Bob Wachter's recent post about health care quality and “the non-scalability of charisma” was quite thought-provoking. In essence, Wachter asked if we can fix health care without having a Don Berwick or Peter Pronovost in every state (or maybe every hospital -- and its board room). And that had me thinking both about health reform and “scalability,” particularly in light of my own recent experience as a family member of a hospital patient.
Wachter laments the slow pace of improvement, even regarding something as clear cut as effective and consistent use of a five-item checklist to reduce central-line associated bloodstream infections.
The fact that it seems impossible to export Michigan's success [with the checklist] to the rest of the country is particularly disheartening, since there are few other safety and quality interventions with such strong evidence of benefit; whose successes were reported in the New England Journal of Medicine, the lay media, and now two books (by Gawande and Pronovost); and whose implementation is so straightforward -- no technology or expensive equipment needed, just a 5-item checklist coupled with some leadership commitment, measurement, and a dab of culture change. If we can’t disseminate this intervention, what will happen when we try the hard stuff?
I understand the point Wachter is making (and my recent experiences deepened that understanding). But I wonder how to factor in the fact that the world is changing, that we're entering a new era -- that health care reform includes incentives for hospitals to improve the quality of care, and to provide care more efficiently. High infection rates are neither good quality nor efficient. Maybe the incentives in the new law will prove strong enough to start stepping up the pace of change. Maybe -- quite possibly -- we’ll have to do more in this area. In addition -- we do have Don Berwick in all 50 states! As head of Medicare and Medicaid, he will still be able to be what Wachter calls a "charismatic physician-leader." He will have a national platform, for a national impact. He will still have his power to exhort and explain -- coupled with the power to regulate and shape public policy.
I also think there are trends and developments outside of federal health reform per se that will come to bear. The Centers for Disease Control, partly because of stimulus package funding, is increasing its work and its public reporting on hospital-acquired conditions. Additionally, more and more states are requiring reporting, and are making it publicly available. CMS is putting more data on Hospital Compare. Some hospitals are voluntarily reporting -- and challenging their competitors to do the same. This will hopefully create a new kind of self-perpetuating momentum for improvement. If a patient or potential patient -- and my family did this -- can easily find out that Hospital A has good infection control and Hospital B does not, isn’t that going to help Hospital B get its act together?
I don't believe that the web can tell us everything that we need to know to slog through all the complexities of 21st century healthcare as "informed health care consumers" or that information will be some kind of patient-empowering panacea. (And there's a big difference between a patient or family researching where to have an elective procedure versus an emergency one, or making decisions about a straightforward or clear-cut set of options versus a set of more highly complex treatment choices they may not fully understand). Even with these weaknesses, I think information transparency may nudge doctors and hospitals in the right direction, both for the sake of quality and for compelling business reasons.
Join the Conversation
Please log in below through Disqus, Twitter or Facebook to participate in the conversation. Your email address, which is required for a Disqus account, will not be publicly displayed. If you sign in with Twitter or Facebook, you have the option of publishing your comments in those streams as well.