Teach the doctors, please!

If you read the Boston newspapers, you would think that the most important thing going on in health care is a proposal to move from one kind of insurance payment scheme to another. Reporters seem willing to accept relatively unsupported and undocumented assertions that global payments are working. You have to be persistent to find these sentences in this story:

But other doctors and health care executives cautioned against drawing definitive conclusions from the insurer’s early results. They have not been independently reviewed and may not be easily reproduced statewide.

If it is working, why do reporters not demand more transparency to demonstrate it? Why this instead?

Blue Cross did not release specific performance results for doctors groups.

Why no mention in these stories of alternative approaches being taken by other insurers?

Why hold off, too, on this really important statement until after the page turn and deep at the end of this story?

Both supporters and critics of global payment agree that any mandate should be flexible, and phased in slowly, so patients and providers can adjust. Thomas A. Croswell, chief operating officer of Tufts Health Plan, suggested a five-year transition.

Much is often made of Atul Gawande's superb writing about the use of check lists and other quality and safety process improvements. If you read carefully, though, you will see that he seldom mentions progress in the medical schools with which his and other Boston hospitals are affiliated. While we wait five years or more for the new pricing regime, why don't the insurers, the state government, and other stakeholders put pressure on the region's four medical schools to introduce and emphasize the science of process improvement in their curriculum?

Local readers might be interested to know that the process improvement world is alive and well in other regions, irrespective of insurance payment regimes. Two of the heroes in this arena, Brent James and Bob Wachter, recently had a conversation about how to teach quality and safety improvement.

Dr. James gave some history of his efforts at Intermountain Health. Dr. Wachter asks:

[Y]ou and others have written about the culture of medicine being so individualistic. It sounds like we came into this with a culture that you would expect would create tremendous variation from doctor to doctor.

Dr. James replies: 

Looking back, that's absolutely true. Of course it came to be called the craft of medicine, a cottage industry, where it's based on purely personal expertise, personal perfection, if you will. Speaking as somebody out of a surgical background—that concept is so central to what it means to be good, I mean for your patients, the best you can be. You don't want to lose that personal dedication. But you start to extend it a step further. Where it ended up for us was a form of Lean.

And later, he relates:

We did other things that were really important. The first is that we built firmly on the foundation of medicine. By that point, we'd understood that there's a whole bunch of jargon with improvement, but you didn't have to use any of it; you could describe the whole thing in the language of medicine. So rather than asking the natives to learn quality improvement jargon, we spoke the language of the native. The second thing was that in order to graduate you had to complete a successful improvement project. Our aim was to get hands-on experience that was real. And boy did that ever turn out well.

Here is an article about a system clinical safety and effectiveness (CS&E) course taught at the University of Texas. An excerpt:

Unfortunately, most front-line caregivers complete their professional training with almost no exposure to even rudimentary QI concepts or methods....

The University of Texas MD Anderson Cancer Center began such a course in 2005 ... and its success led us to implement courses in four of the six health campuses in the University of Texas system.... 

The purpose of the CS&E course is to provide physicians, other key clinicians, and administrators the skills and knowledge required to lead breakthrough change initiatives. After initial success at UT MD Anderson Cancer Center, all presidents of the UT System health care institutions approved a proposal in 2007 to develop and implement CS&E programs on their own campuses. A UT CS&E Steering Committee with representatives from each campus was established to provide oversight for the course expansion, and in 2008 the University's Regents provided funding from the UT System's malpractice liability reserve fund.

We are very quick to find a rivalry between Texas and Boston in other fields. Let's start one here, where lives hang in the balance.

Our patients are sicker

What more do we need to know? The British Medical Journal published a study showing that Peter Pronovost's program to reduce central line infections in Michigan saved lives.

A new study finds that a safety checklist program developed by a Johns Hopkins doctor has reduced patient deaths in Michigan hospitals by 10 percent, in addition to nearly eliminating bloodstream infections in health care facilities that embraced the prevention effort.

The research, published in the British Medical Journal, is the first to show a drop in patient mortality in hospitals using the Hopkins program. Previous studies have found major reductions in bloodstream infections from using the checklist when inserting catheters or central lines to give patients medication, fluids or nourishment.

