Pursuing Perfection

From 2000 until about 2007 Robert Wood Johnson Foundation (RWJF) provided significant funding and the Institute for Healthcare Improvement (IHI) controlled the use of those funds. The stated purpose of this collaboration was to redesign the US healthcare system, within three years.

Some people at Robert Wood Johnson Foundation understood that health care is a complex adaptive system and would require approaches capable of improving or transforming a complex adaptive socio-economic system.

Institute for Health Care Improvement's prior experience was on process improvement. We had to figure this out as we went along.

In Whatcom County, WA we took the grant's mandate seriously but not IHI's methods which were modeled on Toyota's production system. We asked patients with serious chronic medical conditions what they needed. We asked their families what they needed. We ask front line providers, doctors and nurses and pharmacists, what they needed.

I was a local health system executive and the leader of Pursuing Perfection along with local leadership by patients and providers. We did reinvent US healthcare.

The three key innovations for the patients and their families were: 1) Community Health Workers, 2) a personally controlled medical record that can be selectively shared with anyone the patient chooses, and 3) ongoing learning about managing their own medical condition.

We built a sophisticated mathematical model of the system that confirmed that these simple innovations would save lives and money and that no part of the system would be significantly negatively impacted financially.

During those years, 2000 to 2007, the key invention was a new role, the neighborhood health worker-- a non-degreed health support person. There continues to be much fighting over who controls this role. To me it is clear that this role must be an integral part of neighborhoods themselves. Adoption of this role in neighborhoods would have made practicing medicine much more emotionally rewarding and less frustrating for doctors, nurses, and pharmacists. It would have saved Medicare billions of dollars over 15 years in my county alone. It was simple to understand and simple to implement.

However, no institution wanted to implement the simple common sense inventions because the result was increased health, a decreased rate of growth in expenditures (income for medical system).

Simply put, the US medical system is addicted to an increasing rate of growth in profit--it has become a profit center for investors, it is competing for investment on stock exchanges and CEOs are forced to pay attention to growth in quarterly profits. This an unmitigated catastrophe. It is quite literally killing you and your loved ones. And it can only get worse. It cannot be fixed. It must be replaced from neighborhoods up. More to come.

The profound disregard for this hard won innovation set led me to shift my focus toward health creation and maintenance, toward the so called "social determinants of illness" or better yet the neighborhood determinants of health. Working in the US medical industrial complex was not delivering on what the patients I met during Pursuing Perfection were asking for. I still owe them my best effort.

The US health care system I knew has gradually been replaced by an extractive business too often taking more than it gives back. US Health Care is not a very good deal. It often impoverishes, ignores, and too frequently kills. I am not a fan of this worsening situation. Medical (illness) care needs to be largely disentangled from health creation and illness prevention. This will be best accomplished through neighborhood-level, neighborhood-controlled action. Medical care should be left for illness care. Public health should guide prevention. Neighborhoods can and must support and provide active, meaningful, and healthy living.

The purpose of any system is the most important issue. The purpose determines the structure. The structure determines the roles. People fill the predetermined roles. Change the purpose. Don't try to change the people or minds until you have changed the purpose--in this case from profit taking to human wellbeing and neighborhood wellbeing.