Win Whitcomb: A New Quality Paradigm

Hospital medicine has never been bashful about stating its goal to be a financial steward of the most expensive place in our healthcare system—the hospital. At the first gathering of hospitalists in April 1997, the newly formed board of directors debated whether we should promote efficiency as a primary goal of the organization and, by extension, our field. We drafted as the first line of our mission: To promote the high-quality and cost-effective care of the hospitalized patient.

Now, as the cost of healthcare approaches 18% of our nation’s gross domestic product, the jobless rate remains high, and the economic recovery underwhelms us, the emphasis of many thought leaders has shifted to cost as the single biggest barrier to ideal healthcare in the U.S.:

The ABIM Foundation’s Choosing Wisely campaign encourages doctors and patients to “talk about medical tests and procedures that might be unnecessary, and in some instances can cause harm.” Its Physician Charter contains “wise use of finite resources” as a key element.
In April, the American College of Physicians (ACP) announced “5 Things Internists and Patients Should Question in Internal Medicine”.
At the Institute for Healthcare Improvement’s national meeting in December, the organization’s spiritual leader, Don Berwick, MD, had just returned from 16 months as CMS administrator and pronounced in his keynote address: “I would go so far as to say that, for the next three to five years at least, the credibility and leverage of the quality movement will rise or fall on its success in reducing the cost of healthcare … while improving patient experience. ‘Value’ improvement won’t be enough. It will take cost reduction to capture the flag. Otherwise, cutting wins.”

Cost Is the New Quality

I agree with Don: Sure, the other dimensions of quality healthcare—that it be safe, timely, equitable, effective, and person-centered—are critical. But now, efficiency is king. Looking ahead, it will require singular focus.

The problem is, who can get excited about reducing costs? (Don’t all raise your hands at once.) Well-meaning clinicians, when asked by healthcare administrators to order fewer tests or use cheaper drugs, shrug their shoulders and assume it is a ploy for the hospital or health plan to bolster profits off their backs. Or we simply feel that we have better places to focus our efforts. After all, ours is a noble profession, not a bottom-line-focused guild.

Waste Is the New Cost

The thing we can get excited about is reducing waste. We see waste every day and have the genuine wish to eliminate it. As an example, the Lean practice—borrowed from manufacturing—is a widely used tool in healthcare. Its primary focus is the recognition and elimination of waste. Lean recognizes as many types of waste as Eskimos have words for snow.

Dr. Berwick went on to outline six areas of waste in healthcare, at least three of which fall squarely on the shoulders of hospitalists:¹

Failures of care delivery, or lack of uniform adoption of best-care processes. Examples: use of a central-line insertion bundle; early, goal-directed therapy in severe sepsis.
Failures of care coordination. Poor handoffs and follow-up cause readmissions and other harm. Example: failure to provide a reconciled medication list to patient and next provider of care after discharge.
Overtreatment, or exposing patients to care interventions that offer no benefit and could cause harm. Examples: VTE prophylaxis in low-risk patients; endotracheal intubation in a patient who does not desire it; admitting a patient to the hospital because it is easier than arranging outpatient follow-up from the ED (see Table 1).