Well, duh. But I guess it is important to have scientific verification. But I can almost hear the comments from some places: "That wouldn't work here. Our patients are sicker."

So, how long will it take for this approach to be used across the country? This study is based on work from nine years ago. If this is like other innovations in medical care, it will take a decade and a half more to spread.

Here's my proposal to jump-start it. Publish the monthly rate of central line infections for all hospitals on a public website. CMS, IHI, the Dartmouth Atlas group or some other organization could do this in a nano-second, creating a voluntary website, giving each hospital a password through which it could enter its own data. There is no need to audit the figures. We can trust people to be honest.

And, at the bottom of the website, the host could list the hospitals that have chosen NOT to publish.

Then, you would see the power of transparency.

Lessons from Cairo

I think most of us would be hard-pressed not to be inspired by the moral power of the crowds in people in Egypt as they throw off a form of government that they find repressive. But, it is about the US reaction to all this to which I turn today. It is the subject of New York Times columns by David Brooks and Nicholas D. Kristof.

Both authors noted the ham-handed manner in which the United States deals with authoritarian regimes and with popular movements for freedom.

Brooks notes,
The . . . thing we’ve learned is that the United States usually gets everything wrong.

Policy makers always underestimate the power of the bottom-up quest for dignity, so they are slow to understand what is happening.

Then their instinct is to comfort the fellow members of the club of those in power.

Then, desperately recalibrating in an effort to keep up with events, they inevitably make a series of subtle distinctions no one else heeds.

Kristof says,
Yet one thing nags at me. These pro-democracy protesters say overwhelmingly that America is on the side of President Mubarak and not with them. They feel that way partly because American policy statements seem so nervous, so carefully calculated.

The upshot is that this pro-democracy movement, full of courage and idealism and speaking the language of 1776, wasn’t inspired by us. No, the Egyptians said they feel inspired by Tunisia — and a bit stymied by America.

Everywhere I go, Egyptians insist to me that Americans shouldn’t perceive their movement as a threat. And I find it sad that Egyptians are lecturing Americans on the virtues of democracy.

Brooks provided a broader context for all of this:

I wonder if sometime around 50 years ago a great mental tide began to sweep across the world. Before the tide, people saw themselves in certain fixed places in the social order. They accepted opinions from trusted authorities.

As the tide swept through, they began to see themselves differently. They felt they should express their own views, and these views deserved respect. They mentally bumped themselves up to first class and had a different set of expectations of how they should be treated. Treatment that had once seemed normal now felt like an insult. They began to march for responsive government and democracy.

You will excuse me if I draw the connection to health care. I hope you don't think it inapposite.

I do not think that it has been a fifty year trend in health care, but a more recent one. Patients and families have decided that they should be equal partners in the process of diagnosis and treatment. They believe that they have a right to the information that can represent life or death, health or suffering. As Brooks would put it, "treatment that once seemed normal now feels like a insult." Opinions from trusted authorities no longer carry the weight they used to. Questions are being asked. Answers are being demanded.

A few weeks ago, author Charles Kenney asked the question, Isn't there a compelling -- perhaps even overriding -- moral component to transparency?

I responded,

The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the "prior" against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?

But transparency threatens the status quo. In the medical world, status quo confers power, influence, prestige, and money on those who have had a reputational advantage. A close friend and colleague put it this way:

Transparency in self-interested institutions who are making fortunes by deluding themselves and the public that they and only they know what the community wants and needs is a very dangerous concept.

The agents of change in this battle will be the same people who are turning things over in Egypt. Normal people who have experienced pain and suffering, or even just disrespect, in the health care system are starting to find their voice. Like the US in the international arena, the powers that be in the government and their agents, having been captured by the powerful forces of the medical and hospital profession, are slow to react and are protective of the status quo.

Policy makers always underestimate the power of the bottom-up quest for dignity, so they are slow to understand what is happening.

Then their instinct is to comfort the fellow members of the club of those in power.

Then, desperately recalibrating in an effort to keep up with events, they inevitably make a series of subtle distinctions no one else heeds.