This year's Institute for Healthcare Improvement forum, which ended Wednesday in Orlando, provided so many new concepts that could—either quietly or dramatically—alter any healthcare system, at times I thought my head was spinning out of control.
Last year's shock of having to brace for change has worn off. This year, leading-edge providers are thinking much more seriously, in much more detailed and creative ways, about just what form that change must take.
Involving the Patient
For starters, many of the more than 5,700 attendees and presenters said they are figuring out how patients and family members can be a bigger part of the process. In some healthcare systems, providers make sure a patient advocate sits in during interviews with prospective hires for certain clinical jobs. Did they look the patient in the eye? Could they listen as well as they could speak?
A smart, young patient with renal failure told how he got so sick and tired of not being in control of his dialysis, that he pushed the Swedish healthcare system to let him administer his own sessions. With the help of an inspired nurse, the patient created a center where more than 50 patients now administer their own dialysis, with less fatigue, fewer infections, and at reduce cost. The patient with renal failure obtained a transplant and now works as a registered nurse.
Hospital-Centric No More?
Increasingly, hospitals and health system attendees said they are realizing that they need to rethink what kind of care they give and how they give it. And most importantly, where they give it. More often, the conjunction "with" is used, as in we treat disease with patients.
"I think at our system, hospital executives are coming to the conclusion that the hospital will not be the center hub of healthcare much longer," said Patricia Peers, MD, a family practitioner who came to the meeting from Sioux Falls, SD. "My goal now must be to never have a patient in the hospital."
IHI attendee Keith Poisson, COO of Greater Baltimore Medical Center in Towson, MD, said, "Hospitals have been hospital-centric." When he returns home, he said he will raise some questions about whether the hospital should also be involved with the local health department, churches, and schools.
"Part of what we're struggling with is how you do the right thing for the community when you're not incented to do so," Poisson added. "How do we transition from a fee-for-service model to one where we take risks for health, instead of focusing on attracting more doctors and bringing in more admissions."
In her keynote address, IHI president and CEO Maureen Bisognano praised Gundersen-Lutheran Health System in La Crosse, WI for spending its own resources to provide healthier food choices in school cafeterias as well as grocery and convenience stores.
In the hallways, attendees said they were starting to get the idea.
Community Involvement
"We've been doing a lot of work on readmissions, but now we realize we have to bring in other relevant providers into the equation to help us," said Joe Valvona, corporate director of operational effectiveness for Catholic Health Partners in Cincinnati, which has about 25 hospitals.
"It's not just that our hospitals can't do it on their own. But we need to get community resources, like skilled nursing facilities, but even some local health centers and I go so far as to say churches and schools ... to look at the populations they serve –any community resource that's out there that is touched by or involved with healthcare is an opportunity to collaborate, even drug stores, pharmacies."
That of course is the opposite idea of what a hospital or physician's role has historically been—a resource for treating people when they get sick enough to need acute help.
Some attendees acknowledged that they face formidable obstacles in persuading their leaders to spend money now to keep the general population in their cities and communities healthy. And many health leaders remain skeptical.
Blair Sadler, former CEO of San Diego Rady Children's Hospital and now an IHI senior fellow, said that about half of healthcare executives are "hanging on to their old revenue streams for as long as possible. But they are like Thelma and Louise, going over the cliff. The other ones have the courage to say we have got to do the right thing, even though in so doing, we'll earn less money, because to not do it is unethical."
Berwick Blasts 'Death Panel' Rhetoric
The brightest star of this year's forum, however, was IHI founder Don Berwick, MD. Last month he involuntarily gave up his 17-month stint as administrator for the Centers for Medicare & Medicaid Services because he knew he would not receive Senate confirmation.
Earlier in the week Berwick addressed a small group of reporters, and focusing his remarks the formation of the rules for accountable care organizations and the failure of some members of Congress to understand the gravity of challenges the healthcare system in faces .
In Berwick's keynote Wednesday, he blasted the divisive political rhetoric that mischaracterized the Patient Protection and Affordable Care Act by introducing talk of "rationing" and "death panels."
Berwick called "the distorted and demagogic use" of the term "rationing" "another travesty in our public debate." Rather, he said, "The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care.
"It boggles my mind that the same people who cry "foul" about rationing (are the same who) an instant later argue to reduce healthcare benefits for the needy, to de-fund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people—elders, the poor, the disabled—who are least able to bear them."
Rationing, he said, is more like what happens "when the 17 million American children who live in poverty cannot get the immunizations and blood tests they need...[and] when disabled Americans lack the help to keep them out of institutions and in their homes and living independently, that is rationing.
"When tens of thousands of Medicaid beneficiaries are thrown out of coverage, and when millions of seniors are threatened with the withdrawal of preventive care or cannot afford their medications, and when every single one of us lives under the sword of Damocles that, if we get sick, we lose health insurance, that is rationing."
Berwick's temper seemed to rise even more when he talked about the political debate over so-called "death panels."
He described as "nonsense, fabricated out of nothing but fear and lies, [the notion that] that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope," he said.
"The truth, of course, is that there are no 'death panels' here, and there never have been. The truth is that, as our society has aged and as we have learned to care well for the chronically ill, many of us face years in the twilight our lives when our health fades and our need for help grows and changes.
Many attendees leaving Berwick's talk said he was inspirational and gave them the energy and courage to push for change in their own organizations.
In coming weeks and months, I hope to describe in greater detail many of the creative sessions I heard about preventing errors and infections and gathering data and transforming culture to drive change. A lot of it may seem pie-in-the-sky right now, but just wait.