Physicians as Leaders in Improving Health Care: A New Series in Annals of Internal Medicine

If improving health care were easy, we might be seeing more of it. Instead, most physicians nowadays seem to feel that just plain holding on is difficult enough. In fact, searching for one word to describe the state of mind of the physician today, we might choose beleaguered. Threats appear from all sides-from payers, would-be managers of care, the growth of technology, and even patients. A group of physicians and nurses in Massachusetts recently called the First Public Meeting of the Ad Hoc Committee to Defend Health Care. In the same week, the editor of The New England Journal of Medicine wrote an editorial entitled, Our Endangered Integrity-It Can Only Get Worse, which was full of warnings about financial pressures that jeopardize our long-held professional standards [1]. The President of the United States last year appointed an Advisory Commission on Consumer Protection and Quality in the Health Care Industry, and the Commission's first assignment was to draft a health care consumer's Bill of Rights. This is the rhetoric of siege and battle; the key words are defense, jeopardy, and protection. Is this an irreconcilable clash of competing, mutually contradictory values from which only one winner will emerge? What about improvement? Can we achieve a common aim of good outcomes for patients at a cost that society can afford? Honest appraisal of the scientific facts suggests that we can greatly improve health care by closing the often wide gaps between prevailing practices and the best known approaches to care [2] and by inventing new forms of care. Variation in health care procedure rates among sites of care is too great to support the claim that everyone in the health care system is correct [3]. Almost every issue of our major professional journals contains research reports that should be the basis for the continual improvement of our work, and yet much of this knowledge fails to enter routine, day-to-day care. For example, recent evidence has shown the underuse of -blockers in elderly patients with acute myocardial infarction [4]; the underuse of inhaled steroids in patients with asthma [5]; and the high cost of pharmaceutical errors in hospitalized patients, errors due in part to unsafe system designs [6, 7]. What alarms call physicians to take action to close such gaps? Where is the Ad Hoc Committee to Cause Improvements in Care? It seems that in the medical profession, the will and the skill to act are in much shorter supply than the knowledge on which to base action. Improvement and Change It is usually easier to defend the status quo than to change it, and in this difference lie the roots of the dominant professional response to the pressures on health care today [8]. However, evidence is mounting that the excellence of the status quo is a sentimental illusion. Some physicians have begun to confront this issue directly; however, to effect a positive outcome for the emerging structure of our health care system, all physicians will increasingly need to replace handwringing with active citizenship and use of their considerable power and influence in the improvement of care. Because resistance to change runs deep, physicians fail to acknowledge the degree to which the very pressures that threaten their security are the consequences of their own action or inaction. The financial pressures that, in the opinion of the editor of The New England Journal of Medicine, endanger our integrity did not arise spontaneously from avaricious private marketeers. Even if one accepts (as we do not) that avarice and free markets are driving the system now, the opportunity for them to do so arose because health care, as it is pursued today, causes some serious social problems and fails to address others that it should help to solve. The failures of our system breed attempts to control it, some wise, some unwise. A struggle against managed care, price cutting, rationing, or market competition is a struggle against symptoms, not causes. Physicians who want to preserve the integrity of their profession must use that integrity to solve some of the problems that their profession has created or, through inaction, has permitted to accumulate. That will require change, and the first change is in our aims. The professional leadership of improvement must begin with a clear acknowledgment of the need for improvement. For example, take the cost of care. There are two camps. One, plausible and pedigreed, argues that rising costs in U.S. health care are driven by social, demographic, and technological factors beyond our control. Those who defend this view argue that we have no choice but to pay the bill or ration care [9]. One option is economically ruinous; the other, politically untenable. Another camp argues with equal force that it is possible to dramatically reduce the cost of care without causing harm. These experts cite the wide gap between health care costs in the United States and in other nations that have equal or better care. They note the evidence of useless and even harmful excesses in specialty care, procedure rates, medical equipment, hospital bed supply, administrative procedures, and regulatory inspection, and they describe with even more evidence how other industries have found enormous waste deeply embedded in their own time-honored processes. We are firmly in the second camp. We believe that the prognosis for the health care system is good if physicians will contribute actively to improving the system as a whole. If we are wrong, our agenda at least gives professionals something more pleasant to do than complain. More important, if we are correct in stating that the seeds of fundamental improvement in health care systems lie within the reach of physicians, then physicians can best exert their influence by recognizing the problems to be solved and then doing everything in their power to assure that the solutions they help develop are technically proper, ethically sound, and effective. Let us assume that you believe that the changes affecting medical practice get their ammunition from real social problems and that you, as a caring physician, want to take action to influence the solutions to those problems. What can you do? A Model for Improvement How can you know? Nothing about medical school prepares a physician to take a leadership role with regard to changes in the system of care. Physicians are taught to do their very best within the system and to perfect themselves as individual professionals by advancing their skills and knowledge every day. But being a better physician and making a better system are not the same job. They require analogous, but somewhat different, skills. And so we come to the point of this series of articles: to describe the kind of knowledge, much of it foreign to the clinician, that will help physicians participate effectively in the redesign of the health care system. We intend to raise the curiosity of physicians about the new skills they will need to become more active and influential citizens of the health care community in accomplishing improvement. This new knowledge will serve as a conduit for deploying clinical expertise into a debate heretofore informed primarily by economics. Our list of skills comes from a simple model for improvement that one of us has crafted over the past decade in the company of colleagues (Figure 1). The model is a response to the question, What are the components of efforts that continually improve organizational or individual performance? Four elements appear time and time again in the efforts that actually lead to progress: Figure 1. Model for improvement. 1. Aim. Capable improvers answer the question, What are we trying to accomplish? They do not regard improvement as an accident; they intend it. 2. Measurement. Capable improvers answer the question, How will we know whether a change is an improvement? If they are learning to play golf, they watch to see where the golf ball went. If they want to reduce costs without harming patients, they track both costs and harms. 3. Good ideas for change. Capable improvers have ways to identify plausible alternatives to the status quo. They answer the question, What change can we try that we believe will result in improvement (as defined by aim and measurement)? They do not have one source of such ideas, they have many, including good theories; the observations of experts; communication with others; analysis of their own history; and the ability to harvest ideas from other people, such as employees, partners, and those whom they serve. 4. Testing. No improvement actually happens until something in the physical world changes. Capable improvers move promptly to test real changes on a small scale, and they then adjust their actions according to what they learn from these tests. The model for improvement tries to strike a pragmatic balance between the need for action and the desire for action to be timely and scientifically grounded. Use of this model will require physicians, other clinical health care workers, and administrators to change their views about the level of scientific rigor that should accompany changes in systems. Currently, changes in the components of health care systems (such as payment mechanisms, compensation, staffing patterns, referral options, workloads, supply contracts, formularies, and locations of care) are not tested on a small scale, nor are measures of outcomes and costs readily available to assure that changes are improvements. The call to increase the rigor of local tests of change is not a request for the wholesale implementation of research methods. It will usually suffice to collect data over time on a few key outcome and cost measures and to annotate the resulting time series graph with the changes that have been made. The model for improvement also involves an underlying set of theories about how complex systems improve. Most important among these is general systems theory, which has impli