quality: an imperative for organizational survival · ethanol (and other recreational drugs) mdd...

Quality: An Imperative forOrganizational Survival

Brent C. James, M.D., M.Stat.Executive Director, Institute for Health Care Delivery ResearchIntermountain HealthcareSalt Lake City, Utah, USA

University of Texas System Clinical Safety & Effectiveness Building the Bridge at the Quality Chasm

Renaissance Hotel, Austin, TexasFriday, 16 October 2009 -- 7:15a - 8:45a

Disclosures

The content of this presentation does not relate to any product of a commercial entity; therefore, I have no ethical conflicts or relationships to report. I have no financial relationships beyond my employment at Intermountain Healthcare.

The roots of reform ...

Part 1

46 million people without health insurancecost increases that are bankrupting the country

Total health: How long, how well we live

~40%Behavior: Tobacco

Ethanol (and other recreational drugs)MDD (movement deficit disorder - obesity)Sexually-transmitted disease (AIDS)Unwed teenage pregnancySuicide, violence, & accidents (young men)

McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA 1993; 270(18):2207-12 (Nov 10).McGinnis JM, Williams-Russo P, & Knickman JR. The case for more active policy attention to health promotion.

Health Affairs 2002; 21(2):78-93 (Mar).

Genetics~30%

Environment / public health~20%

Health care delivery (hospitals and clinics)~10%

The Great Equation:

Health = medical care

"But the Great Equation is wrong ..."

Aaron Wildavsky. Doing better and feeling worse: the political pathology of health policy. Doing Better and Feeling Worse: Health in the United States, John H. Knowles, ed. New York: W.W. Norton & Co., 1977.

and medical care = "access to care"

Health spending

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

2015

0

5

10

15

20

25

% G

ross

Dom

estic

Pro

duct

0

5

10

15

20

Tota

l $ p

er U

S ci

tizen

(tho

usan

ds)

2,281

4,729

3,762

6,683

9,173

12,357

148 357 1,106

$906

$1,040

$2,376

$0 $500 $1,000 $1,500 $2,000 $2,500

Source: Kaiser Family Foundation, Wall Street Journal, 22Feb06

Healthcare - or a house?

Insurance premium - family coverage at

national average rate

Mortgage paymenton national median-value

($211,000) home

Health care delivery burden fora typical family of 4 when

insurance-funded and tax-funded care are combined

NoncitizensEligible but not enrolledTemporarily uninsured (job change)

Free riders (income > $84,000)

Long-term uninsured

9.5 million (~20.7%)

12 million (~26.1%)

9 million (~19.6%)

7 million (~15.2%)

8 million (~17.4%)

The uninsured - who are they?

Source: Rep. Lamar Smith, Christian Science Monitor, 16Aug09

1960 1965 1970 1975 1980 1985 1990 1995 2000$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

U.S

. Dol

lars

(tho

usan

ds)

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

United StatesCanada

Sweden United Kingdom Germany

Health cost per resident, by country

1960

1965

1970

1975

1980

1985

1990

1995

1996

1997

1998

1999

2000

2001

2002

Birth Year

65

70

75

80

85

Year

s ex

pect

ed li

fe

65

70

75

80

85United States Sweden United Kingdom Germany

Life expectancy at birth, by country

1960 1965 1970 1975 1980 1985 1990 1995 20000

5

10

15

20

25

30

35

# de

aths

per

100

,000

birt

hs

0

5

10

15

20

25

30

35

United StatesCanada


Infant mortality per 100,000 births

What do we get for all that money?

1. Total health -- how long and how well we live

2. High touch -- patients value their relationship with a trusted clinical advisor more than any other element in health care delivery (the clinician-patient relationship)

W. Edwards Deming: Aim defines the system ...Three possible aims of a health care delivery system:

A man stricken with disease today is assaulted by the same fears and finds himself searching for the same helping hand as his ancestors did five or ten thousand years ago. He has been told about the clever tools of modern medicine and somewhat vaguely, he expects that by-and-by he will profit by them, but in his hour of trial his desperate want is for someone who is personally committed to him, who has taken up his cause, and who is willing to go to trouble for him.

D. Emerick Szilagyi, MD: In Defense of the Art of Medicine, 1965(with thanks to Dr. Steven Kappes, Milwaukee, WI)

High touch: Caring, not just curing

High touch? Maybe not ...

