“You’ve got to be very careful if you don’t know where you are going because you might not get there.”
– Yogi Berra
“Would you tell me, please, which way I ought to go from here?” said Alice.
“That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where —” said Alice.
“Then it doesn’t matter which way you go,” said the Cat.
“— so long as I get SOMEWHERE,” Alice added as an explanation.
“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”
– Alice’s Adventures in Wonderland
The country is in the midst of an unprecedented transformation of the health care system and may even be at a ‘tipping point’, yet many of us find it astounding that we have no official (or unofficial for that matter) collective vision of where we are headed, thus how the heck do we know if we are on the right path to get there? Given the very high stakes and costs that extend far beyond financial ones, why is it acceptable to not have a future state in mind so that the current state can be quantified and a gap analysis roadmap can be created to address it? Sure, we have the Triple Aim as the overall goal but what are the ‘guardrails’ that help build the road to it?
The truly great news is that we actually have those ‘guardrails’, and in fact have had them for over a dozen years. It is just that most people have not been aware of this hidden time-tested gem, created by incredibly thoughtful health system transformation forefathers and foremothers back in 2001. This visionary team has overwhelmingly been praised for creating the powerful and gutsy call to action in their Crossing the Quality Chasm Institute of Medicine (IOM) report. What many have missed is that in addition to all the highly visible work, the group created a set of 10 key new rules to inform a future state for the health care system (see figure 1).
Twelve years later, the chart in Figure 1 strikes many of us in two powerful ways: 1) How the ‘New Rule’ column has stood the test of time for the vast majority of its intended direction and spirit, and 2) how sad and disappointing that many of the 2001 ‘Current Approach’ column items are still entrenched even today.
Experts within the Accountable Delivery System Institute® (ADSI) have been privileged to have been involved in numerous IOM workgroup activities in recent years resulting in key published findings, while at the same time, we believe, creating important by-product position updates to the ‘Simple Rules’ table above in Figure 1.
Ideally the IOM would have specifically updated the ‘Simple Rules’ table directly in their 2012 update to the original Chasm report, Best Care at Lower Cost but unfortunately that was not the case. Therefore, we at the ADSI have attempted to carefully and thoughtfully update the original table to reflect a proxy for the most recent consensus IOM thinking in order to create a ‘straw dog’ as to what updated rules can inform an end game vision for health care system transformation. Figure 2 reflects ADSI’s proposed updates:
Ok – great (you may say), but how does that help us to collectively respond to Yogi Berra’s challenge and get us to know where we need to go? Current and proposed policy, business strategies and tactics at all levels can be evaluated against these rules to understand how strongly/weakly they support the 10 revised rules. These assessments can be made at all levels: national, state, regional, and organizational. Starting with these rules to create an informed high-level future state, entities can develop a contextual set of road map milestones along the journey that are specific to their situation, this gap analysis process provides the basis to arbitrate priorities within an entity and their related resource trade-off allocations.
Figure 3 is shown for completeness to facilitate a cross-walk between the original baseline rules and the ADSI’s proposed updates. As you look at the updated rules, you will likely notice that we only suggested changes within each rule where appropriate and not the addition or subtraction of any of the rules – at this point we did not feel comfortable extrapolating that level of significant modification given the incredible amount of consensus effort that went into identifying these specific 10 rules back in 2001.
We welcome both the IOM to tackle this important update directly, as well as the health and health care industry’s feedback to the proposed revised 10 new ‘simple rules’ outlined above. The country and Alice cannot afford an ineffective and inefficient health care system ‘long walk’ and not knowing where we are collectively going.
Accountable Delivery System Institute
The Accountable Delivery System Institute® (ADSI) is the premier resource for hospitals, health plans, large physician groups, and self-insured employers seeking proven solutions and practical guidance on establishing successful models of accountable care. The ADSI-experienced faculty offers exclusive sessions for C-level executives seeking reliable, actionable information on accountable care. Visit the institute.