This course will provide you with an overview of value in health care. We’ll start by distinguishing between cost and value, and understanding how both of these concepts relate to quality.
We’ll introduce you to the growing problem of health care spending, as well as the health care practitioner’s role in managing these costs. Finally, we’ll explain how to identify and overcome barriers to providing high-value, cost-effective care.
This course is part of the Basic Certificate in Quality and Safety. IHI Open School online courses offer more than 35 continuing education credits for nurses, physicians, and pharmacists; Maintenance of Certification (MOC) Part 2 for select medical specialty boards; and a Basic Certificate in Quality and Safety. Learn more about Certificates and Continuing Education »
Course Objectives
After completing this course, you will be able to:
- Explain the potential harm of low-value tests and procedures.
- Distinguish between cost and value in health care.
- Define resource stewardship in health care.
- Describe the ethical case for resource stewardship in health care.
- Identify common barriers to resource stewardship and enablers of inappropriate resource use.
Contributors
Authors
Brian Wong, MD, Assistant Professor, Department of Medicine, University of Toronto
Marisa Leon-Carlyle, Medical Student, University of Toronto
Raman Srivastava, MBT, Medical Student, University of Toronto
Editors
Laura Fink, Director, Editorial and Online Learning, Institute for Healthcare Improvement
Mike Briddon, MA, Director, Multimedia and Virtual Programs, Institute for Healthcare Improvement
TA 103: Increasing Value and Reducing Waste at the Point of Care
This course will provide you with an overview of value in health care. We’ll start by distinguishing between cost and value, and understanding how both of these concepts relate to quality.
We’ll introduce you to the growing problem of health care spending, as well as the health care practitioner’s role in managing these costs. Finally, we’ll explain how to identify and overcome barriers to providing high-value, cost-effective care.
This course is part of the Basic Certificate in Quality and Safety. IHI Open School online courses offer more than 35 continuing education credits for nurses, physicians, and pharmacists; Maintenance of Certification (MOC) Part 2 for select medical specialty boards; and a Basic Certificate in Quality and Safety. Learn more about Certificates and Continuing Education »
Course Objectives
After completing this course, you will be able to:
- Explain the potential harm of low-value tests and procedures.
- Distinguish between cost and value in health care.
- Define resource stewardship in health care.
- Describe the ethical case for resource stewardship in health care.
- Identify common barriers to resource stewardship and enablers of inappropriate resource use.
Contributors
Authors
Brian Wong, MD, Assistant Professor, Department of Medicine, University of Toronto
Marisa Leon-Carlyle, Medical Student, University of Toronto
Raman Srivastava, MBT, Medical Student, University of Toronto
Editors
Laura Fink, Director, Editorial and Online Learning, Institute for Healthcare Improvement
Mike Briddon, MA, Director, Multimedia and Virtual Programs, Institute for Healthcare Improvement
Jesse, a 64-year-old man, is seeing an orthopedic surgeon in the pre-assessment clinic.
His providers recommend that he undergo a knee replacement operation because of his severe arthritis. Jesse is otherwise healthy, and does not take any medications. He has no prior cardiac or respiratory diseases, and he does not smoke cigarettes.
After the usual assessments, the orthopedic surgeon orders a pre-operative chest x-ray.
Your Turn
Let’s pause for a moment. Before we continue with the story, can you think of items that contribute to the total cost of Jesse’s x-ray? You may think about the financial costs associated with getting an x-ray. You may also think about the time it takes Jesse to get to the hospital and have the procedure, as well as the radiation from the x-ray itself. Share your thoughts »
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Direct and Downstream Costs of Care
Jesse’s chest x-ray shows a small nodule (a growth) at the bottom of his right lung. His physicians decide to delay Jesse’s knee surgery to investigate the nodule. These investigations include a referral to a pulmonologist, follow-up CT scans of the lungs, a biopsy, and several follow-up appointments.