1. Total health -- how long and how well we live

2. High touch -- patients value their relationship with a trusted clinical advisor more than any other element in health care delivery (the clinician-patient relationship)

W. Edwards Deming: Aim defines the system ...Three possible aims of a health care delivery system:

3. Rescue care -- the Rule of Rescue

Primary care vs. Secondary care

Rapid response: The Rule of Rescue

subconcious personal identification at an emotional level;a person instead of just a number; "a name and a face"

The child down the wellThe whales trapped in the iceThe dog on the abandoned boat"60 Minutes" program on pertussis vaccination

Joseph Stalin (who killed more than 17 million of his own Russian people)"A single death is a tragedy, a million deaths is a statistic."

Jonsen AR, 1986: The imperative people feel to rescue identifiable individuals facing (avoidable?) suffering or death.*

* McKie J & Richardson J. The rule of rescue. Soc Sci Med 2003; 56(12):2407-19 (June). Richardson J & McKie J. Working Paper 112: The Rule of Rescue. West Heidelberg, Victoria, Australia: The Centre

for Health Program Evaluation; 2000.

14.3

8.1

17.1

9.2

16.5

9.48.2

6.5

Major trauma Heart attack0

5

10

15

20

Mor

talit

y R

ate

(%)

0

5

10

15

20United States Germany Great Britain France

System performance, by nation

16.4

24.5

22.421.1

12.2

Neonates < 1500 grams

0

5

10

15

20

25

30

Mor

talit

y R

ate

(%)

0

5

10

15

20

25

30

U.S. Canada Germany Sweden U.K.

System performance, by nation

1970 1975 1980 1985 1990 1995 20000

20

40

60

80

100

# pa

tient

s on

dia

lysi

s pe

r 100

,000

pop

ulat

ion

0

20

40

60

80

100United StatesCanada


Renal dialysis per 100,000

1996 1998 2000 20020

0.5

1

1.5

2

2.5

# li

ver t

rans

plan

ts p

er 1

00,0

00 p

opul

atio

n

0

0.5

1

1.5

2

2.5

United StatesCanada


Liver transplants per 100,000

1996 1998 2000 20020

1

2

3

4

5

6

# ki

dney

tran

spla

nts

per 1

00,0

00 p

opul

atio

n

0

1

2

3

4

5

6

United StatesCanada


Kidney transplants per 100,000

115

75

81

88

88

92

97

97

106

107

109

109

129

130

132

FranceJapan

SwedenAustralia

CanadaNorway

NetherlandsGermany

AustriaNew Zealand

DenmarkU.S.

IrelandU.K.

Portugal

0 20 40 60 80 100 120 140

0 20 40 60 80 100 120 140

Deaths per 100,000 population

Mortality amenable to health care

Source: World Health Organization, Nolte and McKee, Rutgers Center for State Health Policy Standardized for age (1998)Utah from 2003, normalized for general US change from 1998

On a macro basis, many countries out-perform the U.S.:This is primarily attributable to healthier behaviors, better public health, and a heavy emphasis on easily accessible primary care (easy access = "high touch" = better satisfaction; primary care is relatively cost effective)

the U.S. system performs significantly better for those with severe illness or injury. This is due to several factors:

- Better access to technology- Less explicit and implicit rationing- Easy access to subspecialists - better / more extensive health professional

training; very much less waiting in line for specialty care (queueing)

International health comparisons

Current care deliveryoffers opportunities ...

Part 2

1. Well-documented, massive, variation in practices (beyond the level where it is even remotely possible that all patients are receiving good care)

2. High rates of inappropriate care

3. Unacceptable rates of preventable care- associated patient injury and death

4. A striking inability to "do what we know works"

5. Huge amounts of waste and spiraling prices, that limit access (46.6 million uninsured Americans, and still climbing)

Care falls short of its theoretic potential

50+% of all resource expenditures in hospitals is

quality-associated waste:recovering from preventable foul-upsbuilding unusable productsproviding unnecessary treatmentssimple inefficiency

Andersen, C. 1991James BC et al., 2006

Explicit liabilitiesPublicly held debt (e.g., the national debt)

Military & civilian pensions & retiree healthOther

$ 4.33.1

1.7

$ 9.1

Commitments & contingencies 0.9(e.g., PBGC, undelivered orders)

Implicit exposures

Obligations in excess of trust fundDebt held by the trust fund

4.0 1.7

Future Social Security benefits 5.7

Obligations in excess of trust fundDebt held by the trust fund

8.6 0.3

Future Medicare Part A benefits 8.8

Medicare Part B benefits 12.4Medicare Part D benefits 8.7

Total: $45.6 trillion

Note: Estimates for Social Security and Medicare are the intermediate 75-year estimates of the Social Security and Medicare Trustees as of January 1, 2005.All other data are as of September 30, 2004. Totals may not add due to rounding.Source: 2004 Financial Report of the U.S. Government and 2005 Social Security and Medicare Trustees reports.

