Population Health, Stephen Shortell and ICT

Josep M. Picas

A few days ago, Jordi Varela published his editorial on "The health of the population beyond the integration of services" based on an excellent document from the King's Fund. The truth is that good news about the evolution of health models are rare, although it might be better to speak of "frameworks" in the field of health. The theme seems so powerful that, obviating the already mentioned conceptual aspects, I’d like to use it to bring forward some aspects related to information systems.

Progress in concepts such as Health Maintenance Organizations and Accountable Care Organizations have come together with the evolution of the great potential of information systems and data processing that has been developed in recent years, and here we find some of the best ideologues on health systems in these times, for example Stephen M. Shortell who, among other prominent curricular aspects, is emeritus dean of the School of Public Health at the University of California - Berkeley, discussing ICT tools and content. So I suggest reading two articles written by Shortell. The first, “A bold proposal for advancing population health” which was published as a discussion paper by the Institute of Medicine, develops the conceptual model and suggests the future development of the payment system and health financing towards one based on health and not on disease, more transversal between health care, public health and community services. Shortell emphasizes the problem of professionals’ cultural barriers when faced with this approach, as Varela said in the aforementioned article. In the second article, "A Proposal for Financially Sustainable Population Health Organizations", Yasnoff, Shortliffe & Shortell propose the creation of banks of health information that unifies, under the management of the patient themselves, electronic medical records – the individuals and population’s health, a surely trendsetting approach.

Against medical overuse, more primary care

Atul Gawande, a surgeon and author of the book "The Checklist Manifesto" and "Being Mortal" among others, has published an article in The New Yorker, "Overkill," which talks about the disproportionate clinical practices, especially those in their country, the USA. It’s a long and well-documented writing that I’d like to comment on in this post for two aspects I consider important because they can help fight the epidemic of overdiagnosis and medical overuse. The first question posed by Dr. Gawande is an organizational consideration of diversion of resources, and the second is a proposal to avoid mistakes when prioritizing budgets.

Preventive activity and daily clinical work

The case-mix seen in clinics today has changed dramatically with the impact of secondary prevention programs and the medication of risk factors. Now the doctors’ agendas and especially those of family physicians are filled with healthy people who are afraid of getting sick, a situation that not only uses up medical time but also diagnostic tests, medications and referrals to specialists (if you are interested in this issue don’t miss the book "The patient paradox" written by the Scottish family physician Margaret McCartney). Cost considerations aside, health resources are so busy in offering care for healthy people and invest so little effort in addressing the clinical complexity of some patients that what they need really is multidisciplinary work and integration of services.

Untangling the skein of frailty to leave the maze of disability. From detection to prevention

Marco Inzitari

Following on from Ariadne’s thread which was extended across the concepts of aging, complexity and disability, I will build this new contribution on my previous post entitled “Frail, cracked or broken?”. In that post, I defined as "frail" a person with apparent good health and overall functions but with concomitant alterations of different organs and systems, often sub-clinical, that increase the vulnerability to progress towards disability in case of injuries of a different nature (clinical, such as illness, or social, such as widowhood, etc). The main goal of the detection of frailty is prevention, because frailty and disability are reversible.

In this new post, I will try to move towards the exit of the maze, although this may be an even more complex task than Theseus’ challenge. The metaphor of frailty and, more generally, of aging as a "Minoan" maze, is not accidental: it’s a complex phenomenon where multiple systems and organs begin to be simultaneously altered, different pathologies appear and drug treatments are added. The social situation of the person and their environment can represent added elements of frailty. Besides coexisting, all these factors are interacting, determining an intricate tangle of threads of different colours that are really hard to discern. It’s as if the aging tended towards entropy, just like too many electric cables tend to become entangled. Given this complexity, it’s hopeless to pull a single thread and expect the skein to untangle. This is why "magic" recipes such as an alleged "pill" to combat aging, have failed so far. If we want different results we need a focus shift when looking at the classic "risk factor - disease - treatment".

The dream team of primary care in Europe

Tino Martí

The WHO Europe has published "Building Primary Care in a changing Europe". It is a very well prepared document written by a cast of first class minds (Kringos, Boerma, Hutchinson and Saltman) based on the information collected in the European project PHAMEU (Primary Healthcare Activity Monitor in Europe) reflecting indicators of structure, process and result of all the countries of the European Union provided by either accredited local points of contact (in Catalonia IDIAP). The project has been funded by the European Commission and supported by WHO Europe, the European Forum for Primary Care, the European Public Health Association and the European General Practice Research Network.

