for spotting this one). While there was lots of fuss about the IHI 1OOK lives campaign recently and whether it did or didn’t meet its target—and the NY Times gave it a pat on the back this morning in the Editorial section—there’s perhaps even more important news from a study published in JAMA today. A large multi-center team looked at the Medicare data for performance measures on post-heart attack patients with regard to how improved processes related to outcomes. These measures are the bedrock of the “we know what to do, but we don’t know how to do it” meme of IHI and the quality movement. In other words, the theory is that if we just did it all as well as the literature says we should, then there is potential for vast improvement. Unfortunately the outcomes are sobering for those of us who believe that if you apply relatively simple industrial processes to medicine it can markedly improve outcomes (and lower costs too).

We found moderately strong correlations (correlation coefficients 0.40; P values <.001) for all pairwise comparisons between -blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures (correlation coefficients <0.40; P values <.001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates (P values <.001) but together explained only 6.0% of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI.

In other words, even when the hospitals did well on the performance measures, it only explained a small fraction of the overall variation in outcomes. So there are to my mind only two possible conclusions. Either performance measurements and controlling process variation don’t matter too much, or we actually—in this case at least—don’t know what works. Neither one is a particularly satisfying explanation.

It’s a quiet return around here from the prolonged July 4th weekend. Meanwhile, there’s a new sponsor at THCB. This time it’s a  book called “On Track To Quality” by James Todd, a pediatrician at Children’s Hospital in Denver. The book is a philosophical investigation into quality, involving not a motorcycle trip, but a train journey.  Interesting stuff, and a longer review will be forthcoming shortly.

Here’s my last ever FierceHealthcare editorial. The FierceMarkets team is taking the editorializing of FierceHealthcare back in-house and I wish them luck. It’s been fun for me (and John Irvine who’s supported me all the way) to work on this over the past couple of years, but I’m happy to get away from the deadline grind and concentrate on THCB and my consulting work. And hopefully I’ll find the time to start working on that book I’ve been threatening you all with. Anyway my last editorial is about the two biggest themes in health care—fixing process and fixing insurance.

Perhaps the dominant theme of the decade in healthcare has been patient safety. Since the 1999 IOM report, hospitals and doctors have focused on improving the medical error situation. Last week, Don Berwick’s IHI announced that a precise number of lives (123,000 and change) had been saved since the voluntary 100,000 Lives Campaign started. This week, the carping started with The Wall Street Journal suggesting that the IHI numbers were inaccurate. Commenters also started down the path of whether saving the "life" of a severely ill patient who was going to likely die soon anyway was all that important–or at least as important of saving the life of an otherwise young healthy patient.

But beyond questions about the data, there are two crucial related points we must hold onto. First, medical errors are symptoms of poorly designed medical processes, and we know that reducing "muda"–waste in medical care–is an achievable goal. Second, patients are not just vulnerable to physical harm from interacting with the healthcare system, they’re also extremely vulnerable to financial harm caused by that "muda" and facilitated by our dog’s breakfast of an insurance and financing system. These are two sides of the same coin, and efforts like the 100,000 Lives Campaign should be applauded for focusing on at least part of the problem. It would be nice if there was a similar system-wide commitment to concentrate on the whole of the cost and care crisis rather than just one part.