10th Annual Health Care Effectiveness Forum Offers Evidence of Solid Advancement in Louisiana Health Care

Dr. Michael K. Butler, LSU HCSD chief medical officer, at the tenth annual Health Care Effectiveness Forum, offered extensive evidence of improvement at LSU hospitals and clinics during the past decade in key disease management programs, such as cancer screening, congestive heart failure, asthma, diabetes, HIV, chronic kidney disease, and the health of those in the Medication Assistance Program, but devoted the day to LSU HCSD employees.

"You are the unsung heroes of this process," he told the audience, primarily of LSU HCSD staff. "This is about the work you have done. We now have the facts to support our position."

Though he offered many detailed graphs indicating improvements in these areas, which audience members also had in packets for their perusal, he didn't dwell on technical detail. Instead he lauded staff performance.

"We are here today to honor you," he said. "All of this translates into somebody's suffering being relieved."

Besides dedication and a commitment to excellence, the LSU HCSD staff achieved these improvements because of perseverance, among other things, which is one of the themes Sr. Mary Jean Ryan, one of the featured speakers for the day and CEO of SSM Healthcare System, addressed. "Without perseverance, improvement is impossible," she said and gave examples of Nelson Mandela, Lance Armstrong, and the 2006 New Orleans Saints as those who persevered and succeeded.

SSM received the U.S. Department of Commerce's 2002 Malcolm Baldridge National Quality Award for superior management and achievement. It is the first health care organization in the nation to receive the award. "There were no miracles, just steady progress and a belief that we could get better," she said in the SSM pursuit of excellence. "The satisfaction with the status quo is probably the greatest barrier to achieving excellence," she said.

In the introduction of Dr. Malcolm Cox, chief academic affiliations officer for the Veterans Health Administration, Department of Veterans Affairs, Dr. Michael Kaiser, LSU HCSD associate chief medical officer, touched on another vital component of LSU HCSD: the education of health care professionals. The new LSU/Veterans Administration medical complex will play an important role in this education. "We are firmly committed to providing not only the best patient care but the best training for our future health care professionals in Louisiana," he said. Seventy-five percent of the health care professionals who practice in Louisiana receive their training in LSU hospitals.

Dr. Cox, who defined education as "the translation of discovery into practice, both within and across generations," relied on the success of the Cambridge Integrated Clerkship (CIC) to support his belief that medical education must change. "We must reinject the word change into the concept of reform," he said. The CIC integrates all of the traditional clerkships into one yearlong clerkship concentrating on longitudinal patient care, close mentoring, coaching, role modeling, and developing a community of learners, educators and caregivers.

In a study on the effectiveness of the CIC, the CIC group did better than a control group on various measures including the national medical board exam, ethics-conflict issues, compassion, and awareness of knowledge learned.

"We must look at a new way of training medical students," he said. "We should move to a higher starting point for those coming out of medical school."

The keynote speaker at the forum ten years ago, Dr. Brent James, executive director of the Institute for Health Care Delivery Research at Intermountain Health Care, also helped LSU HCSD initiate its program in health care effectiveness and was the luncheon speaker, which was appropriate since he discussed behavior's affects on health. "About forty percent of a person's health is determined by behaviors," he said and listed alcohol and tobacco use, lack of exercise, genetics, and environment as major forces on one's health. "Only about ten percent of a person's health derives from the health care system."

Changing behavior can change health. "Seeds planted ten years ago are bearing productive fruit," he said referring to the ten-year findings on the LSU HCSD health care effectiveness program.

The theme of change threaded its way throughout the day. Dr. Donald Goldman, senior vice president at the Institute for Healthcare Improvement and professor of pediatrics at Harvard Medical School, put forth six key quality improvement aims of the Institute of Medicine of the National Academies. Health care should be (1) safe; (2) effective, which means providing services, based on scientific evidence, to those who can benefit and not providing services to those not likely to benefit; (3) patient-centered; (4) timely, reducing waits and delays that can be harmful; (5) efficient on all counts, avoiding waste of supplies, equipment, ideas, and energy; and (6) equitable, offering health care to all, regardless of one's place in society.

He does not see the United States meeting these six. "It's an embarrassment as I travel abroad and discuss with others disparities in health care in the United States," he said.

End of life care is often totally uncoordinated, with 32.8% of terminally-ill patients seeing ten or more physicians, he said.

"Patients are the ones who have the biggest stake in all of this," he said.

To allieviate some problems, he proposed the use of "bundles," instead of guidelines for health care because guidelines usually are often long, confusing, and difficult to implement. A bundle, on the other hand, is a grouping of best practices that applied together results in substantially greater improvement in patient care. "Either you do it or you don't," he said. "It's all or nothing." He gave examples of central venous catheter bundle-"You have to train all to exhibit competence; they can do it, not just know how to do it"-and hand washing. Nurses will instruct doctors to stop catheter insertion if they're not doing it correctly. One must complete each step or include each item in a bundle for successful use of it.

Echoing Dr. Goldman's comment that patients have the biggest stake in health care, Dr. David Wennberg, who presented the Mervin L. Trail Lectureship, examined the importance of understanding clinical variation, and advocated more effective health care. "The United States delivers too-little effective care," he said.

Cost does not necessarily affect quality. "Spending more didn't increase one's chances of improvement after myocardial infarction," he said in reference to one study.

In fact, lower cost doesn't necessarily mean inferior care, but patient visits to doctors increase with highest spending regions. "More procedures are done for highest spending at end-of-life care in the last six months of life," he said, for the highest spending regions.

The forum ended with a panel discussion including all of the aforementioned and Drs. Fred Cerise, John George, Jack Andonie, and Mr. Gery Barry, president and CEO of Blue Cross/Blue Shield of Louisiana, and audience comments.