The paper analyzes the strengths and weaknesses of the existing multiple configurations of primary care in Europe, overcoming the usual classifications of Bismark versus Beveridge systems intended to relate their performance and results to develop rankings of countries. The systems reaching the top are considered as possessing an attribute of a "strong" Primary Care.

An interesting exercise based on the published information would be to design the most robust way for creating create a dream team of primary care settings in Europe.

Integration of social and health services: 3 issues and 3 solutions

Aging population has many interpretations, some of them very positive such as the fact that more and more people are fortunate that they live for longer with a fairly healthy life. The other side of the coin is that there are also problems such as increased multiple combined chronic diseases, social deprivation and the fact that many people reach an advanced stage of geriatric frailty. And this is where service delivery models that have been consolidated in recent decades are still struggling to give satisfactory answers. Governments know it and, for this reason, are launching initiatives to address chronic disease and frailty in a more effective manner but these programs often face political difficulties, resistance to change and difficult to overcome bureaucracies.

From everything I've seen in this issue, I think the British are the most daring, so I chose the report of the "Commission on the future of health and social care in England" published by King's Fund, because it synthesizes very well what the problems of current models are and what are the solutions to be put on the table.

First problem: the current model is unfair. The health system is universal and free, while access to social services is restricted. Let's say two examples: people affected by cancer enjoy global coverage, regardless of process costs and economic level of the patient, while Alzheimer's patients suffer from limited access to services, especially in more advanced stages when their needs are more social than medical.

Second problem: funding sources are different. The health system feeds directly from the public budget, while social funding source is hybrid, with participation of different administrations, including the local, and with a variety of complex management copayments.

Precision medicine, personalized medicine and person-centred medicine

Cristina Roure

In recent years we have frequently heard about personalized medicine referring to the use of our growing understanding of genetic variability in medicine for prevention strategies, more accurate and safer diagnoses and more effective treatments for each individual.

I must confess that the use of the "personalized" adjective referring to the individualization of treatments based on the genetic characteristics of each person has always caused me some discomfort, because I think that a person is much more than a set of genetic information, however accurate it may be.

For this reason I was happy to hear the term precision medicine in relation to the new initiative of the Obama Administration announced in his discourse of State of the Nation on January 20th, 2015.

Population’s health beyond service integration

All health systems in the world are immersed in service integration projects aiming to meet the challenge posed by the increased chronic disease and geriatric frailty. Based on this circumstance, King's Fund has published a document, "Population health systems. Going beyond integrated care" wondering how difficult could the integration of public health services be, given that improving health determinants  and risk prevention can most effectively affect the way in which many people grow older and healthier. 

The King's Fund document selects 5 experiences from different countries, that beyond the integration of services, are reaching community action: a) Kaiser Permanente, USA, focused on promoting physical activity and healthy eating; b) Nuka System of Care, Alaska, focused on community work to reduce domestic violence; c) Gesund Kinzigtal, Germany, focused on community groups that promote sport and health; d) Manukau Counties, New Zealand, created programs that emphasize healthy improvements in social housing; and e) Jönköping County Council, Sweden, formed discussion groups to promote health (life cafés, learning cafés, etc.)

Basic instruments for clinical management

In preparing this post I have chosen nine references which, in my opinion, have been milestones in the development of methodologies and tools that have shaped clinical management as we understand it today. To make it more understandable, I have framed these milestones in 5 relevant periods: the introduction of the concepts of quality in the 60s, the protocols in the 70s, the consensus in the 80s, the evidence of 90s and the safety of patients in the first decade of this century.

Hospitalists: functions and competencies

Don’t panic, it’s not about defending a new specialty, it’s about thinking what should be the roles and responsibilities of the physicians in charge of hospital wards if they want to improve safety, quality and continuity of admitted patients’ care.

In 1996 Dr. Robert Watcher and Dr. Lee Goldman described for the first time the term hospitalist as a doctor specialized in the practice of hospital medicine. This matter was experienced then as necessary for the organization of hospital wards in the US, due mainly to the multitasking of specialists who caused that the management of admitted patients was often disorderly. Almost twenty years later the Society of Hospital Medicine reports that there are more than 30,000 hospitalists working in 3,300 hospitals.