U.S. fiscal exposures (Comptroller General David Walker)

trillion

Another way to think about it

Debt held by the public $4.3 trillionTrust fund debt 3.1 Gross debt 1 $7.4 trillion

Gross debt per person: about $25,000

The $46 trillion is fiscal exposures is:a burden of more than $150,000 per person or more than

$370,000 per full-time worker;nearly 19 times the current annual federal budget, and

4 times the current annual Gross Domestic Product;almost equal to the (estimated) $48.5 trillion total net worth,

including home equity, of all U.S. citizens.

1 Includes all debt held by government accounts.

1. Massively raise taxes (mandatory health insurance; increased Medicare copays and deductibles; fees on pharma, device makers, care providers, insurers, etc., passed along to patients)

2. Decrease benefits (e.g., means test Medicare; tighten coverage criteria for specific interventions)

3. Shift money from other areas in the federal budget

4. Shift responsibility to States(bait and switch through block grants)

5. Decrease payments to care providers

Funding federal health care

2022

19

7

32

27

21

9

13

30

46

14

0

7

33

DefenseSocial Security

Medicare / MedicaidNet interest

All other0

10

20

30

40

50

% o

f tot

al fe

dera

l bud

get

0

10

20

30

40

50

1964 1984 2004

Composition of federal spending

Source: Office of Management and Budget

Looming financial crisis

Unsupportable increases in federal spending

Employers exiting health insurance(and transferring cost increases to employees)

Increasing numbers of under- and uninsured

Medical tourism (off-shore treatment)

Specialty: measuring practice variation Observation: ~30% of all health expenditures happen in the terminal episode of life

Question 1: Is there variation in end-of-life spending?(Studies directly adjust for age, gender, ethnicity, burden of comorbid illness)

Answer 1: ~5X variation - $12,000 (Intermountain) to $58,000 (UCLA)Question 2: Is end-of-life spending variation associated

with spending levels before the terminal episode?Answer 2: Yes - >90% correlation 2 years prior, 5 years priorQuestion 3: Is end-of-life spending associated with quality

of care? (2 major studies - 1st examined mortality rates, 2nd looked at blended CMS quality measures)

Answer 3: Yes (consistent, strong, results from both studies)

Unfortunately, the relationship is negative:More spending = lower quality of care (by either measure)

Dartmouth CECS group (Jack Wennberg, Elliott Fisher, et al.)

Baicker, K and Chandra, A. Medicare spending, the physician workforce, beneficiaries' quality of care. Health Affairs Web Exclusive 7 April 2004; W4-184-97.

Medicare cost versus quality

We know why ...

Part 3

(1) Continued reliance on the "craft of medicine" (clinicians as stand-alone experts)

runs up against

(2) Clinical uncertainty

in the context of

(3) Payment that encourages utilization

Why? The collision of 2 forces:

The craft of medicine (each physician an expert)

placing her patient's health care needs before any other end or goal,

An individual physician

drawing on extensive clinical knowledge gained through formal education and experience

Can crafta unique diagnostic and treatment regimen

customized for that particular patient.

This approach will produce the best result possible for each patient.

Medicine's promise:

Clinical uncertainty (a hundred years of science)

Enthusiam for unproven methods ... Mark Chassin, MD

The maxim, "If it might work, try it" ... David Eddy, MD, PhD

Quality means "spare no expense" ... Brent James, MD, MStat

1. Lack of valid clinical knowledge regarding best treatment(poor evidence)

2. Exponentially increasing new medical knowledge(doubling time has decreased to ~8 years; at current rates, a clinician will need to learn, unlearn, then relearn half of their medical knowledge base 5 times during a typical career)

3. Continued reliance on subjective judgment (subjective recallis dominated by anecdotes, and notoriously poor when estimating results across groups or over time)

4. Limitations of the expert mind when making complex decisionsMiller, 1956: The magic number 7, plus or minus 2: some limits on our capacity for processing informationEddy: "The complexity of modern medicine exceeds the capacity of the unaided human mind"

Which, combined with the craft of medicine, leads to:

We have found proven solutions ...

