Editor Discusses the Healthcare System

For too long we have looked at healthcare reform through its many parts rather than as a system. In a series of BBC Reith lectures Atul Gawande states this is “the century of the system”. Gawande argues that better systems can transform global healthcare by radically reducing the chance of mistakes and increasing the chance of successful outcomes. According to Dr. Gawande two million people a year pick up infections in our hospitals, largely because we do not follow protocols.

Decades of articles have demonstrated the toll that medical mishaps, including preventable infections, take on patients and their providers. These avoidable complications cause tens of thousands of unnecessary deaths and injuries, and cost billions of dollars.

Today ‘s healthcare system is a many layered maze of insurance companies and claims, provider organizations, government oversight and regulations and mind boggling technologies developed to improve providers ability to perform and provide better patient care. Add to this the increasing body of knowledge that healthcare providers must know, the health records that must be kept, and the myriad of drugs prescribed, and things begin to be a bit complicated!

Furthermore, the human body has 13 different organ systems with an estimated 60,000 different complex combinations that could go wrong. Add to that, a typical clinic sees 6,000 diagnoses a year and an average clinician sees approximately 400 diagnoses and must be able to diagnose and treat each patient.

Only through thoroughly replicating a process via standardization and developing standards can we hope to transform our healthcare systems. Today we must use a systems approach to educate and train our future providers if we hope to achieve success.

The Pittsburgh Regional Health Initiative (PRHI) is one of the nation’s first regional collaboratives of medical, business and civic leaders organized to address healthcare safety and quality improvements. Founded in 1997, PRHI has approached quality improvement as both a social and business imperative. Its core mission is to show that an unwavering focus on meeting patient needs, and on achieving optimal care outcomes, along with simultaneous dedication to efficiency and zero defects, will create maximum value for the patient and for society.

To achieve its ambitious mission, PRHI developed its own process improvement methodology called  Perfecting Patient CareSM (PPC) based on industrial engineering principles articulated by W. Edwards Deming, to move beyond targeted problem-solving to transforming the way both organizations and healthcare systems achieve, spread, and sustain value. Its goal is to show what’s possible and to excite health providers to design their own transformations in the combined interest of quality, safety, and efficiency.

Another organization that looks at healthcare as a system is the Veteran’s Administration. “Everyone makes mistakes, especially in a hectic, high stress environment with lots of distractions,” said Dr. Ann Polich, Associate Chief of Staff for Patient Safety at the VA Medical Center in Omaha, Neb. However, “patient safety is effective if it makes it hard to do the wrong thing and easy to do the right thing. If the system makes it difficult to make a mistake, then it’s hard to inadvertently hurt someone.” Polich further states, “if you have a system that automatically reminds you to follow correct procedure, it reduces your vulnerability to error. Anything that’s left to memory, a human will forget. Especially humans who are facing as many distractions as doctors and nurses are.”

But before you can build a better system, you need to know where your current system’s weak spots are. And you can’t know that unless your doctors and nurses are willing to report the errors they make while trying to deliver the best care possible to their patients. That’s why the Department of Veterans Affairs is training young residents that it’s OK to report their mistakes and even their ‘near misses.’ At VA, mistakes are regarded as teachable moments and consequently, an opportunity to improve the entire system.