Slides at … tompeters

1. Tom Peters’Health(care) Excellence!Part ILeaders in Healthcare/Dubai/22January2006(Long Version)

2. Slides at …tompeters.com

3. Part I: Healthcare “Manifesto”Part II: Getting It Done!

4. Health(care): Seven Main Messages1. Quality (Error reduction/ Evidence-based Medicine)2. “Healthcare” vs. “Health” (Wellness + Prevention)3. “Models of Excellence” available4. Life sciences (“Singularity”)5. Dubai as global/unique/“insanely great” “Center of Excellence”6. Avian flu7. Africa

5. Manifesto(s)

6. “Healthcare” vs “Health”

7. TP’s Healing & Wellness Manifesto2006(1) Acute-care facilities are “killing fields.”(WE KNOW WHAT TO DO.)(2) Shift the “community” focus 90 degrees (not 180, but not 25) from “fix it” to “prevent it.” (WE KNOW WHAT TO DO.)(3) There are three primary aims for “all this”: Wellness-Healing-Health. (WE KNOW WHAT TO DO.)(4) I’m mad as hell and I’m not going to take it anymore. (I KNOW WHAT TO DO.)

8. Tom’s Rant2006 • Hospital “quality control,” at least in the U.S.A., is a bad, bad joke: Depending on whose stats you believe, hospitals kill 100,000 or so of us a year—and wound many times that number.Finally, “they” are “getting around to” dealing with the issue. Well, thanks. And what is it we’ve been buying for our Trillion or so bucks a year? The fix is eminently do-able … which makes the condition even more intolerable. (“Disgrace” is far too kind a label for the “condition.” Who’s to blame? Just about everybody, starting with the docs who consider oversight from anyone other than fellow clan members to be unacceptable.) • 2.The “system”—training, docs, insurance incentives, “culture,” “patients” themselves—is hopelessly-mindlessly-insanely (as I see it) skewed toward fixing things (e.g. me) that are broken—not preventing the problem in the first place and providing the Maintenance Tools necessary for a healthy lifestyle.Sure, bio-medicine will soon allow us to understand and deal with individual genetic pre-dispositions. (And hooray!) But take it from this 63-year old, decades of physical and psychological self-abuse can literally be reversedin relatively short order by an encompassing approach to life that can only be described as a “Passion for Wellness (and Well-being).” Patients—like me—are catching on in record numbers; but “the system” is highly resistant. (Again, the doctors are among the biggest sinners—no surprise, following years of acculturation as the “man-with-the-white-coat-who-will-now-miraculously-dispense-fix it-pills-and-surgical-incisions-for-you-the-unwashed.” (Come to think of it, maybe I’ll start wearing a White Coat to my doctor’s office—after all, I am the Professional-in-Charge when it comes to my Body & Soul. Right?)

9. “Quality”: COULD IT TRULY BE THIS AWFUL?

10. “When I climb Mount Rainier I face less risk of death than I’ll face on the operating table.”—Don Berwick, “Six Keys to Safer Hospitals: A Set of Simple Precautions Could Prevent 100,000 Needless Deaths Every Year,” Newsweek (1212.2005)

11. CDC 1998: 90,000 killed and 2,000,000 injuredfrom hospital-caused drug errors & infections

12. HealthGrades/Denver: 195,000hospital deaths per year in the U.S., 2000-2002 = 390 full jumbos/747s in the drink per year.Comments: “This should give you pause when you go to the hospital.”—Dr. Kenneth Kizer, National Quality Forum.“There is little evidence that patient safety has improved in the last five years.”—Dr. Samantha CollierSource: Boston Globe/07.27.04

13. Welcome to the Homer Simpson Hospitala/k/aThe Killing Fields

14. 1,000,000“serious medication errors per year” … “illegible handwriting, misplaced decimal points, and missed drug interactions and allergies.”Source: Wall Street Journal/Institute of Medicine