Part 4

We have found proven solutionsShared baselines (a form of Lean Production) -

A multidisciplinary team of health professionals:1. Select a high priority care process2. Generate an evidence-based "best practice" guideline3. Blend the guideline into the flow of clinical work

staffingtrainingsuppliesphysical layouteducational materialsmeasurement / information flow

4. Use the guideline as a shared baseline, with clinicians free to vary based on individual patient needs

5. Measure, learn from, and (over time) eliminate variation arising from professionals; retain variation arising from patients ("mass customization")

Practical limitations on protocol use

When abstract guidelines hit real patient care, experience clearly shows that

protocol fits every patient;No

protocolNo fits any patient.(perfectly)

(with very rare exceptions)

more important,

Methods to manage complexity

Subspecialize (analytic method; reductionism; 'divide and conquer') (old joke: Know more and more about less and less until

you know everything about nothing)

Mass customize (a shared baseline: focus on that relatively small subset of factors that are unique by and for each individual patient [typically 5-15%], concentrating your most important resource -- the trained human mind -- where it can have the greatest impact)

6.66

3.36

2.47 2.65

3.44

4.26

37 38 39 40 41 42

Weeks gestation

0

2

4

6

8

10

Perc

ent N

ICU

adm

issi

ons

0

2

4

6

8

10

Deliveries w/o Complications, 2002 - 2003

8,001 18,988 33,185 19,601 4,505 258n =

NICU admits by weeks gestation

Elective inductions < 39 weeks

5.55.1

6.66.3 65.3

8.2

5.45.76.66.6

7.9

6.4

7.67.6

4.63.5

4.54.3

6.5

3.22.62.3

4.2

2.13.23.4

2.4

5

33.5

26.726.9

2929.2

25.3

27.6

20.4

19.1

16.5

15.2

8.4

10.7

8.1

6.85.96.1 6

5.1

6.3

Jan 01 MarMay Ju

lSep Nov

Jan 02 MarMay Ju

l

Jan 03 MarMay Ju

lSep Nov

Jan 04 MarMay Ju

lSep Nov

Jan 05 MarMay Ju

l

0

5

10

15

20

25

30

% e

lect

ive

indu

ctio

ns <

39

wee

ks

0

5

10

15

20

25

30

382372

490415

430435

422455

430382

356337

372366

455n = 423453

473476 512

475602

557667

564637

578541

573533

505501

474536

562545

535493

520494

430440

500421

474562

549555

528491

3331.4

36.1

28.3

17.7

15.1

17.6

14.4 14.3

5.84.5

2.1

0

20

8.2 8.5

3.6 3.4 3.9 3.22.4

1.1 0.9 10 0

1 2 3 4 5 6 7 8 9 10 11 12 13

Bishop score

0

5

10

15

20

25

30

35

40

Perc

ent c

-sec

tions

0

5

10

15

20

25

30

35

40

Unplanned c-section ratesElectively induced patients by Bishop score, Jan 2002 - Aug 2003

10 49 130 274 567 856 1114 1266 1062 737 415 86 1918 35 61 99 164 278 375 487 453 346 179 47 7

MultipsPrimips

n

22.1

20.7

17.4

15.715

13.8

12.611.6

10.4

9 9

7.58.2

12.4 12

10.810.1

9.28.1

7.67.1

6.45.9 5.5 5.1

4.1

1 2 3 4 5 6 7 8 9 10 11 12 13

Bishop score

0

5

10

15

20

25

Hou

rs

0

5

10

15

20

25

Average hours in labor & deliveryElectively induced patients by Bishop score, Jan 2002 - Aug 2003

10 49 130 274 567 856 1114 1266 1062 737 415 86 1918 35 61 99 164 278 375 487 453 346 179 47 7

