Building the Bridge Across the Quality Chasm in American Healthcare

We Have Already Started Construction

In the last post we discussed Crossing the Quality Chasm together. Today we will review the plans to build the bridge over the massive quality gap. The blueprints for the bridge are in this section of the document. It is difficult to describe the massive change required to cross this huge quality gap. We must move from a system dominated by huge hospital systems to a system based in outpatient primary care designed to treat chronic diseases so skillfully, that it prolongs healthy life and hospital beds are needed less often. We must turn the system on its head.

The National Academy of Medicine did not merely point out the enormous problem, they developed a simple blueprint for bridge construction.

Here is a brief general outline of their assessment and plan.

“The current delivery system responds primarily to acute and urgent health problems, emphasizing diagnosis, ruling out serious conditions, and relieving symptoms. Those with chronic conditions are better served by a systematic approach that emphasizes self-management, care planning with a multidisciplinary team, and ongoing assessment and follow-up…. successful chronic disease management programs:

• Use a protocol or plan that provides an explicit statement of what needs to be done for patients, at what intervals, and by whom, and that considers the needs of all patients with specific clinical features and how their needs can be met. The care plan is a tool that links the multiple visits and contacts that characterize care for chronic illness.

• Redesign practice to incorporate regular patient contact, collection of critical data on health and disease status, and strategies to meet the educational and psychosocial needs of patients who may need to make lifestyle and other changes to manage their disease. Regular follow-up is a hallmark of the design of successful programs.

• Include a strong focus on patient information and self-management so patients and their families acquire skills in self-management and can make needed lifestyle changes. Structured self-management and behavioral change programs improve patient outcomes.”

That is the general outline followed by a very specific construction plan for the bridge itself. I am working with dozens of other stakeholders and construction has begun!

Step One: Bring Together the Stakeholders

We are already collaborating with other stakeholders to provide what employers and employees need. No single entity has all the pieces right now to deliver a comprehensive solution for chronic disease management to self-insured employers and other payers. You can learn more about our stakeholder collaboration here.

Step Two: Identify Fifteen Priority Conditions for Initial Focus

“Based on their prevalence, expense, or policy relevance: cancer, diabetes, emphysema, high cholesterol, HIV/ AIDS, hypertension, ischemic heart disease, stroke, arthritis, asthma, gall bladder disease, stomach ulcers, back problems, Alzheimer's disease and other dementias, and depression and anxiety disorders.”

The conditions in bold type are the ones we will begin with because they are the ones for which best practices are most firmly established. Obesity, chronic kidney disease, other arterial disease, and congestive heart failure are also part of our list. In the 22 years since Crossing the Quality Chasm was written, we have learned that aging and most chronic diseases are related and that optimal medical therapy (OMT) for the conditions in bold type reduces all-cause mortality. OMT makes us healthier so that we need hospital systems less often.

Step 3: Execution

Health care organizations, clinicians, purchasers, and other stakeholders should then work together to:

(1)   organize evidence-based care processes consistent with best practices.

a.    These are our systems of care and protocols.

(2)   organize major prevention programs to target key health risk behaviors associated with the onset or progression of these conditions,

a.      These are our comprehensive patient education programs, nurse coaching, and nurse navigation.

(3)   develop the information infrastructure needed to support the provision of care and the ongoing measurement of care processes and patient outcomes, and

a.      This is the Congruity IT platform and team that uses AI to automate our systems and processes as much as possible sore they can be easily scaled.

(4)   align the incentives inherent in payment and accountability processes with the goal of quality improvement.

a.      We reward high performance while creating simple, transparent payment systems.

Fundamentally, the base of knowledge and information involved in medicine is so massive that it is impossible for any one individual to master it all and integrate it to produce the best clinical and financial outcomes. That is why this Crossing the Quality Chasm document emphasizes systems. Quality and safety are systems properties. Processes, procedures, protocols, job designs, equipment, communication, and information technology should all be integrated and designed to consider human factors, reduce errors, and mitigate the effect of errors when they do occur. Experience has proven that depending on individual patient and clinician responsibilities falls short. All participants in the healthcare effort need carefully designed systems to support them in their work. When we accomplish that, we will finally have much better health at much lower cost. We need every one of you to spread the word and support us in our work.