Don’t wait for Washington

Brent arriving at the IHI Annual Forum

#IHI With these words, Brent James began his keynote address to the attendees at the Vermont Oxford Network meeting this morning.  Noting that the recent legislation in Washington focused mainly on providing insurance to a portion of the 46 million Americans without coverage, he reminded the audience that the law had very little to say about the issue of rising health care costs in the country.  He warned them that “our profession is in the midst of profound change” because the cost pressures would wend their way to affect doctors and hospitals over the coming years.  “If you feel like you have a target on your forehead, you are right.”  Paradoxically, though, he left the audience eventually with the thought, “This is a glorious time to be in medicine.”

“What’s up?” you might ask.  What’s up in Brent’s view is the fact that more and more doctors, nurses, and administrators have started to adopt an approach to clinical care based on reducing variation and on weeding out inefficiencies and waste.  “Quality costs less, “ is his watchword, dating this philosophy back to the work of W. E. Deming.

Brent went through the evolution of this approach at Intermountain Health, hearkening to the initial work done in 1991 by Dr. Alan Morris at LDS Hospital.  Undertaking an NIH-funded randomized clinical trial in treatment of pulmonary disease, Morris’ team of eight intensivists discovered a large degree of variation in ventilator settings, not only among themselves, but even between daytime and nighttime with the same doctor and the same patient.  Morris, looking at the work of Jim Womack documenting Toyota’s Lean process improvement in The Machine that Changed the World, realized that he needed to create a protocol among all the doctors to standardize the care being given.  Only by have enough standardization could there be the possibility of evaluating the “pre” and “post” of the clinical trial.

But Morris noted, “I had no validation data” for the best protocol.  So, the team assembled and designed a protocol based on the literature of the day, but then they applied Lean principles to the use of the protocol.  Physicians were instructed to vary from the protocol if they judged it in the best interest of a patient.  Each time this happened, though, the case would be discussed among the group.  Over time the protocol was modified when there was a scientific basis for doing so, and over time variation from the protocol diminished.

During the following years, this process was expanded to other clinical arenas in the Intermountain system.  The concept of “shared baselines” came to rule:

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

Note that this approach demands that doctors modify shared protocols on the basis of patient needs.  The aim is not to step between doctors and their patients.  This is very different from the free form of patient care that exists generally in medicine.  Notes Brent, “We pay for our personal autonomy with the lives of our patients.  This is indefensible.”  The approach used at Intermountain values variation based on the patient, not the physician.

Brent is optimistic because he has seen this philosophy of learning how to improve patient care extend to more and more doctors and hospitals around the country.  He views it as providing the answer to the rising cost of care, and he is excited about the potential.  He concludes that this is a “glorious time” to be in medicine because it is the “first time in 100 years” that doctors have a chance to institute fundamental change in the practice of medicine.

We left the VON meeting together and flew off to Orlando, where we are now attending the IHI Annual National Forum.