MultipsPrimips

n

15.314

15.314.514.7

11.612.8

11.812.612.8

15.1

12.19.9

8.86.8 6.5 6 6.1

7.66.5 6.6

5.2 4.9

8.4

4.3 4.3 4.56.1 5.4

4.4 3.9

53 53

63

5357

45

5652

41

52

62

4649

35

21 2126 28

3428

2218 20

35

1518

1518

2521 20

110

87

119

109

124

91

107

94100

105

118

8781

67

57 57

4652

6055

49

3733

67

30 3036

4845

3734

Jan 20

03 Feb Mar AprMay Ju

n Jul

AugSep OctNovDec

Jan 20


n Jul

AugSep OctNovDec

Jan 20


n Jul

0

20

40

60

80

100

120

140

Num

ber o

f pat

ient

s

0

10

20

30

40

50

% o

f all

prim

ipar

ous

deliv

erie

s

Primiparous elective inductions

Bishop's score < 10Bishop's score < 8Goal: Reduce "inappropriate" nullip inductions by 50%

Elective induction: length of labor

Jan 20

01 Mar May Jul

Sep NovJa

n 2002 Mar May Ju

lSep Nov

Jan 20

03 Mar May Jul

Sep NovJa

n 2004 Mar May Ju

lSep Nov

Jan 20

05 Mar May Jul

Sep Nov

0

2

4

6

8

10

Ave

rage

hou

rs fr

om a

dmis

sion

to d

eliv

ery

0

2

4

6

8

10

8.5

7.97.5

7.16.9

(note: includes all elective inductions)

Overall c-section rate

96 97 98 99

2000 01 02 03 04 05 06

0%

10%

20%

30%

40%

Perc

ent c

-sec

tions

ove

rall

0%

10%

20%

30%

40%

National Intermountain

2001 2002 2003 20040

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

Cos

t str

uctu

re im

prov

emen

t ($)

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

Cum

ulat

ive

annu

al to

tal (

$)

Combined maternal and neonatal variable costDeliveries without complications resulting in normal newborns

Actual - expected cost, based on year-end 2000 with PPI inflation

Quality-based cost improvement

The healing professions are changing

From craft-based practiceindividual physicians, working alonehandcraft a customized solution for each patientbased on a core ethical commitment to the patient andvast personal knowledge gained from training and experience

To profession-based practicegroups of peers, treating similar patients in a shared settingplan coordinated care delivery processeswhich individual clinicians adapt to specific patient needs

(e.g., standing order sets)

(housestaff ::= apprentices)

early experience shows less expensiveless complexbetter patient outcomes

(facility can staff, train, supply an organize to a single core process)(which means fewer mistakes and dropped handoffs, less conflict)

Why "profession-based" practice?

1. It produces better outcomes for our patients

2. It eliminates waste, reduces costs, and increases available resources for patient care

3. It puts the caring professions back in control of care delivery

4. It is the foundation for useful shared electronic data -- an important next step in care delivery improvement

What does it taketo survive -- and perhaps even thrive --

in this emerging new world?

Part 5

Care management at the bedside

Core infrastructure:

1. Tools to change culture (clinical and administrative)

2. Tools for quality control (a.k.a. quality management)

3. Knowledge management (the key organizational advantage)

4. Administrative follow-through on clinical savings

Formal QI training programs: Facilitator Workshop Series (FWS) - 8 days in 4 sessions

Advanced Training Program (ATP) - 20 days in 4 sessions

miniATP - 9 days in 4 sessions

others (MD intro course, lab series, etc.)

that teach methods (key: hands-on projects - creates quality zealots)

change culture (key: early adopters)

improve front-line work (key: organizational learning that rolls ahead;concrete examples where others can "see the wheels turning")

pays its own way (savings from projects provide a net ROI)

Culture change that pays its way

Manage

Design

Improve

Lean designTPS: Value stream analysis6Σ: Define, measure, analyze,

design, verify (DMADV)

Technically, Quality Control (Juran)Build essential infrastructure

- key process identification- performance tracking (outcomes)- organizational structure

Accountability - e.g., monthly review

100% participation vs.breakthrough models

Identify/prioritize opportunities:- voice of the customer,- voice of the process

Rapid Cycle ImprovementTPS: A3 analysis, w/ coaching6Σ: Define, measure, analyze,

improve, control (DMAIC)

Health care as a system of production

Building infrastructure

Integrated clinical / operations management structure

1998:

(an outcomes tracking system)Integrated management information systems1997:

(mediated by payment mechanisms)cost structure vs. net incomeintegrated facility / medical expense budgets

Integrated incentives1999: (aligned)

Full roll-out and administrative integration2000:

(strategic) Key process analysis1996:

To make it easy to do it right ...(Education programs: A learning organization)(A shared vision for a future state)

