How will the way we deliver care in ten years be similar to the way deliver care today and how will the future be different? One thing that is already in transition is the expectation of patients. Patients want a more “horizontal” and collaborative connection with their doctors and care team. That many patients receive care from a team of providers is itself a future oriented change. Are we ready for the the real digitalization of care? How will IBM’s Watson and our increasing facility with big data support or undermine our clinical opinions and use of “expert intuition”?
What will the experience of care be like on the other side of the great transition from volume to value? How will the professional experience change for those who directly touch patients: the doctors, nurses, NPs, PAs, various therapists, social workers, medical assistants, pharmacists and others. The inclusive list of medical professionals whose work flows will likely change seems endless, but everyone’s contribution working together will be required to maximize our efforts to achieve the Triple Aim. I like referring to this more robust form of collaboration that is augmented by Lean philosophy as a movement from “I” to “we”. The move to “I” to “we” must occur between clinicians, between all healthcare professionals, between organizations, and between healthcare and other social functions like education and social services. The Triple Aim is a goal for the whole community.
Perhaps greater than the challenge that we face today with healthcare finance and our worries about the cost of healthcare is the fact that in the very near future we will experience relative deficiencies in the number of doctors, advanced practice clinicians and nurses needed to staff our current models for those with access to care. Even with every provider working efficiently and “at the top of their license” there is reason to question whether or not in the future we will be able to offer every patient the timely access to care that meets their needs.
We have always loathed the rationing of care, even as we have used healthcare finance as a de facto mechanism of rationing. In the future will further de facto rationing be forced by shortages of the professionals needed to staff our current method of care? Until now we have not spent much time thinking about the most efficient and effective deployment of professional expertise to lower the cost of care for consumers while maintaining or improving quality. It would be hard to argue against the reality that we currently deploy our professional assets to maximize revenue.
Beyond just looking at how care will be experienced by patients and all of the professionals that form the “we” of the delivery team, I also want to look at how the delivery of care will change for professional groups and organizations. In the future alignment between cognitive specialties and procedural practice may become even more complicated than it is today. To completely view the future we will also need to imagine the concerns and needs of employers, commercial payers, regulatory agencies and especially those who take a special interest in improving the lot of the populations who are currently underserved and disenfranchised.
Where do we start? I will not start with Hippocrates but will make references back over the broad expanse of practice between him and the publication of Crossing the Quality Chasm in 2001. I will also embrace Don Berwick’s three eras of practice and some of my comments will reference his Era 3 which we are entering now and even speculate about the eras to follow. It makes sense that if there have been Eras 1 and 2 before Era 3, that there will eventually be Eras 4 and 5 with even more to follow.
So what was so great about Crossing the Quality Chasm and why do I continue to celebrate it and refer to it as something that is as important and as fresh today as when it was published fifteen years ago? There are at least three great ideas in Crossing the Quality Chasm.
- Our system of care is best seen as a complex adaptive system. Improving it and managing it requires understanding complexity.
- Crossing the Quality Chasm gave us a functional definition of what to look for when we were examining a system of care for its quality. What amazes me is that even after fifteen years there are many who still do not know that quality care is patient centered, safe, efficient, effective, timely and equitable.
- Finally Crossing the Quality Chasm gave us a description of the practice or care delivery system for which we were searching. It gave us the :
The Ten Descriptors of Better Systems of Care
1) Care based on continuous healing relationships:
2) Customization based on patient’s needs and values.
3) The patient as the source of control. Encourage shared decision-making.
4) Shared knowledge and the free flow of information:
5) Evidence based decision making.
6) Safety as a system property.
7) The need for transparency.
8) Anticipation of need.
9) Continuous decrease in waste.
10) Cooperation among clinicians. [“I to we” within practices, across practices, across systems and throughout the community.]
There are a myriad of ways to design a better system of care for the future that would have all of these properties and produce care that fits the six domains in the definition of quality. Location, existing assets, and characteristics of the populations that need to be served are all determinants that must be considered as we move from what is to what will be. Different populations will require different systems, but all of the systems that are the answer to the needs of a specific population will contain these ten components or properties.
You may ask, “What problem are we trying to solve?” The answer to that question has been better articulated since 2007 when the IHI published the Triple Aim. Our problem can now be explicitly stated as:
How do we achieve better care for everyone, healthier communities, and sustainable medical costs? When we do achieve the Triple Aim we will finally have:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
I first heard that more fluid and inspiring revision of the “wonky” Triple Aim last year at the IHI meetings. At the same time I was introduced to the IHI’s “100 Million Healthier Lives Campaign” and its “new rules for radical redesign” in healthcare.
New Rules for Radical Redesign in Health Care
Change the balance of power: Co-produce health and wellbeing in partnership with patients, families, and communities.
Standardize what makes sense: Standardize what is possible to reduce unnecessary variation and increase the time available for individualized care.
Customize to the individual: Contextualize care to an individual’s needs, values, and preferences, guided by an understanding of what matters to the person in addition to “What’s the matter?”
Promote wellbeing: Focus on outcomes that matter the most to people, appreciating that their health and happiness may not require health care.
Create joy in work: Cultivate and mobilize the pride and joy of the health care workforce.
Make it easy: Continually reduce waste and all non-value-added requirements and activities for patients, families, and clinicians.
Move knowledge, not people: Exploit all helpful capacities of modern digital care and continually substitute better alternatives for visits and institutional stays. Meet people where they are, literally.
Collaborate and cooperate: Recognize that the health care system is embedded in a network that extends beyond traditional walls. Eliminate silos and teardown self-protective institutional or professional boundaries that impede flow and responsiveness.
Assume abundance: Use all the assets that can help to optimize the social, economic, and physical environment, especially those brought by patients, families, and communities.
Return the money: Return the money from health care savings to other public and private purposes.
Does “I to We”, the concepts of quality, and the descriptors of the ten properties of a better system of care plus the Triple Aim and the New Rules for Radical Redesign in Health Care give us enough clarity to imagine the delivery of care in the future? I think not.
Remember Dr. Ebert’s admonition:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
We need a methodology to organize the framework and operating system of care delivery. My vote has been to use Lean as the tool and the instrument of culture evolution necessary to support the innovation that will design the future of care. I know of no better way than Lean to effectively tap into the wisdom of healthcare’s many professionals, customers and suppliers and organize that wisdom into something that meets the needs of all of its stakeholders.
Lean and the foundational principles above are all necessary for the future but are still insufficient. Dr. Ebert considered several components of the operating system and so far I have not mentioned financing. Will we move toward more risk and more effective use of prospective budgets built on the needs of populations? I think that is what MACRA and the collaboration between payers and CMS is suggesting will happen. I also think that suggestion will move from a nudge to a demand. I certainly would not build an image of the future on a fee for service chassis.
Next week I will look at the future from the perspective of the patient building from the foundation or framework laid down here. Let me know if there are other foundational issues that you would include.