In the video, you can see Dr. Chris Addis explaining the main contributions of hospitalists to the admitted patients’ care, in summary: a) assume the coordination of specialists, b) know how to communicate the patient's clinical information in a simple manner, c) ensure continuity of care, and d) be the referent for family doctors both during admission and during the transfer.

Modern clinical management: the basics

In recent decades, clinical management has had a couple of conceptual disruptions that have generated interest in the welfare act as an object of study. The first was when, in the early 90s a group of epidemiologists moved clinical epidemiology from the academy to the consultation and developed evidence-based medicine; and the second came when governments and health professionals became knowledgeable about the clinical work’s ability to do harm. The "To err is human" from the Institute of Medicine report in late 1999 was the turning point of patient safety programs. Now, in the second decade of the century, starting from those two fundaments (security and evidence), all the interest is in knowing what is the value that clinical practice brings to the health of people.

The conceptual foundations of modern clinical management

Professionals are important, but so is good governance

Professionals in health services are important because without their dedication and enthusiasm patients do not receive the necessary care, especially in times of cutbacks. However, we should not forget that for these professionals to work properly they need their organizations to be well governed and I will exemplify this with two publications, the first of which is the last book of the veteran professor of McGill University Montreal, Henry Mintzberg, and the second is an article on this subject in the New York Times.

One of Professor Mintzberg’s best known lessons has been the conceptualization of the third sector as a balanced element of democratic societies. One sector, he says, called to serve as a counterweight between public and private spheres. Its key differentiator is property that is either collective, such as in cooperatives or is diffuse, such as in foundations or associations, apart of course of their altruistic purposes and their natural space: community services. All this makes the third sector is specially equipped to manage health services in a well weighted basis between the despotic temptations of political power and the interests of private companies.

Are we all mentally ill? About Allen Frances

Allen Frances, psychiatrist professor emeritus at Duke University (USA) led the working group that developed the DSM-4 (Diagnostic and Statistical Manual of Mental Disorders). I follow the author’s activity, always critical and always documented, on twitter (@AllenFrancesMD) and, unaware of the framework of psychiatry, a question started spinning in my head. How could it be that someone who had led the fourth edition of the DSM was now the most lucid voice against the excesses of modern psychiatry? If I wanted to know the answer, I had no choice, but to read his latest book: "Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life".

Saving Blood; Strategies to Shatter Resistance

The evidence is clear: avoiding unnecessary transfusions saves lives and generates savings with clinical criteria. Nature echoes this aphorism in an article that collects research insisting that regarding blood transfusions less is more. This issue of blood is very awkward and contradictory. Not surprisingly, for modern nations, having a system of voluntary donation is a matter of pride. Many people believe it and when there is a disaster, the first reaction of many people is lining up to give blood. And it should be noted that the evidence favours the popular intuition: transfusions work better for the injured with major bleeding and for more complex patients, but can also be harmful for patients with smaller problems.

Transfusion = transplant?

The transfused red blood cells have two problems: the first is that in the storage process they lose flexibility, which can make them less effective in transporting oxygen, and the second is that they are actually foreign cells containing antigens (beyond ABO and Rh) that arouse immunological reactions of varying intensities. On these physio-pathological issues, there is still not enough research, but many believe that the origin of the transfusion problems is in these two points.

When the overdiagnosis is politicized

Rudy Giuliani, the Republican mayor of New York, on that fateful September 11, at an election meeting said: "I had prostate cancer 5 or 6 years ago and I thank God to be an American citizen because here the probability of survival at five years for this cancer is 82%, while in the UK, due to socialized medicine, this value is only 44%." We must clarify that in the US, PSA screening is widespread while in the UK it’s not so. According to Gerd Gigerenzer (I have extracted this case from his book "Risk Savvy"); Giuliani’s words conceal a big mistake, because in reality, although it seems a contradiction, mortality from prostate cancer in the two countries is practically the same. So how is it possible that the survival rates are so different? To explain it, Gigerenzer describes two biases that encourage the intentional error of the conservative politician:

The patient will see you now, according to Eric Topol

Eric Topol, director of Scripps Translational Science Institute, published in 2012, The Creative Destruction of Medicine, and in 2015, The patient will see you now. The future of medicine is in your hands. I had this last book on my reading list for a while and I've finally been able to read it during the holidays. It’s an important book about technology seen from the point of view of a clinical practice with extensive knowledge. I found that this literary piece goes a little too far in some chapters and I struggled to follow the thread of the main thesis, nevertheless I have to admit that the contributions of the genomics professor (and cardiologist) are very relevant and deserve to be discussed.