15. YE GADS!New England Journal of Medicine/ Harvard Medical Practice Study: 4% error rate (1 of 4 negligence). “Subsequent investigations around the country have confirmed the ubiquity of error.” “In one small study of how clinicians perform when patients have a sudden cardiac arrest, 27 of 30 clinicians made an error in using the defibrillator.” Mistakes in administering drugs (1995 study) “average once every hospital admission.” “Lucian Leape, medicine’s leading expert on error, points out that many other industries—whether the task is manufacturing semiconductors or serving customers at the Ritz Carlton—simply wouldn’t countenance error rates like those in hospitals.” —Complications, Atul Gawande

16. RAND (1998): 50%, appropriate preventive care. 60%, recommended treatment, per medical studies, for chronic conditions. 20% chronic care treatment that is wrong. 30% acute care treatment that is wrong.

17. Various studies: 1 in 3, 1 in 5, 1 in 7, 1 in 20 patients “harmed by treatment” Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

18. “In a disturbing 1991 study, 110 nurses of varying experience levels took a written test of their ability to calculate medication doses. Eight out of 10 made calculation mistakes at least 10% of the time, while four out of 10 made mistakes 30% of the time.”Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

19. 20%: not get prescriptions filled50%: use meds inconsistentlySource: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation

20. “In health care,geography is destiny.”Source: Dartmouth Medical School 1996 report

21. Geography Is Destiny“Often all one must do to acquire a disease is to enter a country where a disease is recognized—leaving the country will either curethe malady or turn it into something else.… Blood pressure considered treatably high in the United States might be considered normal in England; and the low blood pressure treated with 85 drugs as well as hydrotherapy and spa treatments in Germany would entitle its sufferer to lower life insurance rates in the United States.”– Lynn Payer, Medicine & Culture

22. Geography Is DestinyE.g.: Ft. Myers 4X Manhattan—back surgery. Newark 2X New Haven—prostatectomy. Rapid City SD 34X Elyria OH—breast-conserving surgery. VT, ME, IA: 3X differences in hysterectomy by age 70; 8X tonsillectomy; 4X prostatectomy Breast cancer screening: 4X NE, FL, MI vs. SE, SW. (Source: various)

23. “A healthcare delivery system characterized by idiosyncratic and often ill-informed judgments must be restructured according to evidence-based medical practice.”Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

24. “Without being disrespectful, I consider the U.S. healthcare delivery system the largest cottage industry in the world.There are virtually no performance measurements and no standards.Trying to measure performance … is the next revolution in healthcare.”Richard Huber, former CEO, Aetna

25. “Practice variation is not caused by ‘bad’ or ‘ignorant’ doctors. Rather, it is a natural consequence of a system that systematically tracks neither its processes nor its outcomes, preferring to presume that good facilities, good intentions and good training lead automatically to good results. Providers remain more comfortable with the habits of a guild, where each craftsman trusts his fellows, than with the demands of the information age.”Michael Millenson, Demanding Medical Excellence

26. “As unsettling as the prevalence of inappropriate care is the enormous amount of what can only be called ignorant care.A surprising 85% of everyday medical treatments have never been scientifically validated.… For instance, when family practitioners in Washington State were queried about treating a simple urinary tract infection, 82 physicians came up with an extraordinary 137 strategies.”Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

27. “Most physicians believe that diagnosis can’t be reduced to a set of generalizations—to a ‘cookbook.’ … How often does my intuition lead me astray? The radical implication of the Swedish study is that the individualized, intuitive approach that lies at the center of modern medicine is flawed—it causes more mistakes than it prevents.”—Atul Gawande, Complications

28. Deep Blue Redux*: 2,240 EKGs … 1,120 heart attacks. Hans Ohlin (50 yr old chief of coronary care, Univ of Lund/SW) : 620. Lars Edenbrandt’s software: 738.*Only this time it matters!

