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2002 Larson Lecture
Building Upon Our Values: Health Care's Promises to Its Patients and Communities
The Annual Roger G. Larson Memorial Lecture
AHA Health Care Systems Section
April 8, 2002
Presented by: Gail L. Warden
President and CEO, Henry Ford Health System
I am honored to be invited to present this year's Roger G. Larson Memorial Lecture. I was fortunate enough to have known Roger in the late '70s when he assisted AHA in creating what was then known as the Center for Multihospital Systems, the precursor to today's Health Care Systems Section. I remember him for his leadership, his commitment to community service, and for, as Dr. Monte Duval put it in presenting Roger's wife Janet the Distinguished Service Memorial Award, "His highly held principles blended with wisdom, compassion, courage, and good humor."
Interestingly enough, in 1989 when Monte Duval was senior vice president of medical affairs at Samaritan Health Service, he was invited to give this lecture. His topic was, "As Values Change, Can Culture Be Far Behind?" In light of the rapidly changing environment in our country and in health care, it seems timely to reflect upon how we can build upon our values and culture by outlining what health care's promises should be to its patients and the communities it serves.
Those of us in this room who have chosen the health care professions have participated in one of the most remarkable chapters in the history of human achievement. The advances made in health care during the last century dwarfed everything that came before - as well as surpassed anything that anyone might have dreamed of.
In the 20th century, infectious diseases like polio, smallpox, and diphtheria have been dramatically curtailed or eradicated. People with heart disease, cancer, or stroke can now enjoy longer, happier lives because of health care techniques that were not available just a few decades ago. The mapping of the human genome, robotics, non-invasive surgery, new clinical information system, and new pharmaceuticals promise more progress in the future.
We also have learned to provide care in ways that are both clinically effective and respectful of the personal needs and dignity of those we serve. Whether founded by religious groups, philanthropists, civic leaders, or government, health care organizations have involved people caring for each other to promote health and reduce the burden of illness. Our health care institutions are not simply a means for providing health care but have represented the highest values of our culture. Let us begin by examining each of those values:
- The Primacy of Quality of Care/Putting the Patient First
The first, and perhaps most important value, is the primacy of quality of care and putting the patient first. From the very beginning of health care management, quality of care has been considered the primary value for every health care organization. More recently we learned an important new perspective involves assessing and improving quality "through the patient's eyes." Hence, the value of putting each patient first.
The second value is voluntarism. We call health care institutions voluntary organizations, and rightly so, because they are the product of the noble tradition of people freely giving their time, talents, and resources for the benefit of others. Time and time again across the country, volunteers, health care trustees, and medical staffs have given their time, talents, and resources for the benefit of the community.
- Public Service
Related to voluntarism is the third value of public service. Regardless of its corporate structure, ownership, or financing, community health care organizations have their first obligation in the duty to serve. Everywhere in this vast country the blue sign with the big "H" is the universal assurance that medical care is available. It is available at any hour of the day or night for the poor, for the rich, for the old or the newly born, for anyone in need.
Of course, these organizations also have served other purposes such as doctors' workshops and ways for some to climb the social ladder. Sometimes they have been used to foster the American spirit of free enterprise because they carry economic significance as major employers and purchasers of goods and services. Most certainly, they stand proudly as symbols of community identity and community benefit. These roles have positive value but must not overshadow the basic mission of public service. Otherwise, society is likely to lose trust, challenge tax exemptions, and imposed charitable work requirements.
- Community Focus
The fourth value is community focus. Health care institutions that have community focus and have been well managed and faithful to their central purpose continue to enjoy the unwavering support of their communities. They have not always been pillars of efficiency, but they have been responsive to the needs of their communities and always stand ready to serve when needed.
- Willingness to Change
The fifth value is willingness to change. In this health care environment, we are constantly challenged as we've never been before. Time-honored approaches are being questioned and are falling by the wayside. Solutions we have known aren't up to the challenges of eroding health care payment, higher public expectations, and a growing shortage of nurses, pharmacists, and other health professionals. Our organizations and our professions are being forced to reinvent themselves.
