pinnaclesYou CAN get there from here!

Imagine being on a precarious rocky pinnacle with sheer cliffs plunging all around you. Yet, off in the distance is a much taller mountain range dwarfing the height where you stand. I think this is a metaphor for the journey towards improved health care quality, in general and especially for older adults. As a country we have climbed up a peak of high tech fragmentation, super specialized workforce, and fee-for-service payments that incent procedures rather than outcomes. And while we are not on top of the world, it sure is a long way down if we take the smallest wrong step.

We are living in a system where the quality of care is not adequate, particularly for those with complex chronic conditions who need coordination, education, behavior change, and caring. Worse the pinnacle where we stand is actually falling apart and bits and pieces are sliding into the abyss around us - the failures of quality and value that will only become worse as the population ages and the burden of complex chronic disease becomes more acute. Our pinnacle is crumbling, but we are almost paralyzed by the fear of losing what we still have if we try to make it to those distant heights.

In this week's New Yorker, Atul Gawande describes a similar paralyzing crisis in the agricultural sector at the beginning of the 20th century. (Testing, Testing - December 14, 2009 .) As he did for aging and geriatric medicine in his 2007 piece The Way We Age Now , in this article Dr. Gawande really captures the key issue of transformational change in health care. His telling of the story of Seaman A. Knapp and the United States Department of Agriculture's extension service's efforts to improve the efficiency of farming is very exciting. As an analogy for health care, it offers the hope that we CAN get to those higher mountains where health care is safe, effective, patient centered, coordinated, health promoting, and all the other things we want.

The "extension service" in health care stands for all the resources and infrastructure that is needed to support change. We do need real extension agents who can go to practices, hospitals, and communities and organize and encourage change. We also need a payment, regulatory, and educational system that makes change possible. I believe that creating such a sound infrastructure is essential if we as a society are to get the quality and value from health care that we all want. In another post, I have offered a "declaration of innovation" that outlines the fundamental principles for a system that adapts and changes on the way to higher levels of performance.

knapp-arch-smallDr. Gawande gives deserved credit to Mr. Knapp, the founder of the agricultural extension service. For all of us who have been committed to the development and spread of innovation, Knapp has long been a hero. He actually has a "triumph" in Washington. Down on the south side of the mall, there is a Knapp Arch dedicated to his contributions to transformational change.

If we are on a hike in dangerous mountains of health care, we need a Sherpa like Knapp to help us get there.