29. Dr Larry Weed/POMR (“problem-oriented medical record”)/Etc: “It’s impossible to keep up with the avalanche of knowledge. Therefore it’s essential to use a valid diagnostic-decision aid like Larry’s” —Neil de Crescenzo, VP Global Healthcare/IBM Consulting “There is no other profession that tries to operate in the fashion we do. We go on hallucinating about what we can do.” —Dr Charles Burger (using Weed’s software for 20 years)

30. Probable parole violations: Simple model (age, # of previous offenses, type of crime) beats M.D. shrinks. 100 studies: Statistical formulas > Human judgment.“In virtually all cases, statistical thinking equaled or surpassed human judgment.”—Atul Gawande, Complications

31. PARADOX:Many, many formal case reviews … failure to systematically/ systemically/ statistically look at and act on evidence.Source: Complications, Atul Gawande

32. Genius Required?

33. Leapfrog Group:CPOE/Computerized Physician Order Entry*ICU staffing by trained intensivists**EHR/Evidence-based Hospital Referral****Duh I: Welcome to the computer age.**Duh II: How about using experts?***Duh III: If you do stuff a lotta times, you tend to get/be better.Source: HealthLeaders

34. The Benefits of …FOCUSED EXCELLENCE Shouldice/Hernia Repair: 30-45 min, 1% recurrence. Avg: 90 min, 10%-15% recurrence.Source: Complications, Atul Gawande

35. Hospitals Pay AppropriateAttention To Medical ErrorsYes ………………………………. 1%Aware and Trying Hard ……... 8%Aware But Tepid Response … 22%No ………………………………... 25%An Inexcusable Tragedy …….. 44%Source: 12.2005 Poll/tompeters.com

36. About Time!100,000 Lives Campaign**Don Berwick/Institute for Healthcare Improvement

37. What’s your name? When’s your birthday?

38. The Necessary IS/Web REVOLUTION

39. We all live inDell-Wal*Mart-eBay-Google World!

40. We [almost] all live inDell-Wal*Mart-eBay-Google World!

41. “Some grocery stores have better technology than our hospitals and clinics.”—Tommy Thompson, HHS SecretarySource: Special Report on technology in healthcare, U.S. News & World Report (07.04)

42. Computerized Physician Order Entry/CPOE: 5% of U.S. hospitalssource: HealthLeaders/06.02

43. Henry Lowe, U. of Pitt. School of Medicine: “Broadband, Internet-based, ‘multimedia’ electronic medical records”

44. Telemedicine: E.g. …HANC* [Home Assisted Nursing Care]*BP, ECG, pulse, temp

45. Telemedicine …Reduces days/1000 patients and physician visits for the chronically illDecreases costs of managing chronic diseaseExpands service areas for providersReduces travel costs to and from medical ed seminarsDouglas Goldstein, e-Healthcare

46. “Our entire facility is digital. No paper, no film, no medical records. Nothing. And it’s all integrated—from the lab to X-ray to records to physician order entry. Patients don’t have to wait for anything. The information from the physician’s office is in registration and vice versa. The referring physician is immediately sent an email telling him his patient has shown up. … It’s wireless in-house. We have 800 notebook computers that are wireless. Physicians can walk around with a computer that’s pre-programmed. If the physician wants, we’ll go out and wire their house so they can sit on the couch and connect to the network. They can review a chart from 100 miles away.” —David Veillette, CEO, Indiana Heart Hospital (HealthLeaders/12.2002)

47. Health

48. “Gwen has wonderful health insurance and an abundance of healthcare. What Gwen does not have is health. And there is nothing our health system can do to give it to her.” “The battle cry is always health, but in fact the struggle has always been over healthcare.” “For all its inspiring, high-tech cures, medicine is just not very effective at curing our era’s major killers.” “Medicine doesn’t do much [for] chronic disease.” “When the most common killers of our era are mostly incurable and our preventive treatments pretty feeble, you have to wonder about medical care as a whole.” “There is a widely held view that medical care contributes little to health.”(John Bunker/Journal of the Royal College of Physicians)Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation

49. Part 1: “The Leading Causes of Health”Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation

50. “Our mistake is not that we value medical care—but that we have misunderstood what it can and cannot do.”Source: Tom Farley & Deborah Cohen, Prescription for a Healthy Nation