The sixth value, the spirit of inclusiveness, has always served us well. It has raised us above parochial interests and allowed us to reach out to other health-related groups. Our organizations have gained the benefits of collaboration and avoided the costs of contention. In matters of public policy, this collaborative approach has directly contributed to landmark achievements such as Blue Cross and Blue Shield, the Hill Burton Program, Medicare, the Joint Commission on Accreditation of Healthcare Organizations, the National Committee on Quality Assurance, and numerous others. Inclusiveness also has improved our response to changing community demographics and the development of diverse management and professional care teams at every level.
- A Respect for Diversity
The seventh and final value is a respect for diversity. Health care has traditionally respected the diversity of its patients, workforce, culture, and ideas. The field has built upon the values held by our early leaders. In the tradition of voluntarism, individuals and organizations have learned to contribute time, expertise, and facilities, and to collaborate across cultural boundaries. Out of voluntarism emerged a social consciousness, a feeling that individuals and their organizations count, and that the organizations should be open to everyone. This is the core virtue of community life. In many ways, it is more important to American society than health care itself.
The Challenges We Face
Having reflected upon our values, let's examine the challenges we face. While we have stood fast on these values because they have served us well, we cannot be complacent. Like it or not, there have been events and new information in the last few years that challenge everything we do and how we do it.
- Crossing the Quality Chasm
The first challenge is related to quality of care and patient safety. In the last three years, the Institute of Medicine of the National Academy of Sciences has issued two reports that have shaken our health care institutions. The first report entitled To Err is Human chronicles the challenges we have in preventing and reporting medical errors and guaranteeing patient safety. The second report, and perhaps the most far reaching, is entitled Crossing the Quality Chasm and makes a very strong case for the fact that "between the health care we have and the health care we should have lies not just a gap but a chasm."
The report challenges the health care sector to adopt what we have learned about quality improvement from the manufacturing sector and to develop some new values and rules to redesign and improve care. Some of the rules it recommends include care that's based on a continuous healing relationship, instead of care based primarily on episodic visits; care that is based upon the needs and values of the individual patient, instead of the needs of professionals; evidence based decision making, instead of decision making based on training and experience; anticipation of patient needs, instead of reacting to needs; a focus on patient safety; and better cooperation among clinicians. Our challenge is to make these new values and rules possible by focusing on improving our delivery processes, focusing on each patient first, and committing to eliminate the chasm in our own institutions.
In these same reports, the Institute of Medicine presented research evidence that challenges us to pursue perfection in 15 to 20 clinical conditions. Currently, can we promise a patient suffering from depression we won't let them commit suicide, or can we promise a person who is dying they will have no pain, or can we promise a pregnant woman she will not have an unnecessary C-section? We have the scientific knowledge to make these promises, but our organizations are challenged to deliver them.
- The Events of September 11th
A second set of challenges is related to 9/11. The events of September 11th and their aftermath have reminded us how important freedom and liberty are in this country and that they can't be taken for granted. As a nation and as individuals, we have been threatened by people who don't share our culture or our values. The response of Americans has taught us some important lessons about voluntarism and public service.
Voluntarism and public service are required if we are to protect the country and its people. As Chuck Lauer, the publisher of Modern Healthcare, described it in an editorial just after 9/11, "Our men and women in the armed services, our policemen, our firefighters, and our health professionals-all volunteers-rose to the occasion, performed well beyond our expectations, and were courageous heroes."
Health care professionals are committed to public service and are as courageous as any group of professionals. We have all heard incredible stories about health professionals from all over the country who descended upon Ground Zero to care for, offer comfort to, and provide backup to their colleagues.
Yet, at the same time, we found that our public health enterprise has deteriorated and was not prepared for the challenges of bio-terrorism. Local reporting systems were not in place. We thought we had eradicated smallpox, but it was still a threat. Our hospitals were not ready to handle the anthrax scare, and our disaster preparedness left a lot to be desired. The nation's hospitals have begun to see public health and public service redefined.
A final consideration in the war against terrorism and the events of 9/11 is the disparity between health care expenditures in our country compared with others around the globe. We must understand that terrorism thrives in societies that don't have the social advantages of education and health care that we have in this country. For that reason, some suggest we should export more health care as a blow against terrorism.
