Organized Practice Fosters More Reliable Care
The Institute of Medicine released a report recently on safety in health care. Its major conclusion: As many as 44,000 Americans die each year as a result of preventable medical errors--more people than die each year from breast cancer or AIDS, and many more are injured.
What kind of mistakes? They include the rare but obviously terrible cases such as operating on the wrong leg or the wrong side of the brain, all the way to the wrong medication being dispensed because a pharmacist misread a doctor’s handwriting on a prescription. While you can argue about the data itself, because it is an extrapolation from a small number of studies to the entire U.S., it is hard to contest that the complexity of medical care has outstripped our systems to ensure safety.
But another, more important theme runs through the report, and as a surgeon and the administrator of a large physician practice plan I truly hope it penetrates the American consciousness. The report points out that the overall decentralized and fragmented delivery system itself contributes to unsafe conditions. The report finds that organizations improve quality by focusing on processes, not by tracking down and punishing mistake-makers. In other words, creating an effective culture of accountability in a more integrated American health system will eliminate most medical mistakes.
What does the report mean when it says that health care in the U.S. is not organized? One key group--physicians, who retain almost fierce independence--largely lies outside organized practice. As the report notes, “Physicians in community practice may be so tenuously connected that they do not even view themselves as part of a system of care.” Hospitals do not, in reality, control their medical staffs. Unless physicians develop a greater culture of accountability, hospitals and nursing homes will have a hard time improving quality.
How can physicians working together improve medical quality? An example from our experience at UCLA may be instructive. Data emerged that patients having heart attacks are more likely to survive if they receive clot-dissolving drugs quickly after the attack.
It might seem simple to accomplish this, but to do so requires close coordination between many different specialists. UCLA cardiologists, emergency medicine physicians, internists, radiologists and pathologists sat down together with the goal of optimizing the treatment of patients with heart attacks. Their efforts resulted in a 75% reduction in deaths for UCLA’s heart attack patients. The cost of treatment has declined by 50%, confirming what many believe: Higher quality care can actually cost less. This would not have been possible without doctors coming together, being willing to change their practices, and then being held accountable by their peers.
California physicians have been national leaders in coming together in group practices. One of the earliest of these, the Permanente Medical Group of the Kaiser system, developed a deserved reputation for a systematic approach to quality assurance and recently won the Pacific Business Group on Health’s Blue Ribbon Award for Quality. But other medical groups in the state also have developed in the past 10 years in response to society’s mandate to figure out how to deliver high-quality, cost-effective care.
Managed care has taken a beating recently because of consumer dissatisfaction, but it has created an incentive for physicians to create group practices. Now approximately 25% of doctors in California practice in groups. Unfortunately these groups are at risk due to the current instability in the health system in California. If physician groups are forced from the scene, a critical component capable of systematically improving safety in an organized health system will be lost. This fact has not been readily appreciated by policymakers, regulators, the media or the public.
California now has thousands of physicians who have stepped forward and expressed their willingness to be held accountable and to be a part of systems of care. Policies should be examined through the prism of whether they enhance and offer incentives to the continued development of physician groups. Failure to do so will make the task of hospitals and other organizations to successfully take on the challenge of the Institute of Medicine all but impossible and invite a self-defeating “find the bad apple” regulatory approach to safety and quality. In our clinical language, that would be a very bad outcome.
