a new design for healthcare delivery - the boston globe

local search site search

sign in | register now
hometoday's globenewsbusinesssportslifestylea&ethings to dotravelcarsjobsreal
estatelocal searchcity & regionnationworldglobe businessglobe
sportsliving/artsopinionobituariesregional editionsideasmagazine

this story has been formatted for easy printing

home / globe / opinion / op-ed steven j. spear and donald m. berwick

a new design for healthcare delivery

email|print| text size � + by steven j. spear and donald m. berwick
november 23, 2007
more stories like this
the sax pack
seattle trolley makes maiden run
bank will cut costs, 3,150 jobs as loan losses roll in
answers on distance aren't always in the stars
stem cell stars found company to reprogram adult cells
the choice between expanding health coverage and controlling healthcare costs is
a false choice based on a false assumption: that resources committed to
healthcare are used efficiently and effectively. the mistaken notion makes
budgeting the key decision and masks a much better alternative. there is ample
evidence that better care could be provided to more people at lower cost if care
delivery were organized in a more sophisticated fashion.
today, healthcare is delivered as it was 50 years ago, when only a limited range
of illnesses could be detected and treated, and when even the most sophisticated
treatments involved only a few professionals. professionals were organized in
silos: nurses in one, various types of doctors in others, and so forth. grouping
by peers afforded the benefits of professional association, such as sharing
knowledge, setting standards, and camaraderie, and, for simple treatments, ad
hoc, informal coordination across silos was adequate, management of patient
information was simple, and piece-rate payment - paying a certain amount for
each person's time - worked fine.
medical science has advanced dramatically. once-terminal diseases are now
manageable - like aids - and even curable - like many cancers. but, care
delivery, information, and payment systems have not kept pace with the science.
professionals are still organized in silos, despite the pressing need to
integrate their work into coherent processes; information is still fragmented,
despite the benefits of holistic views of patients; and payment is still
piece-rate even though practitioners are no longer in any meaningful sense
independent of each other.
the consequences are destructive. too little preventive care increases the need
for chronic care. ineffective chronic care for diabetes, heart disease, and
depression increases the need for costly acute care of limited effectiveness,
and which often causes needless harm. the chance of being injured by hospital
care is greater than one in 10, and the chance of accidental death due to
mismanaged care is about one in 300. problems are so pervasive that medicare
announced it will withhold payment for fixing some of the problems created by
defects in care.
needless suffering from badly delivered care is tragic; squandering hundreds of
billions of dollars is unconscionable. in part because of these inefficiencies,
the united states spends twice as much on care, per capita, as other developed
nations do. us government spending alone on healthcare is enough to buy all of
the healthcare per capita in many developed nations.
there is an alternative. some organizations have started emulating outstanding
nonhealthcare organizations in actively managing how the process, information,
and payment pieces mesh together. the results have been sometimes spectacular.
pioneers have reduced rates of hospital-acquired infections, falls, medication
errors, and other complications - symptoms of fragmentation - by 90 percent and
more, saving thousands of lives and hundreds of millions of dollars. ascension
health, the largest catholic healthcare system in the united states, reports
pressure ulcer rates in its 67 hospitals 93 percent lower than the national
average, birth injury rates 74 percent lower, and patient falls 86 percent
lower. virginia mason medical center in seattle targeted its gastroenterology
department, freed capacity, saved millions of dollars in capital investments,
and increased access by 50 percent. it taught its migraine patients how to avoid
and manage recurring pain, thereby reducing emergency department visits for this
by 50 percent, with sharp reductions in expensive imaging, contrary to trends
for the broader, non-vmmc population of migraine sufferers. mayo clinic has
reported more than a 50 percent drop in rates of medical injuries to patients in
all three of its flagship hospitals. hospitals that have adopted better
processes to deal with 11 common challenges - such as acute heart attacks,
patients on ventilators, early identification of deteriorating patient
conditions - championed through the institute for healthcare improvements 5
million lives campaign, have documented major improvements in outcomes.
if these stories were national norms, not exceptions, the benefits to patient
well-being and to costs would be staggering. getting there need not be a
fantasy. hospitals, nursing homes, dialysis units, ambulatory surgery centers,
and physician offices can improve the reliability of its own processes, and
their coordination with other organizations, in managing preventive, chronic,
acute, and urgent care. medical, nursing, pharmacy, and other professional
schools can complement medical science training with training in managing
complex work systems, preparing their graduates to be excellent in their roles,
and also in tying the pieces together in total systems of patient care.
insurers, employers, and other payers can change their buying patterns, to
demand and reward coordination and uncompromising process excellence across the
entire care continuum. since the public sector is the nation's largest payer,
and it supports large medical schools, it can insist on system improvement.
this is a hard sell. the wonk factor is high. focusing on improving the
processes by which care is delivered lacks the rhetorical punch of advocating
for universal coverage. making healthcare processes better is more diffuse work,
done at the organizational level, not through dramatic legislative, regulatory,
or fiscal flourishes. it requires leaders to get into the nitty-gritty of
patient care, finding deficiencies in current approaches, confronting
professional norms and habits that overvalue autonomy, tolerate unscientific
variation in practice, and undervalue cooperative behaviors, and making
continual improvements. but a strong link exists between the moral obligation of
universal care for americans and the hard work of redesigning and improving
healthcare processes. indeed, given the costs and waste in the healthcare status
quo, redesign may be our only sustainable route to justice and financial
solvency.
steven j. spear is a senior lecturer at mit. donald m. berwick is president &
ceo of the institute for healthcare improvement in cambridge.
� copyright 2007 globe newspaper company.
more stories like this
email

email

print

print

single page
 single page

reprints

reprints

share

share

comment

comment

share on digg share on facebook save this article powered by del.icio.us

your name

your e-mail address

(for return address purposes)

e-mail address of recipients

(separate multiple addresses with commas)

name and both e-mail fields are required. message (optional)

disclaimer: boston.com does not share this information or keep it permanently,

as it is for the sole purpose of sending this one time e-mail.
ads by googlewhat's this?

cis for icu, ob, and or

from philips medical systems learn more.
medical.philips.com/cis
caring for troubled teens
find success helping others as year-round youth counselor
www.eckerdyouth.org
healthcare marketing?
find customers with google adwords get your ad online in just 15
mins!
adwords.google.com

advertisement

inside boston.com
photo gallery

scenes from thursday's storm

things to do

find out what's happening this weekend, like this pillow fight
sports > photo gallery

fallen icon? a look back at some clemens highlights

news
 remembering those who died in '07
plus...
blogs |games |podcasts |puzzles |personals |movie listings |classifieds
|globe magazine most popular
e-mailed searched
most e-mailed stories
heavy snow grinds traffic to a standstill
the region's first big one
celtics rule again
snowy standstill

rising falling | full list | about

see full listhot searches

� weather
� globe santa
� cheap eats
� celtics
about this list
more in search
home| today's globe| news| business| sports| lifestyle| a&e| things to do|
travel| cars| jobs| real estate| local search
contact boston.com | help| advertise| work here| privacy policy| mobile| rss
feeds| make boston.com your homepage
contact the boston globe| subscribe| manage your subscription| advertise| the
boston globe extras| the boston globe store| � 2007 ny times co.