- A Nation of Spectators
A third set of challenges relates to our civic responsibility. While most health care institutions try to be responsive to their community's needs, they often ignore some of the conditions around them, and, instead of becoming engaged, act like spectators. It was pointed out in the final report of the Commission on Civic Renewal in 1998 that when our country assesses its civic and moral condition, we are deeply troubled--and with good reason. "During the past generation, our families have come under intense pressure and many have crumbled. Neighborhoods and communities have frayed. Many of our streets and public spaces have been unsafe. Our public schools are mediocre for most students and catastrophic failures for many. Much of our popular culture is vulgar, violent, and mindless, and our character framing institutions are enfeebled. Public trust in our leaders and institutions has plunged."
It is very easy for us to ignore these issues or pass them off as, "something that happens in other communities, not mine" or "let's be realistic, these are the facts of life." When we are asked to get involved, we say "we do not have the time for civic life." The facts are that we have never had more opportunities for participation, or more time to do it, yet we plead powerlessness, and instead of becoming engaged, we act like spectators. You're probably thinking, "Yes, you are right, but what does that have to do with health care institutions and health care professionals?" It has a lot to do with health care. Every one of the issues I mentioned has a health care condition associated with it.
Let's take the issues related to the quality of public education and safety for youngsters in inner-city Detroit. By mounting a school-based health initiative and a violence prevention program, we have seen less violence, healthier students, higher test scores, a drop in teenage pregnancies, and stronger parental involvement as volunteers in the schools.
In this case, health care organizations in Detroit took leadership, but more important, they assumed their responsibility as citizens. Today in our democracy, the challenge is not just leadership, it is citizenship.
- Diversity Takes on a New Meaning
A fourth challenge is that as our economy, our political environment, and our society become more global, the challenge of diversity as we know it takes on a new meaning. In the United States, according to the most recent census, upward of one-third of Americans are people of color. By the middle of the 21st century, white Americans will be less than 50 percent of the population. Already, 54 percent of American people are women. This means that in the not too distant future, a prototype American would be a woman or a person of color. For our health care institutions, this has major patient population and workforce implications. We have all begun to be prepared for the diversity of our patient population and our workforce in the future but have not thought about what this means in a global sense.
Let's consider "The Human Global Village" based on figures by Dr. Phillip M. Harter of Stanford University School of Medicine and put together by the British Humanist Association: If we could shrink the earth's population to a village of precisely 100 people, with all the existing human ratios remaining the same, it would look something like this:
14 from the Western Hemisphere both North and South
52 would be female
48 would be male
70 would be non-White
30 would be White
70 would be non-Christian
30 would be Christian
6 people would possess 59 percent of the entire village's wealth
and all 6 would be from the United States
80 would live in sub-standard housing
70 would be unable to read
50 would suffer from malnutrition
1 would be near death
1 would be about to give birth
1 (yes, only 1) would have a college education
and only 1 would own a computer
When one considers a world from such a compressed perspective, the need for acceptance, understanding, and education becomes glaringly apparent. While most American health care institutions are not global, the implications of this information reinforce the challenge in diversity in a multi-cultural society. Ronald Reagan's speechwriter, Peggy Noonan, writing in the Wall Street Journal about diversity just after 9/11 said, "We are going from a point of respecting our differences to having essentially no differences. We are Americans. That's a lot to have in common."
- Shedding Light on our Business Practices
The fifth challenge is shedding light on our business practices. In the past several years, the business and accounting practices, the executive salaries and perks of large corporations and even large health care systems have been under scrutiny. Wherever this happens, it destroys the public trust, causes tax exemptions to be challenged, and tarnishes the image of even the most ethical of our professional community.
The collapse of Enron has reminded many of the AHERF collapse and has raised scrutiny of accounting practices, executive privileges, IRS audits, and, in some cases, has led to "witch hunts" aimed at organizations, their management, and their boards of trustees.
Another issue related to business practice in this time of growth in the uninsured population has been sloppy reporting in the cost of uncompensated care. Bad debts result in uncompensated care but they are not necessarily because of the uninsured.
As an industry, we are challenged once again to come up with mandatory standards of financial reporting to protect our own not-for-profit status and our tax exemption. Only this will shed light on our business practices and restore the public trust.
- Caring for the Uninsured
Finally, perhaps the most overwhelming challenge we have in health care is the challenge of the 45 million uninsured. The growth of our uninsured population combined with rising health care costs, reductions in health care coverage, an economic downturn, layoffs, downsizing, and little hope for increased funding through Medicare and Medicaid all contribute to what Dr. Henry Simmons of the National Coalition on Healthcare calls "the perfect storm."
