It’s Not About The Box Improving Care at Group Health with People, Process and Technology

April 30, 2012

Don Berwick presenting the Birnbaum Lecture

Filed under: Policy — Matt Handley @ 9:25 am

A great way to start a week in spring – Don Berwick is presenting at the Birnbaum lecture at the Convention center in Seattle.  Really looking forward to Don’s talk – take one of the foremost innovators in Health care and season him with time leading CMS, and you get a remarkable perspective.  Don has inspired me for years – I have had the opportunity to learn from him in many ways over many years, including having him shadow me in clinic.  His introduction includes many honorifics, including Knight Commander of the Most Excellent Order of the British Empire. Love that one.

To save notification Emails for those subscribed I will blog happily along and then just post the piece rather than live-blog the event.  ITs a great story, so a long post.

One of my favorite mantras is “No stories without data, and no data without stories” – and Don is the master of storytelling with data.  Today’s talk (not transcribed – but a good faith effort to relate the story):

Midway through residency in 1974 in a NICU rotation, he is awakened at 3 AM to perform an exchange transfusion (a procedure no longer necessary thanks to Rh testing) for a small baby, call her “Baby Gray”.  A sleepy resident, a lot of tubes and stopcocks and a bag of O neg blood.  Basically, in an exchange transfusion blood is taken out of the baby’s umbilical vein, a stopcock is turned and the blood is thrown away, the stopcock is turned and blood is taken out of the O neg bag, the stopcock is turned again and the blood is pushed into the umbilical vein of the baby.  Repeat this many, many times, to basically change out the baby’s blood cells and serum (which contains Mom’s antibodies).  But something went wrong that night.  It was hard to push the blood into the baby, and the baby didn’t look well.  Both the baby and our pediatric resident are tachycardic.  Don stops the process, called for lab tests and help.  A neonatology resident came in as the blood test came back.  The baby has a hematocrit of 90 (normal about 35 – 40).  Crisis.

The hospital where Don has done the procedure before delivered whole blood in one bag.  A different blood bank supplying the hospital where Baby Gray is used a different strategy for delivering the blood.  The red cells were separated from the plasma and red blood cells and plasma were delivered in two different bags.  Don had been using red blood cells without the plasma for the exchange transfusion.  Don sees the clear bag with the plasma dangling below and recognizes that he has been part of an error that has put the baby’s life at risk.  The neonatology resident saved the day (after some complication the baby does well) and reassured Don that this could have happened to anyone.

Don responded as most all of us would have (especially then).  He did not come forward and talk about the error so that it could prevent other patients and doctors from the same error and harm.  Don did nothing.  He carried the pain privately.  His internal dialogue has not kind. “How could I have done anything so stupid”.

Our knowledge of safety and error are now pretty good.  One of the first books about safety, “Human Error” by James Reason may be the best of its kind – the source of the “Swiss cheese model” – laying out the idea that latent causes of error (sleepy resident, non-standardized blood bank procedures, etc) happen to line up like holes in Swiss cheese.  Safety science has enabled us to build safer systems, including more just cultures.

Shift frames – Don Berwick as the self-described amateur ethicist.  Surely it is unethical to allow any other baby to be injured.   It is more than the error itself, it is in the silence that follows.  The silence that makes it so that the error is still possible for other patients, and that keeps the error from the family.  We are now all aligned around safety, just culture, disclosure and quality.

The ethical answers to this case scale to the question of our health system.  The fist locus is that the ethics of quality lie in the professionals that practice medicine.  The second locus of the ethics of quality is leaders.  Imagine that the next day, wracked by guilt, Don brings the cause to leaders so that things can be made safer.  “You are not a superhero, and you can make mistakes – but the well being of your patients and of other patients depends on your sharing what goes wrong so that we can build stronger systems of support to minimize the errors humans make”.

There is an inescapable connection between the ethics and actions of individuals and leaders.

Segue (the one that Don’s wife believes is hard to follow)

There are many dimensions of quality that we know well – safety, effectiveness, patient centeredness, timeliness, efficiency and equity.   And some of these stories, especially safety, are compelling.  The story about the baby and the exchange transfusion “has us at hello” – heartstrings are tugged, and we feel for both the patient and for the caregiver.

But we can and need to expand the ethical call beyond just safety and effective care, to all of our quality goals.  Now the particular aim that needs to be driving us is Efficiency – the issue of cost.  We need to grapple with the premise that we have an ethical duty to address cost, for the sake of individuals and for society.  Our ability to do everything else that government might do for good is hanging in the balance.  We will not be able to fund schools or maintain support for the disadvantaged unless we address the costs of our health care system.  And we know that this burden is not necessary if we cease our concessions to waste.

We can use an analogy to environmental models (Dons’ recent article in JAMA) where no single strategy can fix our carbon problem, but many different strategies (“wedges” like solar power, more efficient cars, carbon sequestration, etc) can work together to get enough reduction to prevent catastrophic global warming.   In health care, there are 6 wedges of waste:

  • Overtreatment
  • Failures to coordinate care
  • Failures in care delivery
  • Excess administrative costs, excessive health care prices
  • Fraud and abuse.

The minimum estimates of the sum of health care spending for these categories is 21% of all health care spending, the median is 34% and the highest estimate is 47%.  Scary as those estimates are they should bring us hope – if we tackle waste we can continue to provide all the care we should and save considerable resources.  Over 9 years we are looking at $11,000,000,000.  There is a “T” involved in that number.

At the individual level, it is easy to see that the next “Baby Gray” will die unless leaders in health care accept their accountability to learn from error.  We are well down the road to making care safer, but the analogy to affordability has not achieved engagement.

The harm from the health care system on our society will not cease unless the leaders accept their responsibility for the waste in our system.  It is easy to see that while there are a set of excuses for all of the wastes, the analogy to safety is inescapable.

Health care leaders need to assume the responsibility without excuses to tackle waste.

Harm to an individual patient by medical error is different than the harm from waste.  With waste, you can’t name who is hurt.  No one wasteful act harms an individual.  But waste is theft and theft is wrong.  Waste threatens healthcare as a human right.

Don’s Principles for a Framework for action.

  • Put the patient first
  • Protect the disadvantaged
  • Start at Scale
  • Return the money
  • Act Locally

One step further to an ethics of improvement

  • Professionals have an duty to help improve the systems in which they work
  • Leaders have a duty to make #1 logical, feasible, and supported
  • No excuses for inaction on #1 and #2 are ethically acceptable.
  • The duty to improve across all five, and that includes waste
  • Those who educate professionals have a duty to prepare them for this important work

There is a lot of anguish over how we can get things on track – the public is looking for sanity to come out of this.  While politics and policy matter, they are insufficient to fix this.  It will necessarily fall to those who provide care, and those who make it possible for them to provide great care, to lead change to reduce waste and improve value.

Hard to listen to Don and not run out of the room and take action.  I know that my meetings later today will some different focus.

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