Deploying EBMClinical OperationsLeadership Team

Clinical Program leadersSenior admin execs

Financesupport staff

Sr VP - hospitals, clinics, MDs

Clinical ProgramGuidance Council

regional Clinical Program MD, nurse admin leaders

Info SystemsFinancesupport staff

Clinical Program MD leaderClinical ops administrator

regional administrators

Medical directorClinical ops admin

Urban North Region Urban Central Region Urban South Region

MDs MDsMDs

MDs MDsMDs

MDs MDs MDs

CardiovascularNeuromusculoskeletalWomen & NewbornPrimary CareOncologyIntensive MedicineIntensive PedsSurgical Specialties

CoreWork Group

DevelopmentTeam

Everybody

(+ 1/4 FTE)

(1/4 FTE)(full time)





Development Team structureTeam leader- respected physician leader, in active practice- functionally a knowledge expert

Core work group- knowledge experts- build initial Care Process Model- provide academic detailing, run referral clinic- geographically base

Front line clinicians- physicians, nurses, clerks, techs, etc.- first level review; keep knowledge experts grounded- 2-way street: fundamental knowledge up, ownership down- geographic representation

Staff support - flow charter, statistician, data manager, clinical ops administrator

Managing clinical knowledge

1. Generate initial evidence-based best practice guideline (flowchart)2. Blend the guideline into clinical workflow

(clinical flow sheets, standing order sets, etc.)3. Design outcomes tracking reports (using electronic data warehouse)4. Design and coordinate decision support (electronic medical record)5. Design patient and professional education materials

Initial development phase

6. Keep the Care Process Model current (research pipeline; protocol variations; outcomes; improvement suggestions)

7. Academic detail front-line teams (Clinical Learning Days)8. Run the referral clinic (last step in treatment cascade)9. Manage specialist care managers

Maintenance phase

Core work group (knowledge expert) responsibility -build and maintain the Care Process Model:

No good deed goes unpunishedNeonates > 33 weeks gestational age

who develop respiratory distress syndromeTreat at birth hospital with nasal CPAP (prevents

alveolar collapse), oxygen, +/- surfactantTransport to NICU declines from 78% to 18%.Financial impact (NOI; ~110 patients per year; raw $):

Birth hospitalTransport (staff only)

Tertiary (NICU) hospitalDelivery system total

Integrated health planMedicaid

Other commerical payersPayer total

Before 84,24422,199

958,4671,064,910

900,599652,103

429,1011,981,803

After 553,479

- 27,222 209,829736,086

512,120373,735

223,2151,109,070

Net 469,235

- 49,421 -748,638-328,824

388,479278,368

205,886872,733

115

74

75

81

88

88

92

97

97

106

107

109

109

129

130

132

UtahFranceJapan

SwedenAustralia

CanadaNorway

NetherlandsGermany

AustriaNew Zealand

DenmarkU.S.

IrelandU.K.

Portugal

0 20 40 60 80 100 120 140

0 20 40 60 80 100 120 140

Deaths per 100,000 population

Mortality amenable to health care

Source: World Health Organization, Nolte and McKee, Rutgers Center for State Health Policy Standardized for age (1998)Utah from 2003, normalized for general US change from 1998

Wells Fargo inflation summary, 1988-2006

The Wall Street JournalPerverse Incentives in Health Care

April 5, 2007John C. Goodman, President, National Center for Policy Analysis

Research at Dartmouth Medical School suggests that if everyone in America went to the Mayo Clinic, our annual health-care bill would be 25% lower (more than $500 billion!), and the average quality of care would improve. If everyone got care at Intermountain Healthcare in Salt Lake City, our healthcare costs would be lowered by one-third.

Of course, not everyone can get treatment at Mayo or Intermountain. But why are these examples of efficient, high-quality care not being replicated all across the country? The answer is that high-quality, low-cost care is not financially rewarding. Indeed, the opposite is true. Hospitals and doctors can make more money providing inefficient, mediocre care.

"I am sorry for you, young men (and women) of this generation. You will do great things. You will have great victories, and 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."

At the opening of the Phipps Clinic in England, near the end of his career. Cited in

-- Sir William Osler

Reid, Edith Gittings. The Great Physician: A Life of Sir William Osler. New York, NY: Oxford University Press, 1931 (p. 241).

quality: an imperative for organizational survival · ethanol (and other recreational drugs) mdd...

Documents