Fortunately, after six months of investigations, physicians determine that the nodule is benign. Jesse books his knee surgery three months later, and the procedure is successful and free of complications.
Your Turn
Use the checklists below, and consider again the total cost, including non-financial harm, of the x-ray to Jesse and the health care system. Check all the items that contribute to the cost.
Direct costs to Jesse and his family:
Delayed knee surgery — and ongoing knee pain affecting Jesse’s quality of life and ability to work
Disruption to Jesse’s daily routine
The anxiety that Jesse and his family face as they wonder what the nodule could be
Radiation from the x-ray
The time it takes Jesse to go to the hospital and get the x-ray done
Personal financial costs to Jesse (e.g., out-of-pocket health care expenses, cost of gas to drive to hospital, cost of parking)
Immediate opportunity costs (costs of alternatives that Jesse and health professionals sacrifice to pursue the action):
Delay in care for other patients due to Jesse’s x-ray
Loss of time that Jesse could have spent at work or with family
Direct costs to the health system:
The radiologist’s time to read and report the x-ray findings
The radiation technician’s time to perform the x-ray
The financial cost to the health care system associated with getting a chest x-ray (e.g., cost of machine, cost of materials, administrative overhead, health care personal wages)
Downstream costs (costs that manifest over the long term):
Financial costs to the health care system associated with further investigations and referrals
Radiation exposure from the repeated CT scans
The financial cost that Jesse’s family must bear as he pursues further health care, including transportation and parking at the hospital
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True Cost of a Health Care Test
Did you check all the boxes on the previous page? The true cost of a test or procedure is much more than the dollar amount that appears on a hospital bill. To truly understand any cost, you need to consider the impact on the patient, the family, the hospital, the community, and the health care system.
This graphic will help you visualize the different categories included in the total cost of health care:
Costs to patients can be especially challenging because unlike in other industries, customers often don’t know the price of services until after their payment is due. Anila Hussaini, RN, MPH, describes the surprise her family felt after her father’s simple outpatient procedure. The bill was one of the most painful parts of the care process:
Read the video transcript.
Going back to Jesse’s story, you can see how the costs of his care quickly added up — both for him and for the medical system.
The real problem, though? There wasn’t a valid reason to do the original chest x-ray.
Clinical guidelines indicate chest x-rays aren’t needed for routine knee surgeries unless a patient has symptoms of heart or lung disease. Guidelines state that only 2 percent of images for patients such as Jesse, who have no relevant history or symptoms, actually lead to a change in management — while exposing 100 percent of patients to costs and potential harm.1
Overall, the decision to order a chest x-ray for Jesse was a low-value decision and an example of overuse of medical services. On the next page we’ll explain how we define value, and how it’s different from cost.
- American College of Radiology. Ten things physicians and patients should question. Choosing Wisely website. Published April 4, 2012. Updated June 29, 2017.
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Defining Cost and Value
Determining true cost in health care can be very difficult, especially because all kinds of hidden costs (administrative overhead or electricity bills for example) may be present. Determining value can be even more problematic.
Providing high-value care means providing the highest quality care at the lowest cost.1 You can improve value by either increasing quality or decreasing costs. To put that into a simple equation:
This relationship is a reminder that spending more money doesn’t necessarily mean better health care. As costs go up, value goes down — unless quality increases, too.
Because value is proportional to the quality of an intervention, some high-quality treatments — chemotherapy, for example — may be expensive but offer good value because they help the patient achieve the best outcome. Meanwhile, some low-cost interventions may have little or no value, if they lead to poor experiences or results (either immediately or downstream).
Given this complexity, assigning value to particular interventions can be difficult, both for individual providers and overseers.
One example of a system-level approach to distinguish between high- and low-value interventions is the Committee to Evaluate Drugs (CED) in Ontario, Canada. This group comprised of clinicians, patients, and an economist decides whether the government should subsidize new medications based on an analysis of efficacy, safety, and cost.2 A sample CED assessment of a smoking cessation aid is available here: CED review of VARENICLINE (Champix®) (PDF).
