Imagining the future of health care.

Competition is coming. And it will improve health care enormously.

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In the unforgiving light of changing payment systems that give consumers unprecedented power to choose, new transparencies will emerge that hand out institutions' true prices and safety records to potential customers, and new competitors will strive to entice patients across town, across the country or around the world.

All health care organizations will soon be forced to unimagined levels of cost-effectiveness, quality and customer cosseting.

What would it take to build health care organizations and systems that were as reliable as FedEx? That were as customer-friendly as the Ritz Carlton? That had the transactional accuracy and speed of American Express?

"What would it take," as one hospital executive asked me recently, "for a discharged hospital patient to say, 'Now, that was a pleasure'?"

Is this possible? Absolutely.

Some people complain that such expectations are "unrealistic." The human body is not a machine, they say. It's not a stack of numbers. Diseases can be mysterious, people's lives are complex and the information they give you is incomplete and sometimes false.

True.

And because people are not crystalline, it is unlikely that health care will ever approach the "Six Sigma" perfection for which many industries strive--3.4 defects out of every million opportunities.

Still, it is absurdly likely that we can do better than we are doing now. When Beth McGlynn and the Rand Corporation set out three years ago to use normal industrial process measurement techniques to build "The First National Report Card on Quality of Health Care in America," (published in the New England Journal of Medicine, 2003, 348.), they found a "defect rate"" in U.S. health care not of 3.4 per million, or thousand, or even hundred, but of 45 per hundred.

According to this report, using accepted medical guidelines, when you enter the U.S. health care system you have a slightly better chance than a toss of the coin that you will get a correct diagnosis and a correct treatment regimen correctly applied.

Add to that defect rate the unconstrained cost inflation at nearly every stage of the health care supply chain and system transaction costs that exceed 25 percent.

Top it off with a customer blindness that led legendary Dr. Hook rock guitarist Rik Elswit--who struggled with cancer for years--to comment to me recently, "I don't see why, just because I was sick, they had to treat me like a prisoner."

What can we imagine that this "next heath care" will be like?

First, think of health care, for the moment, as a vast system of transactions from patient intake and appointment management to tests ordered, pharmaceuticals delivered, patients followed up.

Imagine a system that made every transaction as error-free as possible, that in fact, in its million details, made it as difficult as possible to make a mistake just as a commercial airliner cannot take off, or a city bus cannot leave the curb unless the doors are closed because of mechanical interlock systems.

One tiny example in health care--networked automatic infusion pumps that require bar-code scans of patient, drug, and nurse, that will not work unless the patient, drug, and time data match the programmed regimen for that patient.

The pumps also have programmed "soft bumpers" that keep doses within guidelines unless overridden, plus "hard bumpers" that prevent lethal doses--from misplaced decimal points (for instance)--and allow no overriding.

Finally, the pumps have network capabilities that allow a nurse administrator to track outliers by patient, by shift, by floor, by individual nurse.

A simple, low-tech example has become common in surgery. During the pre-surgery examination, surgeons often draw their incisions with heavy indelible markers on the part to be cut, so that they will amputate no limb before its time.

Similarly, many hospitals, rather than depending on the surgeon to remember to order them, have standing orders for perioperative antibiotics, with some kind of checklist procedure to make sure that no patient enters the operating room without them.

Imagine that kind of thought and fail-safe design put into every transaction in the system. In fact, imagine a system that is automated wherever possible. Rather than looking for a return on each automation investment within the particular transaction, look for the return on investment (ROI) across the system in cost-effectiveness, quality and customer-friendliness.

For instance, it's hard to find a positive ROI for a PACS digital image-handling system within the transaction itself. But look across the system, and you find it reducing messenger and storage costs, easing clinicians' workflow, reducing the possibility of error through mislabeling of images, and making customers happy because they don't have to come back next Wednesday when the images are available.

When Northwestern University Medical Center in Chicago automated its lab, it dropped the human handling steps from 14 to 1.5, and the turnaround time from eight hours to 90 minutes.

The cost, including amortizing the automated equipment, dropped by 30 percent, largely because of a drop in personnel costs per transaction. And the error rate went to zero--since they installed the system, they have not discovered an error.

Imagine a system at which every opportunity minimizes handoffs, whether in human or automated systems. Every handoff introduces the possibility of error. Every handoff evaporates the possibility of a single mind seeing the situation whole.

A friend of mine nearly died from handoffs. He went into a major teaching institution in Toronto for a minor operation and caught a nosocomial infection whose overall progress over weeks of home nursing care, readmissions and tests was never fully recognized until he went into shock.

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In three weeks, 10 different doctors treated him. The doctors did not communicate except through the medical record--which was imperfect, and which the doctors did not read fully (since some of them did not know items that were in it).

And he never once saw the same nurse from one shift to the next. No single nurse could easily notice the contradictions between one doctor's orders and another's, and no single mouth could say, "Wow, you have really gotten worse since yesterday."

The case is a classic example of a system in which the convenience of the providers dictates frequent and imperfect handoffs that put the patient at risk.

Imagine a system in which every design decision, from the placement of vents to the color of the walls explores a wide array of concerns such as:

* What is the clinical best practice?

* What will facilitate the staff's workflow and their interaction with patients?

* What will save steps?

* What will reduce stress?

* What is more beautiful?

* What do patients really want?

Over the years, the story has been repeated: The building or renovation that cost millions, looks gorgeous, and is useless to the staff and patients.

One new psychiatric lockdown facility was built without staff input and never shown to them until the day of the grand unveiling when the staff said, unanimously, that they would never work in it? Why?

The architect, for aesthetic reasons, had designed the halls with curves that the staff could not see around, not something you want in a psychiatric lockdown.

Griffin Hospital in Derby Conn., got a surprise when it did focus groups for a new wing. Clinical studies show clearly that private rooms have better outcomes, with less stress, less noise, more privacy, and especially lower infection rates.

And everyone in the design group would clearly prefer a private room. But focus groups told them that a significant fraction of the population, especially older people, said that they would feel less isolated and afraid in a semi-private room with one other person.

So they built a portion of the rooms L-shaped, with the beds in the legs of the L and a bathroom between, to allow a semi-private room with a maximum of privacy and a minimum of paths crossing.

Imagine a health care system in which every encounter is as respectful, as kind, as supportive as possible. Opportunities to build a better patient relationships are as common in health care as postcards in Yosemite.

Some are clinical, such as proper ventilation, doctors and nurses washing their hands between patients and someone actually responding to the nurse call button. The No. 1 cause of accidents in hospitals is patients struggling out of bed, alone, to go to the bathroom because no one showed up to help them.

Others are about simple dignity: providing hospital gowns with Velcro closure tabs or straps, for modesty, answering telephones by the third ring, knocking before entering a hospital room, telling the patient who you are and why you are there when you enter.

To make these imaginings real, we have to think that we will take apart every single process in the hospital, no matter how tiny, and imagine how we could do it better, faster, cheaper, more beautifully, and with greater compassion.

We have to imagine not only doing this within our own walls, but working with our suppliers, payers and regulators, persuading, cajoling, modeling, negotiating, and sometimes forcing them to do the same thing to build the next health care today.

Joe Flower is a nationally known health care futurist and CEO of Imagine What If, Inc., which is building the new online world for health care executives, the Healthcare Futures Exchange. He can be reached at [e-mail]