The challenge to all of us is to strengthen the organizations that are the safety net in our own communities, utilize our resources for caring for this population prudently, and aggressively pursue public policy changes that will address the problem. The "blind eye" approach of making providers deliver free care is not working.
Health Care's Promises
The challenges we have just considered raise the question of, "What do we do now?" We can wring our hands; we can lobby for governmental solutions; we can look to our associations, or we can accept the responsibility on our own shoulders. I propose that the health care sector proactively address these issues and make some promises to its patients and its communities that build upon our values. These promises should be:
- We promise to lead our organizations in taking the necessary steps to "cross the quality chasm" and ensure patient safety. We will put patients first by providing each patient the quality of care, safety, and comfort we want for our families and ourselves. We will pursue perfection in the clinical conditions most prevalent in our patient populations.
- We promise you that we will promote, facilitate, and foster voluntarism in our communities. We will partner with other organizations to provide new services not currently available. We will recognize and reward those who volunteer their time and resources for the improvement of health care in communities they serve.
- We promise that we will actively become involved in rebuilding our public health enterprise and make public health a priority for our community. Our institutions will partner with schools of public health to recruit public health professionals, promote health services research, and improve public health reporting.
- We promise to stop being spectators and engage in the civic issues in our communities. We will use our health care knowledge and resources to make our communities a safe place, support the rebuilding and strengthening of our school systems, partner with social agencies, and promote citizenship as a part of good health. We advocate improved community health by getting involved. We will do whatever it takes to be a responsible citizen and a good neighbor volunteering our time, expertise, and facilities.
- We promise to commit our organizations to recognizing, practicing, and celebrating diversity as a value in our society. We are all in this together. We embrace the dignity of our diverse workforce and patient population. We respect the people of our communities as Americans like ourselves, and we will reach out to them because we have so much in common with them.
- We promise to preserve the public's trust through standardized and ethical business practices. We believe in transparency and full disclosure in our financial activities. We believe in the rights and responsibilities of boards of trustees to make policy and take action to ensure the public trust.
- We promise to have a social conscience. We believe that our presence counts in our communities and that our doors must be open to everyone. We recognize that until government helps us solve the problem, the care of the uninsured is our responsibility and that we have an obligation to use our resources wisely, to be aggressive about addressing the issues in public policy forums, and to work closely with our peers for the best local solution.
In conclusion, as the waves of change continue to break upon us, we may be tempted to batten down the hatches, look after ourselves first, and ride it out. We must avoid these tendencies. We must reach out to our patients and our communities. We must greet change not as a threat but as an opportunity. Common concerns, common needs, common principles, and common values bring all of us together in health care as an extended family. We must hold fast to our values, carry out our promises, and turn challenges into opportunities for improvement. If we do this, we can have another century of extraordinary health care; thus providing longer, happier lives for all Americans. Thank you.
Gerteis, Margaret; Edgman-Levitan, Susan; Daley, Jennifer; Delbanco, Thomas L.; Editors. Through the Patient's Eyes; Josey-Bass Inc. 1993.
Harter, Dr. Philip M., Stanford University School of Medicine, "The Human Global Village" and put together by the British Humanist Association. Contact Marilyn Mason on 020 7430 0908 or email: firstname.lastname@example.org
Institute of Medicine, Crossing the Quality Chasm: A New System for the 21st Century, National Academy Press, 2001.
Lauer, Charles. Modern Healthcare, February 4, 2002, p. 32.
National Commission on Civic Renewal Final Report, A Nation of Spectators, 1998.
Noonan, Peggy. "What We Have Learned," Wall Street Journal Editorial, February 27, 2002.
Sigmond, Robert M. "Learning From the Ghost of Healthcare Past," Health Forum Journal, November/December, 1995, pp. 14-19.
Warden, Gail L. "Caring for Each Other," Chairman's Inaugural Address, American Hospital Association, January 29, 1995.
Warden, Gail L. Pattullo Lecture, "The Interface Between Health Administration Education and Practice in the New Millenium." The Journal of Health Administration Education, 18:3, Summer 2000.