1 Porter M. What is value in health care? New England Journal of Medicine. December 2010;363:2477–2481.
- How drugs are considered: funding decisions. Ontario Ministry of Health and Long-Term Care website. Updated April 2013.
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Rising Cost of (Wasteful) Health Care
As we have discussed, overuse is problematic; it is ineffective and can add unnecessary harm and stress to patient care. It can add stress to budgets, too. It’s no secret that health care consumes a large part of budgets around the world.
The graph below shows Organization for Economic Cooperation and Development (OECD) data on health care spending as a percentage of gross domestic product (better known as GDP) for member countries:1
View the chart on OECD.org.
As you can see, a significant portion of many countries’ economies consists of health care spending. Focusing on value and eliminating waste in medical care is a worldwide concern. If we are spending so much money on health care, we need be sure we are spending it appropriately.
- OECD (2020). Health spending (indicator). Paris, France: OECD Publishing. Used with permission. © OECD
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Rising Cost of (Wasteful) Health Care
In 2012, Dr. Donald Berwick, President Emeritus and Senior Fellow at IHI, and Andrew Hackbarth studied the distribution of health care waste in the US. They found that administrative complexity (waste from needlessly complex and inefficient procedures) was the largest area of waste.
The second largest area of waste was overtreatment — described as “the waste that comes from subjecting patients to care that, according to sound science and the patients’ own preferences, cannot possibly help them.” The authors estimated that overtreatment accounted for as much as $226 billion in wasteful spending in one year.1
How can we combat this waste in health care?
Take a moment and look at a post from a blog called Healthy Debate, which is based in Ontario, Canada: Weighing the Evidence — Should Ontario Fund Avastin for Brain Cancer?
In the article, Dr. Andreas Laupacis discusses the difficult decision of determining whether a mother with an aggressive brain tumor should receive a particular treatment. This treatment has uncertain benefits and potentially severe side effects, and it costs the publicly funded Canadian health care system more than $100,000 per year. On the other hand, the treatment may slow the mother’s tumor growth and give her an extra year to live.
Barriers to Resource Stewardship
Resource stewardship is the appropriate allocation of resources — so that limited health care resources provide the greatest benefit to the greatest number of patients. The meaning of “appropriate” varies by clinical situation, but generally it refers to allocation of resources that results in high-value, effective (i.e., evidence-based) care.
According to the Commonwealth Fund, physicians’ decisions directly and indirectly account for more than 80 percent of overall health care expenditures.1 That number doesn’t even factor in the decision-making power of all the other health care professions!
Unfortunately, health care providers also face a number of common barriers to practicing resource stewardship and incentives for overuse.
Barriers to Stewardship
Established habit
Providers may have been trained to pursue tests, treatments, or actions that lack therapeutic value in the clinical scenario used.
Disapproval of “do nothing”
Lack of feedback
Time pressure
Discomfort with diagnostic uncertainty
Ease of access to service
Incentives for overuse
Incentives for Overuse
New technologies
With the development of new medical technology, providers may use new, more expensive technologies that are not proven to provide superior care.
Patient requests and expectations
Request from referring provider
Financial incentives
Defensive medicine
Ease of access to service
While in training, health care students are susceptible to additional barriers to stewardship and incentives for overuse. These may include a desire to impress faculty and/or gain experience. Faculty often give praise for thoroughness, but they rarely give it for thoughtful resource stewardship.