Physical examination is reclaimed

Acute vestibular syndrome, characterized by dizziness, nausea and vomiting, is often due to a local neuritis of the inner ear, despite the fact that a doctor cannot overlook that with these symptoms he or she must first rule out the vertebrobasilar stroke, a less common aetiology, but obviously a lot more serious. I chose this health condition because the neurologist David Newman-Toker from Johns Hopkins (and the team) have systematized HINTS (Head Impuls, Nystagmus and a Test Skew), an examination that requires nothing more than some basic neurologist’ tasks: a) the patient is asked to move his head while focusing at the examiner’s nose; b) the nystagmus is measured on lateral gaze, and c) one of the patient's eyes is covered with the hand while the other eye will focus at the examiner’s  nose and then the other eye is suddenly uncovered. On the understanding that family physicians and emergency room doctors know how to do this (and they probably do) the essential neurological examination before a persistent vestibular syndrome, should be aware that the study published by the team Newman-Toker in the Stroke journal states that HINTS has shown 100% sensitivity and 96% specificity so that the doctor can rule out the vertebrobasilar stroke in people with acute vestibular syndrome, values exceeding those of nuclear magnetic resonance.

The road to excellence

Antoni Peris

We often ask ourselves whether we are still good professionals or whether we are stagnating; whether our work is good or whether it can be better; whether we treat our employees well or whether they’re taking the Mickey; In this case, can we ask more from them? How do we inspire them to do better?

Whiplash has been one of the best rated films of the season. The story of Andrew, an ambitious young man who wants to become the best jazz drummer, enrols in the world’s best school in New York and has to face a teacher who demands everything he has to offer and a lot more. Whiplash shows us the path to excellence, assumed by teacher and student. However I think it’s very far from what we need to think about in our organizations.

Risk savvy according to Gerd Gigerenzer

Gerd Gigerenzer, Director of Harding Center for Risk Literacy at the Max Planck Institute for Human Development in Berlin, has published "Risk Savvy. How to make good decisions" (Penguin 2014). It’s a book that addresses the difficulties of making decisions in uncertain environments and the need to know how to communicate risks in an understandable way. According to the author, according to his own experience, 80% of doctors do not understand the meaning of a positive result in a diagnostic test and, following this line, in an Australian study, from the 50 doctors surveyed, only 13 responded that they understood the concept of "positive predictive value" (which is the probability of having a disease if a specific test is positive), but only one of them finally was able to explain it properly. In a post on this blog, "Too much mammography or the mirage of screenings", Cristina Roure said that a woman's risk of breast cancer after showing a suspicious lesion on a screening mammogram is 10%, when most doctors believed to be 90%. After this introduction, we can understand why we ought to consider Gigerenzer’ book as essential in medical practice in a world of probabilities.

Big Med or wholesale medicine

A few months ago, Josep Maria Monguet published a post on this blog about the low cost medicine in India, and along these lines I thought it would be interesting to comment on an article by Atul Gawande in the New Yorker with some comparative reflections between medicine and restaurant chains. "In medicine -says Gawande- try to provide a wide range of services to millions of people at reasonable costs and an acceptable level of quality, but the reality is different: the costs continue to rise, the service we offer is mediocre and the quality, uneven. Each doctor has his own way of doing things and the variations in the results, even within the same health centre, are inexplicable.

Dave Luz, regional manager at the Cheesecake Factory in the Boston area, explains to Gawande that his mother, with advanced Alzheimer's, fell down at home the other day and has been taken to the emergency room, where doctors visited her, did various tests and kept her under observation for the night. Luz received three types of explanations: from the emergency physicians, from the internist at the observation room and from a specialist, and these were not exactly coincident. He soon realized that there was no plan involved there. The next morning, a nurse told him that his mother was fine and that they would prepare her for discharge but because the nurse in charge was having her breakfast, they would have to wait, and that process, seemingly bureaucratic lasted until the afternoon because the doctor who had to make the discharge report could not be found. To cap it all, when it was time to dress his mother, the auxiliary disappeared and Luz had to fend for himself. With the discharge papers, he would schedule a control visit to collect the results of urine tests and one to see a neurologist. A couple of weeks later, the neurologist, after an examination that lasted a couple of minutes, called for new tests (by the way some matched those that had been made in the emergency services) and prescribed some medication that, once asked what they are for he admitted they‘re useless. Dave Luz says that this kind of disorganization among professionals and circuits, this lack of an overall plan, was to be found everywhere where he had to go to accompany his mother for receiving medical care.

