It's a rare day when Maureen Bisognano, President and CEO for the Institute for Healthcare Improvement, says anything negative about anybody. Usually she's effusively praising systems or individuals who've found creative ways to improve care.
But on Tuesday, during her opening keynote address to more than 5,000 providers attending the 24th IHI National in Orlando, she made a brief exception.
She first heaped praise on how one hospital treated a patient she knew named Jess, who had a sudden and serious medical issue requiring emergency hospitalization. But for the way another unnamed hospital treated a patient whose care she also personally observed, she let the criticism fly.
That patient was her brother-in-law, Bill.
What happened to him, she says, was an example of how even with all the progress in healthcare reform so far, many hospitals and systems have a very long way to go.
In a hallway conversation, she elaborated on her brother-in-law's story of confusion and anxiety after he underwent a colostomy procedure.
"When he was admitted to his semi-private room, we experienced the opposite of Jess's care. There was no white board, (a wall hanging to orient the patient and other caregivers on the care plan) and there was no team. So each individual professional came in one by one, and often offered him completely conflicting advice.
"The first physician who came in to Bill's room said 'Bill, take a lot of pain medication. Because that will allow you to get up and walk, and the more you walk the earlier you'll get home.'
"The next physician came in said 'Don't take a lot of pain medication because your colostomy won't work.'
"The next physician came in and said 'I think you should eat as much as you can.' And then the nurse came in and said, 'You're N.P.O,' and took the tray away.
"So all day long Bill was confused," Bisognano said. "He never had a plan for the day. And he never knew when his discharge would be until the very hour he was discharged. Each individual professional was managing his symptoms from their own knowledge, but there was no sense of team, in that care was not designed around his needs.
"It was designed around the individual actions from the point of view of the professional."
This hospital obviously upset the wrong change advocate.
But maybe, just maybe, things are about to change.
Bisognano noted that two days after the November election, IHI held a meeting with 100 political and healthcare industry leaders such as former U.S. Senate Majority Leaders Tom Daschle, William Frist, MD, Gary Kaplan, CEO of Virginia Mason Health System in Seattle, Christine Cassel, MD, President and CEO of the American Board of Internal Medicine, and Bruce Siegel, President and CEO of the National Association of Public Hospitals and Health Systems.
What they all were thinking, she said, was that the election changed nothing for most of America. Frist, she said, noted 'that the same people are sitting in the same conference rooms, with the same issues behind the same closed doors.
"But with healthcare, in the last two days, everything has changed.
"There's a sense of certainty about the destination. There are going to be more people coming into the system."
And the challenge is to make sure that costs are lowered while quality improves, two goals that some healthcare systems are finding are not mutually exclusive.
"But what's really causing uncertainty is how do we get there," Bisognano said. "In the last weeks, I've heard more people say, 'Okay. I realize now I have to control my costs,' more than I've heard more than the last 20 years."
Now, Bisognano says, the trick is to figure out how reducing costs can improve quality.
In his keynote talk, Don Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and IHI's cofounder, did not mince words about where he thinks much of the quality improvement and cost reduction should come from.
Alluding to the "monsters" that his grandson believes hide under his bed, Berwick identified 11 "monsters" that now block the road to higher quality and lower costs. And many of these monsters are policies or practices that encourage waste and maintain elaborate infrastructures to perpetuate unjustifiably excessive profits for some companies and providers, he said.
For example, he referred to credible estimates that more than 50% of the stenting and coronary bypass procedures performed today don't resolve symptoms, and don't extend life or prevent heart attacks.
Just imagine, he implored the crowd, if this were correct.
"All those angiography suites, all those operating rooms, all those proud and technically brilliant interventional cardiologists, what happens to them? What happens to the business models of heart hospitals, the stent vendors, when the evidence accumulates that what we do a lot of doesn't help nearly as much as we thought it did. It is scary to ask," he said.
"It is going to take courage to name and address the large portion of American healthcare that simply does not help," Berwick said.
Another "monster," he said, is excess profit, which companies are legally allowed to make through marketing approvals of drugs. One, hydroxyprogesterone, a drug to prevent premature labor and low-birth-weight babies, costs payers such as Medicaid as much as $25,000 for a course of treatment, instead of the $300 the drug would cost if it were still allowed to be sold in its generic form.
One of the attendees, physician pathologist Lisle Eaton from St. Peter's Health Partners in Albany, NY, expressed a similar view, but said most physicians he knows, especially oncologists, "have their heads buried in the sand" about the problem.
For example, he said in between sessions, for oncologists, the desire is to treat with drugs, even if the drugs are extremely expensive, and even if these same drugs "may not have the best track record" for helping these same patients, and which carry serious side-effects as well.
"Nevertheless, they march down that road. I'm not saying they're not good doctors or they don't care, but sooner or later, we have to see quality and cost savings can go hand and hand."
In any year, attending the IHI National Forum is like—to use a cliché—drinking from a fire hose. And this year was no different, with an impossible number of inspiring ideas for dozens of stories and columns.
I hope to capture many of them in this space in the weeks and months to come. Stay tuned.