One of the most important steps you can take to provide appropriate care is simply being aware of the incentives for overuse and barriers to stewardship, and how they might impact your behavior. Download the list of common barriers to value-based care »
Anila Hussaini, RN, MPH
When I think of resource stewardship, I think of the analogy to voting. Everyone would say that voting is our social responsibility; if we don’t vote, we’re impacting the democratic process and most people don’t question you on that. When you think about resource stewardship, it’s the same thing. No one knows whether you’re doing it or not. No one’s going to hold you accountable to say, “Oh, did you put the extra equipment back?” or, “Did you order an unnecessary test?” But it is your responsibility as someone who works in health care to manage the cost of health care. I think that we owe it to our patients to not produce undue stress on them by ordering extra equipment or by ordering extra tests.
I think we also owe it to society knowing that with the Affordable Care Act, there’s going to be an endless amount of individuals who are now going to access the health care system — and the costs are growing exponentially. What is our responsibility in managing the extra load that is coming into the health care system and the reduced amount of dollars that exists?
I think that’s one of the reasons that everyone, regardless of your role — whether you’re a nurse, whether you’re a clinician, whether you’re an administrator — you have a role in this critical time to be a steward of resources. And if you, as a young nurse or as a young clinician, don’t do it in your first year, the ones that you train below you are also not going to do it. But if you do it, you are responsible for a cultural shift in health care. If you show that it’s everyone’s responsibility, people will follow you. I think it becomes part of the training of our younger nurses and physicians, if we disAs a health professional of any discipline, you have a responsibility to practice resource stewardship. Like Anila said, “We owe it to our patients to not produce undue stress on them.” A place to begin is to know the newest guidelines in your field so that you can determine why certain tests, procedures, equipment, or treatments may be unnecessary.
Another opportunity to make an impact is through local improvement efforts. Dr. Neel Shah is the founder of Costs of Care, one of many groups taking the lead to rethink how health care is delivered. In the video, he explains why frontline workers are essential to reducing waste in health care. He also talks about a barrier he faces in his work — the fear of litigation:
plaVideo Transcript: Balancing Overuse and Fears of Litigation
Neel Shah, MD; Assistant Professor, Harvard Medical School
I’m an obstetrician, and I carry a high malpractice premium in my specialty. Part of my job is to train brand new doctors how to operate and do C-sections for the first time. I’d be lying if I said that medical malpractice isn’t something that crosses my mind. I think the fear of medical malpractice is definitely much higher than the risk of medical malpractice. There’s an opportunity to maybe reconcile that a little bit. That, of course, is easier said than done.
I think along with that, there’s an opportunity to do tort reform and other things that really matter. I would not put that in the low-hanging fruit category for improving health care value.
Given that, if you take medical malpractice and you put it aside, there are probably 10 to 20 other reasons why clinicians knowingly over-order tests all the time that have nothing to do with medical malpractice that are much easier to get to than tort reform.
Just as a pragmatist and somebody who cares about this, one of the number one reasons in a hospital like this why overuse happens is inefficiencies in workflow.
If you’re a resident, you’re the one who actually does all the ordering, and you’ve got a patient in the emergency room, and you’re just getting slammed. Your pager’s going off. You’ve got 50 patients to care for. Your number one goal in life is to un-occupy the stretcher in front of you. You’re not thinking about medical malpractice. You’re not thinking about getting paid more money. You’re thinking, “I’m just under siege.”
So your choices, you can either take that patient and admit them to the hospital list by clicking a mouse and not thinking about it again, or you could try to coordinate their care and send them out into the wild. What are you gonna do?
I actually think that given that that’s a workflow challenge, that’s something that we can solve through care redesign, as opposed to in the halls of congress. I think care redesign is something that’s owned by the people that work inside of health care delivery systems, which is the IHI community.
y thLearn how to integrate quality improvement into the daily work of health care in QI 102: How to Improve with the Model for Improvement »
Another group advocating for value in health care is Choosing Wisely. Through Choosing Wisely, many medical specialty societies have identified five or more tests or procedures that are commonly overused. Make sure you and your colleagues are familiar with the list for your field.
For medical students and clinicians in training, the campaign offers six guiding principles.1
• Don’t suggest ordering the most invasive test or treatment before considering other less invasive options.