Hospitals: 10 necessary structural reforms

Hospitals are structures that generate a powerful influence on the overall health system. Their effectiveness in the resolution of certain acute diseases, especially surgical, gives them a great social prestige. This fact should not, however, hide two structural problems that are burdening their perspective:

a) The first problem is internal. Bureaucracies themselves are showing signs of fatigue and this affects the quality of services, especially in the safety of admitted patients.

From the Triple Aim to the Quadruple Aim

Cristina Roure

Readers of the blog Advances in Clinical Management will be familiar with the term Triple Aim coined by Donald Berwick from the Institute for Healthcare Improvement of the United States(1) which recognizes those clinical projects that simultaneously achieve the triple objective to:

1. Improve the patient experience (satisfaction and quality)
2. Improve clinical outcomes in the population
3. Reduce health care per capita costs

The four habits of high value health care organizations, according to Richard Bohmer

In an article in Harvard Business Review, Fixing Health Care on the Front Lines, Richard Bohmer presented the three pillars of modern clinical management (see post: Clinical management as a mechanism of change). I like Bohmer’s contributions because he always looks at what can be done to bring the concepts to the real world, so it has seemed appropriate to comment on another one of his articles published in NEJM, The Four Habits of High-Value Health Care Organizations, which raises the logical point: if you want to encourage high value clinical practices, high value health organizations are paramount and for this reason, the author has studied the ways of working of the US healthcare institutions that are showing the best results in clinical and cost effectiveness (referencing the outcomes of Michael Porter) and he extracted 4 habits that, according to him, should be exportable:

Frail, cracked or broken?

Marco Inzitari

The concept of frailty historically has been the object of a lot of debate among those who work in the field of elderly health, with differences between epidemiological and clinical outlook.

Frail

For geriatricians the frail have for a long time been people with multiple health problems and often with an already advanced disability, such as those that can be found in hospitals or nursing homes. Epidemiological Revolution introduced by Linda Fried, a most prominent geriatrician and epidemiologist that I have already quoted in the post "Thinking differently in healthy aging", changed the paradigm in early 2000.

In plain language, she indicated as "frail" something at risk of breaking, not already "broken", as in the case of people with advanced disabilities that we mentioned. So a frail person, in this view, is a person with apparent good health, and even without a disability, which has reduced physiological reserves of different organs and systems that makes them particularly susceptible to descend towards disability in case of injuries of a different nature (clinical, such as illness, or social, as a widow, etc). Detection of frailty in this sense is mainly based on measures of physical or cognitive performance, with a clear objective of prevention, since it is proven that the frailty is reversible and targeted interventions (exercise, nutrition, geriatric assessment) can prevent disability.

Dying in hospital

The neurologist Oliver Sacks published an article in the New York Times "My own life" in which he announced that he has just been diagnosed with a liver metastasis. "I find myself facing death. It’s up to me to choose how I will live the remaining months of my life. I have to live as good, as deeply and as productively as possible." Death is an inscrutable fact that each person has to go through in their own way, so far it’s all normal, and Sacks dealt with it calmly, taking the reins of the time left. But how about the health system? When someone calls the ambulance because they have a sudden chest pain, the entire health organization is tense, protocols are activated and everyone knows what to do. The health system has full control of that process so all that’s left to do for the patient is to remain confident. But on the other hand, when what’s left to be done depends on how the patient sees life and death, as is the case with Sacks, the system no longer feels so confident and can act inappropriately, even disproportionately.

Clinical management as a mechanism of change, according to Richard Bohmer

Richard Bohmer is a doctor, a professor at Harvard Business School and the author of "Designing Care". In his article, Fixing Health Care on the Front Lines, Bohmer defines the three pillars that should underlie modern clinical management, in short, these are: a) thoroughly implement the best practices, b) address the complex processes with mechanisms of trial and error, and c) learn from daily activity. "Almost none of the health organization is prepared to excel in these three pillars nowadays, says the author. In fact, most clinical services providers lack the capacity to adapt to the challenges imposed by science, innovation and social pressure, unlike what happens in other industries, constantly reengineering their models to suit the changing needs of their business core".

