From Repair to Transformation: The Healthcare Quality Revolution

1. From Repair to Transformation: • The Healthcare Quality Revolution Karen Wolk Feinstein,PhD President & Chief Executive Officer Investing in Health Care Quality and Patient Safety Grantmakers In Health June 13, 2011 Spreading Quality, Containing Costs.

2. “A Think, Do, Train and Give Tank” • A public charity with two supporting organizations • Pittsburgh Regional Health Initiative (PRHI) • Health Careers Futures (HCF)

3. Staff and Functions • Think • Researchers • Data analysts • Communications, media, writers • Policy analysts • Evaluators • Give • Program officers • Grant managers • Fiscal agents for HIV/AIDS funds • Accounting • Do • Program directors • Event planners • Trainers • Grant writers • Web designers • Public relations • Train • Curriculum developers • Coaches and trainers 40+ Staff

4. Phase One: 1997 to 2001 Pre-IOM Reports

5. What and Why: PRHI • Pittsburgh Regional Health Initiative (PRHI) • A not-for-profit, regional, multi-stakeholder coalition formed in 1997 • An initiative of a business group, the Allegheny Conference on Community Development • PRHI’s message • Dramatic quality improvement (approaching zero deficiencies) is the best cost-containment strategy for health care

6. The Persistence ofMedical Errors in U.S. Adapted from Milliman: The Economic Measurement of Medical Errors, June 2010

7. Toyota/Lean Production Thinking: The Basics • Problems identified and solved • Rapid root cause analysis • Organized work areas • Concise communication • Active involvement of managers • “Go and see” • On the floor • Intense respect for the employee: • Every employee has what they need, when they need it to succeed • Career development • Team problem solving to meet customer need

8. What We Observe in Health Care W. Edwards Deming, PhD: “Where Art Thou?” • Chaos • Uncertainty • Random Behaviors • Work-Arounds • Confusion • Disorder • Errors • High Turnover • Secrecy

9. PRHI’s Prescription for Transformation NOW FUTURE Services That Add Value Preventable Complications Unnecessary Treatments 40% Waste All Services Add Value Inefficiencies Errors 100% Value 60% Value

10. The Journey: From Vision to Innovation PPC in New Technologies and New Models PPC for Systems Transformation Increasing Value with Each Step PPC for Organizational Transformation PPC for Repairs A Method for Perfecting Patient CareSM (PPC) An Early Vision for Perfecting Care

11. Where Value Derives • THE PATIENT • Outcomes of Care • Efficiency of Care • Zero Defects Value begins at the front line where patients receive care

12. Our Method: Perfecting Patient CareSMPRHI’s Unique Brand of Quality Improvement • Adapted from Lean • Patient-focused systems redesign • Can be applied in the course of everyday work • The ultimate goal is perfection

13. Phase 2: 2001 to 2008 QI in Acute Care

14. A Defining Initiative:Reducing Hospital-Acquired Infections • 30+ hospitals participating in PRHI’s community-wide infection control project reported an average 68 percent reduction in CLABs overfour years • Results varied among institutions • The Power of Perfecting Patient CareSM: one hospital virtually eradicated CLABs from its main intensive care units

15. The Champion Role in Transformation PPC empowers frontline staff…and more Physician Champions Nurse Navigators Long-term Care Workers Patient Safety Fellows Nurse Managers Salk Fellows Team Leaders Clinical Pharmacists Librarians Hospital Trustees Caregivers Emergency Medical Technicians

16. Perfecting Patient CareSM (PPC) Training Where We’ve Taught

17. PRHI Stories of Success in Acute Care 68% Drop in CLABs in 34 regional hospitals 35 to Zero! defective charts 50% Fewer Readmissions w/ COPD focus 50% Reduction in pap smear sampling defects 17% Drop in pediatric clinic wait times Efficiency Increased 100% in pathology lab 180 to Zero! Lost patient hours per month due to ambulance diversions >20% Decline Nosocomial C. difficile infections 100% Compliance w/guidelines & aspirin use in a diabetes clinic 100% Reduction in nurse turnover 86% Reduction in medication errors

