2005 Trust Award
Quality in Health Care
The healing profession has a history that goes back more than 6000 years. During much of that time there were only two things that a practitioner of the healing arts could typically do: explain the present (“you have a terrible disease”) and predict the future (“you’re going to die in three months”).
Starting about the turn of the nineteenth into the twentieth century, there was a major change in what it meant to be a physician or a nurse. The change was lead by people like Florence Nightingale, a nurse during the American Civil War, and Sir William Osler, the “great physician,” the father of internal medicine. They and other clinical leaders established the scientific method to explain how we know what we know today about medicine and the delivery of health care. They massively reformed clinical education, reorganized hospitals in the model that we still use today, and put the caring profession on a fundamentally new trajectory.
L.J. Henderson, a professor of medicine at Harvard Medical School, dated 1912 “the great divide.” “For the first time in human history,” he said, “a random patient with random disease, consulting a doctor chosen at random stands a better than 50/50 chance of benefiting from the encounter.” For the first time in human history, we were able to show a population-level benefit through the delivery of health care.
Six thousand years of healing history, but only in the last 100 years can we show demonstrable improvement. A child born in 1900 had a life expectancy of 49 years. A child born 100 years later nearly doubled that, to just under 80 years. Longevity is presently increasing by about 2-3 years with every passing decade. It was Einstein, though, who noted “today’s problems are usually yesterday’s solutions.”
When we separated hospital management from medical practice, we created the “craft of medicine” – the idea of the physician as a stand-alone clinical expert. In a very real sense, it was and still is the duty of the hospital administrator to create an environment and provide resources, while each physician exists within their own intellectual “pocket universe,” as they define individual treatment plans for each of their patients. Beyond explaining the present and predicting the future, the healing professions can now routinely change the future for people who are suffering. But, treatments that are powerful enough to heal can also harm. At least 100,000 Americans die each year from hospital-based, treatment-associated injuries that are, in retrospect, preventable.
The last 100 years have taught other hard lessons: The healing professions are founded on core ethical principles. Physicians and nurses place each patient’s needs before any other goal. Coupled with massive clinical knowledge mastered through formal education and experience, they craft a unique diagnostic and treatment experience for each patient. The healing profession’s promise is that this “craft of medicine,” built around individual expertise, guarantees the best possible results in each instance.
Exponentially exploding biomedical knowledge now exceeds the capacity of the unaided human mind. That creates clinical uncertainty, massive practice variation, high rates of clinically inappropriate care and an inability to consistently deliver even simple, proven therapies to all who would benefit. Our traditional “divide and conquer” solution to complexity — subspecialization — has reached its limits. Human beings are more than the sum of their anatomic, physiologic, and genetic parts. The resulting clinical complexity has produced a chaotic delivery system that bewilders patients and challenges health professionals. In fact, I would argue that today no physician, no matter how intelligent, how dedicated, how well educated, could effectively manage within the health care system today to consistently achieve best outcomes for all patients who seek their help. At the same time, these practices have also fueled unsustainable growth in health care costs.
There is an alternative, complementary, and proven method to manage complex environments. ”Mass customization” was first developed in industries outside of health care. It is based around teams — physicians, nurses, pharmacists, therapists, technicians and administrators — that can work together, building evidence-based, best practice guidelines. Teams that can plan, staff, train and supply to a shared baseline. More importantly, shared baselines provide the foundation for clinical data automation – a truly effective electronic medical record.
As teams use “shared baseline” evidenced-based standards of care, health professionals are in a better position to adapt it to the unique needs of individual patients. A shared baseline approach typically reduces complexity to about 5 to 15 percent of what an individual clinician faces without a team-based approach. It allows the focusing of our most important resource – the trained human mind – to those areas where it can be most effective and productive. Finally, using a more structured care environment, we are in a much better position to gather data, measure results, and systematically improve clinical outcomes while reducing costs.
Said another way, care delivery is now a team-based enterprise. It is no longer feasible for an individual clinician to treat a patient, acting alone. In almost every care context today, clinical excellence requires a team of health professionals. Too often, though, we aren’t working effectively enough together, as teams to significantly improve the quality and safety care we are trying to deliver to our patients.
As health professions, we are moving from the craft-based approach that has been defined over the last 100 years, to an evidence and team-based practice approach – clinical teams who can work together to control complexity and better serve the needs of our patients. It is not just physicians who are facing a need for change; it is also administrators, nurses, and all the other clinical disciplines that make up our care continuum.
In coming to my current position, I followed 2 separate tracks. I first trained as a physician – one of those “craft experts.” I then moved into the leadership of a care delivery system. During this process I have learned something about organizations. It really is about sharing abilities, and about personal relationships. It is about having the reliability and trust that are so essential to really make things happen. In that context, I stand before you to report that what I have just described is working. It is not just working in Intermountain Health Care, but in many care delivery organizations across the United States and around the world. We are seeing major changes in care delivery - frankly, far better care - in a diverse array of locations and circumstances. I realize that mass customization still isn’t a dominant practice in health care today, but we are well past the critical tipping point. The health professions, and care delivery systems, are rapidly transitioning from craft-based medical practice to evidence-based, team-delivered care.
That brings us back to the changes that were made within our professions 100 years ago. At the end of his career, Sir William Osler had returned to Great Britain. He had been knighted for his contributions to the human condition through medical practice. In 1916, he was speaking at the dedication of the Phipps Clinic in England, to a new generation of young physicians who had just entered clinical practice. The core of his remarks documented the massive change that he had seen during the course of his career: “I feel sorry for you, young men (and women) of this generation,” he said. “You will have great victories. Standing on our shoulders you will see far, but you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools, remodeled hospitals – a new outlook for humanity – is not given to every generation.”
Today, we in care delivery are poised at a similar crossroads. We have the opportunity to redefine what it means to be a physician, a nurse, a hospital administrator – to fundamentally redefine what we can achieve for those who seek our help. That is not given to every generation. It goes without saying that this can be both a blessing and a curse, to live within such interesting times. The pressures are immense … but what an opportunity!
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