Streamline Training & Documentation: Learning from Positive Outliers in Healthcare

Tuesday, August 18, 2009

Learning from Positive Outliers in Healthcare

Back in December, I wrote a series of posts dealing with learning from "positive deviance." Positive deviants are people who manage to do a way-above-average job of solving a particular problem, despite having no more resources than others coping with the same issue.

A topical example of this approach to identifying good solutions to what can seem to be intractable problems is provided by an op-ed column published on August 12 in the New York Times, written by Atul Gawande (Brigham and Women's Hospital), Donald Berwick (Institute for Healthcare Improvement), Elliott Fisher (Dartmouth Institute for Health Policy and Clinical Practice), and Mark B. McClellan (Engelberg Center for Health Care Reform).

These four healthcare professionals report on a study they conducted in which they set out to find regions of the US that are "positive outliers" in terms of:

per capita Medicare costs

effectiveness, as measured by an array of federal quality metrics

From the 74 regions that fit their criteria, the authors chose ten to come to a meeting in Washington where regional healthcare leaders "could explain how they do what they do." The authors found a variety of successful approaches to controlling costs while maintaining quality:

"Some have followed the Mayo model, with salaried doctors employed by a unified local system focused on quality of care."

Some, with "several medical groups whose physicians are paid on a traditional fee-for-service basis," have been able to find "ways to protect patients against the damaging incentives of a system that encourages fragmentation of care and the pursuit of revenues over patient needs."

"The physicians and hospital leaders from Cedar Rapids told us how they have adopted electronic systems to improve communication among physicians and quality of care."

"The team from Portland told us of a collaboration of doctors, state officials, insurers and community leaders to improve care. For more than four years, physicians have been tracking some 60 measures of quality, like medication error rates for their patients, and meeting voluntary cost-reduction goals."

"Asheville, after gaining state support to avoid antitrust concerns, merged two underutilized hospitals."

"In Sacramento, a decade of fierce competition among four rival health systems brought about elimination of unneeded beds, adoption of new electronic systems for patient data and a race to raise quality."

In sum:

In their own ways, each of these successful communities tells the same simple story: better, safer, lower-cost care is within reach. Many high-cost regions are just a few hours’ drive from a lower-cost, higher-quality region. And in the more efficient areas, neither the physicians nor the citizens reported feeling that care is “rationed.” Indeed, it’s rational.

As the healthcare reform debate continues, I will be interested to see how much weight is given to the experience of the positive outliers whose approaches are outlined in above.

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Labels: Decision-making, Expertise, Knowledge management

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