Identifying Reform Targets

All systems can be improved. Systems that serve the public, particularly those with public funding, deserve ongoing attention and extra vigilance from the public served.

What are we looking for in improving public systems? All the usual business requirements are important: improved quality, reduced costs and better usage outcomes. We should also be seeking opportunities for the softer improvements: make both providers' and consumers' lives more productive, less risky, simpler, more convenient, more environmentally friendly and more fun. Those soft improvements are an important source of motivation to initiate and sustain commitment to improve on the status quo.

Where do we start? Systems oversight requires a great deal of insider knowledge. Participants, particularly providers, are in the best position to observe the system in repeat operation. From just such a genesis came the Choosing Wisely campaign, an initiative sponsored and continued from inside US organized medicine. Choosing Wisely has identified health care tests and interventions with low returns on costs, time and risk.

The Choosing Wisely lists have been available for 5 years, involve almost every medical specialty and are both discretely described and well supported by evidence. There is little indication however of significant reductions in these tests and interventions. Why?

With rare exceptions everyone believes that they are doing a great job, their clinical choices are accurate and their interventions required. Even more egregiously, many retreat behind the defense that the patients insisted on the unnecessary test or intervention. The information systems they work within do not routinely supply feedback about the accuracy of those assumptions. In the absence of focused and current local information identifying priority areas, targets and timelines for system reform becomes a matter of local opinion or perceived attainment ease. Even more often, no system reform is attempted at all. The attitude is "we're alright Jack; look somewhere else for your reform targets".

Would it be worth the effort to change this resistance to health system improvement? A McKinsey report* suggested that the annual value of using US health care data more effectively would be an 8% reduction in expenditures; more than US $300 billion. European savings were estimated at more than 100 billion euros in operational efficiencies alone. Canadian data is both better developed and more extensive than either US or European health system data sets suggesting even more potential productivity from organized data mining. Even applying the conservative 8% target reduction to Canadian health care expenditures would yield $16 million CDN annually available for reinvestment in health sector improvement.

And that is just the easy stuff, the direct cost savings from already recognized waste. Think what could happen if we addressed the soft improvement targets. Improved operations data integrated across public systems, more focused data mining and clearly rewarded expectations for continuous improvement could make health care and other public systems more productive, less risky, simpler, more convenient, more fun and more environmentally friendly. Now we're talking!

*Manyika, J.; Chui, M.; Brown, B.; Bughin, J.; Dobbs, R.; Roxburgh, C.; Byers, A.H. Big Data: the next frontier for innovation, competition and productivity. McKinsey Global Institute, McKinsey & Company. Toronto, Canada, 2011. 

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