We Can Finally Cross the Quality Chasm Together

And We Can Do It Now

Nearly a quarter of a century ago, the National Academy of Medicine (NAM) produced a landmark guide to reform American medicine named Crossing the Quality Chasm. The name says it all. Our healthcare is much too expensive, and it does not protect us as well as the systems in other developed countries. The NAM did not sugarcoat it.

“Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case. Crucial reports from disciplined review bodies document the scale and gravity of the problems. Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm.” That quality canyon makes our healthcare more expensive and less effective.

So, what are they talking about? Scientific medicine is a relatively recent development. Our current system came out of the early 1900s and our needs were very different then. Life expectancy was just over 40 in 1900. Now it is almost 80. In 1900, there were no antibiotics and very few vaccines. Our understandings of disease were primitive and there were very few medicines that worked. Our health system was developed to deal with acute needs. It was developed to treat infections, injuries, heart attacks, and strokes. When you only live to be 40, chronic illnesses are much less common. The system evolved to address sudden health challenges.

When Americans live to be 80, everything is different. Sudden, acute health challenges are no longer the problem. Five percent of the patients with multiple chronic diseases generate half of health care costs. Twenty percent generate 86% of costs. Chronic diseases lead to most premature death and disability. The needs of patients with chronic disease are completely different from those with acute events. That is the key reason the National Academy of medicine says “The American health care delivery system is in need of fundamental change.”

Since Crossing the Quality Chasm was written, the reasons to change have multiplied. Our understanding of chronic illness and our ability to make a difference is greatly enhanced. In 2001, we thought chronic diseases were inherited. We thought they were due to changes in the DNA sequence. Now we understand that most chronic diseases are not genetic, they are epigenetic. They are not due to changes in the DNA sequence. They are due to changes in DNA regulation that result in increased oxidant production and inflammation. We understand those changes well enough that we can block them precisely using a protocol that combines lifestyle and medical measures. When we do that, patients with diabetes have one fourth as many heart attacks and one fifth as many strokes. Patients who have had a heart attack treated in this way are ten times as likely to be alive 5 years later. Our system has not changed to reflect these advances.

We cannot have better health at lower cost by further stressing current systems of care. “The current care systems cannot do the job. Trying harder will not work. Changing systems of care will…The committee's report on patient safety offers a similar conclusion in its narrower realm. Safety flaws are unacceptably common, but the effective remedy is not to browbeat the health care workforce by asking them to try harder to give safe care. Members of the health care workforce are already trying hard to do their jobs well. In fact, the courage, hard work, and commitment of doctors, nurses, and others in health care are today the only real means we have of stemming the flood of errors that are latent in our health care systems. Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.”

The critical insight is that we need systems to treat chronic disease and that is not the way American medicine works now. When you go to see a doctor, you depend on his training in medical school and his continuing medical education that must be applied in a very short visit every three to six months. Your doctor must figure out how to help you on the spot based on his individual knowledge. It takes time and a longstanding trusting relationship to effectively treat chronic illness. The National Academy of Medicine recommends “evidence-based care processes consistent with best practices.” These care processes are like the systems used to produce any product consistently. That is why protocols and teams are so successful in chronic disease management. If you don’t use systems and protocols—if you are not set up to consistently produce a product—you cannot scale the new medical approach you have developed to treat millions of people.

As I said, the advice in Crossing the Quality Chasm has been almost entirely ignored and the consequences are predictable. Some of the most successful companies in our country have tried to solve the problem of high cost and low quality in American healthcare and they have failed or are failing— Berkshire Hathaway, Walgreens, Amazon, and now finally Walmart. I don’t believe they followed the recommendations in Crossing the Quality Chasm. Almost no one has done that.That document is the main guide for what I do and write about. My copy of the book is worn, dog eared, and highlighted. Very few organizations have taken this document seriously, but Vestra Health has, and they provide very high-quality care at half the cost. Their patients are healthier too. They are hospitalized one fifth as often and in the emergency room one third as often. The next post will go into more detail on the specific pathway to success in chronic condition management. We will not have better healthcare until we cross the quality chasm. We all have a stake in getting this done.