Transforming medicine and saving lives

By Sarah Arnquist

This week, Don Berwick will announce the results of the 5 Million Lives Campaign before thousands of people in Nashville attending the National Forum on Quality Improvement in Health Care.

Twenty years ago, it was almost heretical to question the quality of American health care. The common refrain being that it was unarguably the best in the world.

Decades of work by Berwick and others, however, have dispelled that myth, and the underlying belief that medical errors and hospital acquired infections are simply an artifact of the business. These quality champions deem it unacceptable that as many as 98,000 Americans die annually from preventable medical errors, and that most Americans receive the recommended care only half the time. They've spent years building their case, and in turn created a social movement around their cause.

In the book, "The Best Practice," Charles Kenney chronicles this long march toward a culture within American health care that demands continuous quality improvement.

The book was published in July. I finally finished it a month ago and just now getting around to writing about it, but I guess my timing works well with the Institute for Healthcare Improvement upcoming convention.

"The Best Practice" is an amazingly readable book. My amazement is not a reflection on Kenney's writing, but rather that he managed to make health care quality interesting for nearly 300 pages.

He succeeded by introducing readers to characters. There's heroism and tragedy at the forefront, and the science, research and business cases are woven into the background.

The heroes include, but are not limited to, Berwick, Paul Bataldan, Lucian Leape, Rick Shannon, Paul O'Neill and Peter Pronovost. These leaders took on "the establishment," learned from other industries and rejected the notion that medical errors weren't preventable. Then, they spread their enthusiasm and mission to others.

We also meet the victims of tragic errors, such as Boston journalist Betsy Lehman, who died from a chemo overdose at the Dana Farber Cancer Institute, and toddler Josie King, who died of dehydration at Johns Hopkins Hospital. The reader quickly learns that if such errors can occur at these prestigious institutions, surely they must not be anomalies.

Five chapters are essentially case studies of specific efforts at Virginia Mason Medical Center, the Pittsburgh Regional Health Initiative, the Cincinnati Children's Hospital, Kaiser Permanente and Jonkoping County, Sweden. Each case makes a distinct point.

With the Kaiser example, for instance, Kenney points out the importance and opportunity that integrated systems and linked electronic medical records have for improving quality.

Kenney takes us to a county in Sweden, where the people are already healthier than most others in the world, but whose leaders continue working hard and innovating to further improve the quality of health care.

Throughout the book, Kenney weaves in the seminal research that provides the foundation for the quality movement: The Institute of Medicine's "To Err is Human" which estimated up to 98,000 people die annually from preventable medical mistakes; and its subsequent report, "Crossing the Quality Chasm."

Kenney also introduces readers to the work of Elizabeth McGlynn, of RAND Health, whose frequently cited studies calculated that Americans receive the recommended care only about half the time.

He quotes McGlynn describing her findings to Congress: "Overuse occurs when a patient is given an intervention for which the expected risks substantially exceed the expected benefits. Underuse is the failure to provide services when the expected benefits are greater than the expected risks. Errors are mistakes in the provision of services that have the potential to result in serious adverse consequences for the patient."

My main criticism is that Kenney so narrowly focuses on the quality movement within the hospital and structural health care system. If we truly want to do something about the fact that Americans receive the recommended care only half the time, we must look at underlying factors that go well beyond whether a hospital system can model itself after Toyota.

The Institute for Healthcare Improvement has recognized a need to expand its mission and focus on improving health care at the population level. In the last few pages, Kenney mentions IHI's new mission called the Triple Aim. The three simultaneous aims are guaranteeing high quality care for individuals, improving health of the population and reducing the cost of health care per capita.

"The Best Practice" reminds us that a philosophy of quality improvement is about people. It's about the patients who become victims of errors. It's about the doctors and nurses working to innovate and improve care. It's about the hospital administrator who is dedicated to full transparency despite the risk of a public black eye. And it's about the janitor who recognizes a faulty cleaning process.

Quality improvement, Kenney tells us, is about teams of people working together to establish systems that protect patients, protect clinicians and reward progress.