18. Our Methods and Successes Have Attracted Attention

19. Phase 3: 2009 and On Post ACA: Managing Complex Patients

20. The Second Systems Vision: Transforming the Care of Complex Patients Informed Activated Discerning Consumers Data to Treat,Measure,Evaluate Collaboration and Integration Perfect PatientCare Rewards for Collaboration Across Care Settings Medication Reconciliation Screening and Tx Essential Services System Requirements Hospice/Palliative Long Term Care Rehab Hospital Emergency Services Specialty Care Primary Care Care Mgt Patient Engagement Health IT QI Training Payment Incentives Clinical Pharmacy Behavioral Health

21. What is essential to our vision for reducing readmissions? Isn’t reimbursed

22. The Complex Patient Who is frequently hospitalized? Do you know your customer? Are you meeting their need?

23. Let the Data Guide Work The Complex Patient Skilled Nursing Chronic Disease (COPD) Behavioral Health and Substance Abuse Multiple Conditions PRHI Current Project HIV/AIDS End of Life

24. The Solution Coordinates Transition Between Hospital and Community COMMUNITY HOSPITAL Patient is discharged WITH training in use of inhaler Improvedpatient educationandsupport*in thecommunity Patient educationto addresscauses of admission Patient uses inhaler properly, leading to improved functioning *Care Mgt Clinical Pharmacy Patient Engagement Behavioral Health + + +

25. COPD Readmissions Reduction Results By focusing on the transitions between care settings: • 30 readmissions prevented • $160,000+ saved • Net savings of $80,000+ after cost of Care Manager 44% Reduction PRHI Current Project

26. AHRQ Grant: Partners in Integrating Care $3.5 million from AHRQ to disseminate and implement behavioral health services in primary care settings PRHI Current Project

27. PRHI’sAccountable Care Network in Pittsburgh PRHI Current Project

28. Closure / End of Life “Closure” is a 5-year initiative approved by the JHF Board in 2008 to change expectations for end-of-life. Our goal is to empower consumers and healthcare professionals with easy-to-access, simple-to-understand information and resources to make educated decisions about end-of-life care PRHI Current Project

29. Reducing Preventable Hospitalizations:PPC in Skilled Nursing Facilities (SNFs) • 6% of seniors in SNFs = 17+% of healthcare costs • 20% of hospital patients discharged to a SNF were readmitted • 51% of residents have one or more ER visits • 38% have a hospitalizations: 41% are readmitted • Kaiser Family Foundation data Long Term Care Champions PRHI Current Project

30. Disruptive Innovations • Simple, less expensive, “upstream” innovations • Serve more with fewer features • Do not overshoot customer need • Show better understanding of customer need

31. “Training dosage had most important effect on measures of success. A combination of PPC training, additional training, and coaching were associated with improved outcomes. Social networking or on-line technology can foster a virtual PPC community.” - Donna O. Farley, PhD RAND: Results from the Retrospective Evaluation Effects of PPC University Training The Technology Innovation

32. Tomorrow’s HealthCare™ Spreading & Sustaining Change PRHI Current Project

33. Summary of Good Investments

34. The Current Agenda For the Patient, it is care that is kind, competent, customized, comprehensive, safe and efficient; addressing the needs of vulnerable populations, including: • Seniors (Caregiver Champions) and Long Term Care Champions • The poor (Safety Net Medical Home Initiative) • The chronically ill (Accountable Care Network) • Those who are approaching End-of-Life (Closure) • Persons living with behavioral health problems (AHRQ grant), and persons living with HIV/AIDS (Readmissions Reduction project)

35. The Current Agenda (cont’d) For the Healthcare Worker, it means that care is: • Informed and supported (Regional Extension & Assistance Center for HIT) • Incentivized (Robert Wood Johnson Foundation payment reform grant and the Fine Awards) • Prepared by training and coaching (Perfecting Patient CareSM, Tomorrow’s HealthCareTM, PPC University, Fellowships and Champions Programs)

36. The Current Agenda (cont’d) For Organizations and Systems, this focus includes: • Training, coaching and leadership development (Perfecting Patient CareSM) • Comprehensive improvement and education tools (Tomorrow’s HealthCareTM) • Transformations and new models of care (Patient Centered Medical Homes, Accountable Care Networks, Primary Care Resource Centers) • Payment Reform (Robert Wood Johnson Foundation payment reform grant and the website The Center for Healthcare Quality and Payment Reform— www.chqpr.org)