Rigorously implementing the best practices

The clinical practice guidelines (CPG) and the recommendations supported by strong evidence should translate in care routes (see Care Delivery Value Chain). Modern organizations know that the GPC are not only a matter regarding the medical profession, so they invest a lot of effort in the development of plans to make them feasible. Anyone even slightly concerned must be involved. Transforming a GPC into an operating process is equivalent with improving clinical effectiveness. Some examples: a) applying industrial methods to standard cardiac surgery processes at the Mayo Clinic, b) the myocardial codes and stroke codes that, in many regions, have been deployed with excellent results and c) development of organizational models that aim to reduce resistance to antibiotics (PROA) or to avoid unnecessary blood transfusions (PBM).

Addressing the complex processes with mechanisms of trial and error

A significant number of patients are suffering with pathologies that are not well known or show complexities resulting from a combination of clinical or even social circumstances that are difficult to manage. For these cases, the organizational response is teamwork which aims to find specific solutions while the actions will have to be adjusted by trial and error methods. Some examples: a) advancing the introduction of palliative care in cancer patients who are still following therapeutic healing guidelines, b) reconciling patient medication when transferring between hospital and primary care, and c) developing individualized therapeutic plans for complex chronic patients.

Learning from daily activity

The other day, in a class, I came across a few permanent and non-permanent markers and, as it happens, without realizing it, I ended up ruining the whiteboard. At the end of the class, I sincerely apologised to the head of the classroom and suggested that it would be a good idea, for the sake of their class boards, to withdraw the permanent markers, but the response I’ve got was one of those type "here we, always have done things this way". I assumed that they must go through a change of budgets in order to make changes in the classroom stationery. However to improve every day, is above all, a question of attitude. Some examples: a) in an office, faced with the fact that 20% of scheduled patients do not keep their appointment, a working group was created in order to analyse the causes and find solutions, b) in a hospital, ward nurses make proposals to be able to shift from intravenous to oral medications as soon as possible, regardless of the oversights of medical orders, and c) in an emergency department, they organize daily huddles to ensure that all the professionals can share their opinion on what happened that day and advance proposals to avoid the same problems reoccurring.

When we talk about structural reforms, I suspect that not everybody says the same thing. Many think of labour rights, or in financing or investment. These and other aspects are important, which is why the health care system has a recognized complexity. But make no mistake, only from the clinical management can the effectiveness and resource optimization can be improved. As Bohmer advocates, organizations, with doctors and nurses included, should apply best practices rigorously, should learn to make decisions as a team when the issues are peculiar and ought to have the appropriate attitude in order to change everyday things.

Jordi Varela

Editor

How about the Patient Experience?

David Font

In my previous post, I talked about the formula E = mc2, that is, to achieve excellence (E) we need the commitment of workers (c), trust in the institutional project of the governing bodies and health officials (c from confide) and the appropriate methodological development (m). I would like to delve into the methodology and in particular on the importance of the patient experience when deploying improvement projects and consider it as a priority in the strategic development of our institutions.

The public health system methodically evaluates patient satisfaction which allows us to obtain global information regarding users’ perception. However, we abuse studies that are too general and in which the evaluation differs excessively when it comes to the time dedicated to healthcare. These and other methodological limitations make it difficult to draw conclusions and the possibility of using the information related to the patient's experience as a source of identifying opportunities for improvement is also an element that limited by cultural aspects. To expand on these aspects, it’s interesting to read the articles "The Patient Experience and Health Outcomes" Matthew P et al [1] and "Collecting data on patient experience is not enough: they must be used to Improve care" A Coulter et al [2].

Saving Plans: 5 Errors and 5 Proposals

Remember the games of the analogue times, precisely the moment when the player put the piece in the wrong place and there came a warning sound and the red light lit up the nose? Now it looks like a naff old thing, but I liked that Robert Kaplan and Derek Haas have chosen the image of one of these games, precisely one that is for operating a patient and that they have chosen it to illustrate their article published in the Harvard Business Review blog, "How not to cut health care costs".

When faced with budget cuts, they say, health managers around the world apply the same recipe: reducing staff costs (both in numbers and in wages), optimize the use of space to save general services, stop investments and rationalize spending. The authors do not maintain that this package of measures is poorly done, but they question whether behind these policies there isn’t a strategic way of thinking that combines resources to achieve the best results in the most efficient manner possible and the efforts of the basic savings pack can become counterproductive for the health of people and also for the economy of organizations.

Therefore, we should appreciate that the article analyzes five errors of the basic savings pack, while proposing five alternatives focused on efficiency and effectiveness.