A New Design for Healthcare Delivery

By Steven J. Spear and Donald M. Berwick

The choice between expanding health coverage and controlling healthcare costs is a false choice based on a false assumption: that resources committed to healthcare are used efficiently and effectively. The mistaken notion makes budgeting the key decision and masks a much better alternative. There is ample evidence that better care could be provided to more people at lower cost if care delivery were organized in a more sophisticated fashion.

Today, healthcare is delivered as it was 50 years ago, when only a limited range of illnesses could be detected and treated, and when even the most sophisticated treatments involved only a few professionals. Professionals were organized in silos: nurses in one, various types of doctors in others, and so forth. Grouping by peers afforded the benefits of professional association, such as sharing knowledge, setting standards, and camaraderie, and, for simple treatments, ad hoc, informal coordination across silos was adequate, management of patient information was simple, and piece-rate payment - paying a certain amount for each person's time - worked fine.

Medical science has advanced dramatically. Once-terminal diseases are now manageable - like AIDS - and even curable - like many cancers. But, care delivery, information, and payment systems have not kept pace with the science. Professionals are still organized in silos, despite the pressing need to integrate their work into coherent processes; information is still fragmented, despite the benefits of holistic views of patients; and payment is still piece-rate even though practitioners are no longer in any meaningful sense independent of each other.

The consequences are destructive. Too little preventive care increases the need for chronic care. Ineffective chronic care for diabetes, heart disease, and depression increases the need for costly acute care of limited effectiveness, and which often causes needless harm. The chance of being injured by hospital care is greater than one in 10, and the chance of accidental death due to mismanaged care is about one in 300. Problems are so pervasive that Medicare announced it will withhold payment for fixing some of the problems created by defects in care.

Needless suffering from badly delivered care is tragic; squandering hundreds of billions of dollars is unconscionable. In part because of these inefficiencies, the United States spends twice as much on care, per capita, as other developed nations do. US government spending alone on healthcare is enough to buy all of the healthcare per capita in many developed nations.

There is an alternative. Some organizations have started emulating outstanding nonhealthcare organizations in actively managing how the process, information, and payment pieces mesh together. The results have been sometimes spectacular.

Pioneers have reduced rates of hospital-acquired infections, falls, medication errors, and other complications - symptoms of fragmentation - by 90 percent and more, saving thousands of lives and hundreds of millions of dollars. Ascension Health, the largest Catholic healthcare system in the United States, reports pressure ulcer rates in its 67 hospitals 93 percent lower than the national average, birth injury rates 74 percent lower, and patient falls 86 percent lower. Virginia Mason Medical Center in Seattle targeted its Gastroenterology Department, freed capacity, saved millions of dollars in capital investments, and increased access by 50 percent. It taught its migraine patients how to avoid and manage recurring pain, thereby reducing emergency department visits for this by 50 percent, with sharp reductions in expensive imaging, contrary to trends for the broader, non-VMMC population of migraine sufferers. Mayo Clinic has reported more than a 50 percent drop in rates of medical injuries to patients in all three of its flagship hospitals. Hospitals that have adopted better processes to deal with 11 common challenges - such as acute heart attacks, patients on ventilators, early identification of deteriorating patient conditions - championed through the Institute for Healthcare Improvements 5 Million Lives Campaign, have documented major improvements in outcomes.

If these stories were national norms, not exceptions, the benefits to patient well-being and to costs would be staggering. Getting there need not be a fantasy. Hospitals, nursing homes, dialysis units, ambulatory surgery centers, and physician offices can improve the reliability of its own processes, and their coordination with other organizations, in managing preventive, chronic, acute, and urgent care. Medical, nursing, pharmacy, and other professional schools can complement medical science training with training in managing complex work systems, preparing their graduates to be excellent in their roles, and also in tying the pieces together in total systems of patient care. Insurers, employers, and other payers can change their buying patterns, to demand and reward coordination and uncompromising process excellence across the entire care continuum. Since the public sector is the nation's largest payer, and it supports large medical schools, it can insist on system improvement.

This is a hard sell. The wonk factor is high. Focusing on improving the processes by which care is delivered lacks the rhetorical punch of advocating for universal coverage. Making healthcare processes better is more diffuse work, done at the organizational level, not through dramatic legislative, regulatory, or fiscal flourishes. It requires leaders to get into the nitty-gritty of patient care, finding deficiencies in current approaches, confronting professional norms and habits that overvalue autonomy, tolerate unscientific variation in practice, and undervalue cooperative behaviors, and making continual improvements. But a strong link exists between the moral obligation of universal care for Americans and the hard work of redesigning and improving healthcare processes. Indeed, given the costs and waste in the healthcare status quo, redesign may be our only sustainable route to justice and financial solvency.