Institute of Medicine Releases Better Care at Lower Cost

I was asked by the I.O.M. to review this extensive document. For the most part I think they got it right. There are some weaknesses in this review and, although the final document is not actually released, I have a couple of concerns.

First, there is too much emphasis on technology as the answer to the health industry ills. I have visited 116 hospitals in 11 countries in the last seven-plus years and I find two problems almost everywhere I go. As long as hospital leaders and doctors think they have the latest and greatest bar coding system or EMR or other technology they are doing everything they can to deliver patient safety. That thinking could not be further from the truth. Technology is only a tool that may or may not help to support care delivery processes. I find most organizations have no clue what the current state of the process is. They haven't mapped out the patient experience and the process is generally in chaos because there is little or no standard work in place. In addition, I also find there is no "system" in place to assure problems are identified on a daily basis and solved by front line staff. Most organizations have a typical top down management structure that Deming called "management by objectives." In fact, a continuous improvement culture is supported by what Deming described as "mangement by process" (Out of the Crisis 1983). I can count on one hand the number of health systems that have a management by process system in place.

The second weakness is the lack of focus on the principle that 99% of the problem in healthcare today is faulty processes not faulty people. In the 1960s the FAA took the airline industry by the horns and mandated fail safe process implementation. This was at a time when there was a plane crash every other week with hundreds dying at a time. Aviation is now known as one of the safest industries because they have adopted processes that prevent human error. This is what we are fundamentally missing in healthcare. Standard work for care processes leads to zero errors. Members of the Healthcare Value Network prove this every day. Using standard work St. Jude's has had zero ventilator associated pneumonias for three years in a row. Mercy Hospital--North Iowa has had zero lab specimen tube errors for two years. ThedaCare has had zero medication reconciliation errors for 5 years running.

I have published extensively including in my new book Potent Medicine the three things required to fundamentally transform American healthcare: payment that rewards value, redesign of care processes using lean, and public reporting of provider performance. I would have liked to have seen the I.O.M. report emphasise public reporting more strongly. It did mention this in several sections.

Despite my above criticism I think this report is a welcome addition to the literature on the problems facing healthcare and a good set of recommendations to address them. I am particularly happy with the clear focus on building a continuous improvement culture. I'm also in complete agreement with the focus on the unnecessary deaths occurring every day in our hospitals. These unnecessary deaths should be the only confirmation required for healthcare leaders and boards to sprint to change. As this report points out we have so much to do to make healthcare safe but we also have a direction ahead.

Read the report summary here.