• Don’t suggest a test, treatment, or procedure that will not change the patient’s clinical course.
• Don’t miss the opportunity to initiate conversations with patients about whether a test, treatment or procedure is necessary. (We’ll give ideas to help with this later in the course.)
• Don’t hesitate to ask for clarification on tests, treatments, or procedures that you believe are unnecessary.
• Don’t suggest ordering tests or performing procedures for the sole purpose of gaining personal clinical experience.
• Don’t suggest ordering tests or treatments pre-emptively for the sole purpose of anticipating what your supervisor would want.
Learn more about Choosing Wisely and Costs of Care, their work, and how you can get involved at the end of this course.
Your Turn
Practice overcoming the barriers to resource stewardship we listed earlier in this course: What would you say to help a colleague overcome incentives for overuse?
Your colleague is feeling pressure on her time. She feels she is too busy to explain to patients why an intervention is inappropriate.
Ordering a test instead of explaining why the test shouldn’t be ordered may not save time. If the test results in a false positive, following up with that false positive result can consume much more time than it would have taken to originally explain that test was unnecessary.
Your colleague has an established habit and is used to pursuing tests that lack therapeutic value in a specific clinical scenario.
•
•
Your colleague is practicing defensive medicine. He is seeking to defend himself against any potential malpractice claims by pursuing interventions that are not otherwise clinically indicated.
Individual and Population Health
Let’s take a moment to step back and examine the bigger picture, outside the walls of the clinic or hospital. Part of appreciating resource stewardship is understanding the effect of rising health expenditures on our communities.
The need to practice resource stewardship goes beyond providers’ responsibility to their individual patients. Inappropriate health care actions (e.g., unnecessary tests, procedures, and exams) deplete funds and resources that could be better used elsewhere, with a detrimental effect on populations at large.
Dr. Atul Gawande, a prominent journalist and surgeon, illustrated this effect with a powerful story at the 2010 IHI National Forum:
Video Transcript: What We Are Doing to Our Communities
Atul Gawande, MD, MPH; Surgeon, Writer, Public Health Researcher; Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health
And I think for all of us the challenge is looking into our own communities and asking, “Who are we trying to help?” And one moment when it came to me was when I went to my children’s parent-teacher conference day, and went to their school and ran into the new school superintendent — a guy who was about my age, just starting off, known to be someone who understood a lot about education reform and the really neat experiments that are going on at charter schools and elsewhere, and I said, “What are you working on? What are you thinking about? Just coming in, you’ve been here about three months, what are you spending your days on?” And he said, “I thought I was going to come in to spend my time trying to think about how we structure education, what we do, but what I spend time on is health care.”
Then he put out the map for me. He said, “We have a law in Massachusetts, like many states, that property taxes are limited. Prop. 2 ½ says no more than 2 ½ percent of property taxes — and guess what? Under this economy, the property values have gone down.” So his overall budget has shrunk, but his teachers’ health care costs have gone up 9 percent. And so he spends his time in life trying to understand what to do about those costs.
I went to my parent-teacher conference, and the teacher pulled out her lists of students because she couldn’t quite remember where my son, Walker, was in his course of events. And that’s an indication of what the answer had been in my school district, which is that my son’s classes are up to more than 30 people — his math class has 35 students — for one teacher and he was disappearing in the middle of that.
I left the classroom and I ran into another teacher in my community whom I’d operated on. She had a lymphoma. She survived. She had a tough, serious problem that required surgery, radiation, chemotherapy. The superintendent had mentioned that 5 percent of his population of covered members in the teachers’ union accounted for 60 percent of their health care costs, and I realized that I was part of the reason my own child was getting neglected in his middle school class. And unless you see that, unless you understand what we are doing to our community, we will not get it.
Gawande’s conversations with educators at his son’s school made him realize that rising student-teacher ratios were partly related to growing health care costs: As teachers’ health care coverage became more expensive, the school could not afford to pay as many teachers.
