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How can we re-engineer health care?

Peter J. Fabri, MD, PhD
Associate Dean for GME, Professor of Surgery, Professor of Industrial Engineering, University of South Florida, Tampa

Start with the assumption that US health care is badly broken and very expensive, plagued by inefficiency, waste, error, and duplication, further compounded by inequities in distribution and access, and safety. In some ways this is like having an old, expensive car that you really like. It fits your self-image. It’s quick and agile. But it constantly requires adjustment, goes through tires quickly, only has two seats, gets poor gas mileage, and costs a lot to insure. For a while, it might make sense to keep finding the money to deal with the issues, but eventually it makes sense to get a car that actually meets your needs and not your memories. However, since we can’t just get rid of our current healthcare system, the only rational alternative is to roll up our sleeves and actually fix it. By fix it I mean improve efficiency, minimize waste and error, limit duplication and unnecessary redundancy, develop "supply chain" approaches to distribution and access, design-in safety, and change the culture of the workplace. This isn't about management and finance schemes. It's about redesigning and reengineering the health care delivery system, piece by piece.

Fixing healthcare will largely be a "reeducation" process before it can become a "reengineering process." Much of the inertia and resistance to change is a matter of culture and attitudes, carefully mentored during the decade of formal medical education. It will require training highly visible and credible physicians to become analytical problem solvers and system thinkers. And it will require training an entire cohort of individuals in new competencies that have either slipped through the cracks of current education or represent new territory. Every long journey begins with a single step. So too, this journey must start somewhere and must achieve tangible, early success.

If we leave this for lawyers and politicians to fix, the solution will look like it was made by lawyers and politicians. And it is highly likely that we won't like it. But it will be too late. As a profession, we have tended to sit back and watch, fully expecting that nothing much will happen. This time, something is going to happen! I propose the "house of medicine" accepts that health care is broken, that we are a critical part of the solution, and that together we can design solutions that make sense for patients and make sense for America. I propose that patient safety, which no card-carrying physician can reasonably ignore, is the natural starting point. Once a beachhead has been established, the next steps might address the processes of how healthcare is delivered and the processes of how healthcare professionals are educated and trained. But it will depend on the willingness of physicians to accept the responsibility to fix healthcare, to roll up our sleeves, and to lead the march. In the words of George Bernard Shaw, "Some men see things as they are and ask why. Others dream things that never were and ask why not."

For more reading . . .

Human error, not communication and systems, underlies surgical complications
P. Fabri, J. Zayas-Castro
Surgery, Volume 144, Issue 4, Pages 557-565
(abstract)

MD turns to I.E. for systems repair (in "Saving lives just in time: DePuy serves health care through orthopedic supply and demand")
David Brandt
Industrial Engineer, July 1, 2007

A Strategy for Health Care Reform -- Toward a Value-Based System
Michael E. Porter
N Engl J Med. 2009;361: 109-112

Diagnostic Errors--The Next Frontier for Patient Safety
David E. Newman-Toker, Peter J. Pronovost
JAMA. 2009;301(10):1060-1062.