Money saved through resource stewardship can be used to improve:
• Health care (for patients whose clinical outcome will improve with additional interventions)
• Health (e.g., disease prevention, promotion of health equity, addressing the social determinants of health)
• Other publicly funded industries (e.g., education, public transportation)
But it is important to always keep one thing in mind: Resource stewardship is not about rationing care.
You can learn more about the relationship among individual experiences of care, per capita costs, and overall population health in TA 101: Introduction to the Triple Aim* for Populations »
Even if you have the needs of a larger population in mind, the goal is not to reduce health care opportunities for individual patients who need them. If a test is expensive but can also be used to definitively diagnose a patient when there are no alternatives, the test should be considered an appropriate use of resources. The goal is to eliminate waste.
Dr. Wendy Levinson, a professor at the University of Toronto, has contributed to the Choosing Wisely campaign in both the US and Canada. Listen to her explain the difference between resource stewardship and rationing care:
Read the video transcript.
You just heard Dr. Levinson mention the idea of providing care that is “patient-centered.” The next page will look at how patients and providers can work together to reach the health goals that matter most to the patient.
*The Triple Aim is one overall aim for health and health care improvement that consists of three dimensions: Improving the health of populations, improving the individual experience of care, and reducing the per capita cost of care.
Empowering Patients
When considering the reasons to pursue high-value care, you will notice alignment with some important ethical principles. For example:1
• Beneficence: Promote the well-being of others.
• Non-maleficence: Do no harm to others.
• Justice: Distribute resources fairly and equitably.
• Autonomy: Respect the individual’s rights and opinions.
Beneficence and non-maleficence support care that improves patient outcomes while minimizing harm and costs.
Following the justice principle means allocating time, money, and energy into high-value interventions, so that resources are being used appropriately and not wasted or underutilized.
But what about autonomy, an individual’s right to make his or her own health care decisions? If a patient asks for a low-value intervention, does respecting patient autonomy require health care professionals to always grant a patient’s request?
Watch the video below, and pay attention the provider’s communication skills that allow her to: provide clear recommendations, elicit patient beliefs, provide empathy, and reach an agreement — which is different from the patient’s initial request:
Read the video transcript.
While patients have the right to make their own health care decisions, they can only exercise this right with full information and proper understanding. Respecting patient autonomy does not mean you should say “yes” to every request. With good communication skills, you can provide counsel about the evidence-based choices available and the risks and benefits of different options.
When patient preference is strong, Dr. Levinson shares the following advice:
Sometimes what they come for is reassurance. Many patients are reassured when you share your understanding of what their diagnosis is, the likely outcome, and how you might treat it. And they’re reassured when you listen carefully and explain things.
If someone is really adamant about getting a test, the most important question to ask her is, “What is your greatest worry?” Often exploring what the patient’s worry is allows you to understand why she’s adamant about that test. If you can address her worry, she may not need the test.
If the patient is persistent, you may consider ordering the test, because the psychosocial benefits, which contribute to value, outweigh the costs.
Patients differ tremendously in financial resources, cultural norms, expectations, and education, and empowering patients is not a standardized process. It is up to you to factor in guidelines, the specifics of the clinical situation, and the patient’s preference into the decision-making process, and to seek advice from colleagues as needed.
Learn several concrete skills any provider can use in clinical interactions with patients to foster effective partnerships in PFC 101: Introduction to Patient-Centered Care »
Changing the Culture
Throughout this course, we’ve covered a lot of the bad news associated with the overuse of resources in health care. We’ve talked about the difficulty in determining value, the rising costs of care around the world, and the barriers to stewardship that lurk around every corner.
We’ve also given you strategies you can use as an individual health care provider to provide high-value care. As a place to begin, you can:
• Get informed. You’ve taken a great first step by (nearly) completing this course. Look for additional resources on the next page.
• Get involved. There are many organizations that are taking the lead nationally and internationally to rethink how health care is delivered. You now know of a couple, and you can find more information on the page to follow.
• Learn the skills of quality improvement. Part of the daily work of health care should be identifying and redesigning inefficient processes. The Open School’s Quality Improvement courses teach these skills.
• Empower patients. As we discussed, good patient-clinician communication is critical to reducing unnecessary tests. All patients have unique concerns, so counseling patients on the benefits and harm of a procedure will allow both the patient and the clinician to select the option best for the specific patient. (Learn more in PFC 101: Introduction to Patient-Centered Care.)
All of this is an excellent start. Beyond the steps you should take as an individual, for health systems to improve it will take people at all levels working together. Dr. Neel Shah explains a cultural shift taking place in US health care:
Read the video transcript.
No matter where you are or your position in health care, here are some ideas to work on changing the culture in your local setting:
• Share your knowledge. If everyone understands the importance of stewarding resources and reducing the cost of health care delivery, together you can make a more conscious effort to monitor practice habits. Active feedback between peers allows all clinicians to keep their knowledge and skills up to date.
• Seek new, fresh perspectives that will make the group reconsider how effective current practices are. For example, new trainees are sometimes the most up to date with the literature and guidelines — they just learned them in school. Role models should be open to feedback and questions.
• Change the discussion. Faculty and experienced clinicians often ask health care trainees, “What would you order for this patient?” Discussions could instead be framed as, “What information do you need next, and how can you get that information?” or, “How would ordering this test change your management?” Presented with these questions, learners can showcase their knowledge while incorporating value into their decision-making process.
Video Transcript: Providing Better Care for Less
Neel Shah, MD; Assistant Professor, Harvard Medical School
Well, there’s a window of opportunity right now to do this. Right now in the C-suite of most big, complicated delivery systems — or honestly even smaller practices, where I know lot of the IHI membership is working — there is this top-down directive from policy-makers and payers and others to be accountable for both the quality and the cost of services. We know that.
We also know there’s mounting bottom-up pressure from our patients. More Americans are in high-deductible plans than ever before. An average deductible if you get a silver plan on any health insurance exchange in the country is $3,000 to $5,000. That’s like real money no matter who you are or what kind of income you have. It’s not money you want to blow, for sure.
So, clinicians in the front line are feeling this, and people that are at the health system leadership level, they, I think, often and set the culture. I think culture is often set in a top down way. You now have an aligned interest around this.
So I think if you’re leading a health system, in 2013 your health system was probably like a revenue center. That’s how you ran it. You thought about it as a revenue center, like, “I need to get more patients in it so we can make more money.” But now it’s being managed more like a cost center, like, the way to protect our margins is to figure out where the waste is and get rid of it.
The people that know where the waste is are the people that are running the show for real. The truth is you can walk onto any ward of any hospital in the United States and ask anybody there — the unit clerk, the nurses, the residents, anybody — “What are five things that we do every day that are wasteful, that don’t need to happen?” And they could give you 10. So, lots of opportunity there.
No matter where you are or your position in health care, here are some ideas to work on changing the culture in your local setting:
• Share your knowledge. If everyone understands the importance of stewarding resources and reducing the cost of health care delivery, together you can make a more conscious effort to monitor practice habits. Active feedback between peers allows all clinicians to keep their knowledge and skills up to date.
• Seek new, fresh perspectives that will make the group reconsider how effective current practices are. For example, new trainees are sometimes the most up to date with the literature and guidelines — they just learned them in school. Role models should be open to feedback and questions.
• Change the discussion. Faculty and experienced clinicians often ask health care trainees, “What would you order for this patient?” Discussions could instead be framed as, “What information do you need next, and how can you get that information?” or, “How would ordering this test change your management?” Presented with these questions, learners can showcase their knowledge while incorporating value into their decision-making process.
