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Superior Quality and Safety through Reform…. … What Successful Organizations Must Accomplish . Despite whatever happens, or does NOT happen in Washington… or Bismarck. Steven M. Berkowitz, MD SMB Health Consulting Austin, TX steve@smbhealthconsulting.com 512-415-6095.

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slide1

Superior Quality and Safety through Reform…

… What Successful Organizations Must Accomplish

Despite whatever happens, or does NOT happen in Washington… or Bismarck

Steven M. Berkowitz, MD

SMB Health Consulting

Austin, TX

steve@smbhealthconsulting.com

512-415-6095

slide2

2012- 2013 Clients- Two Lessons Learned

Every System is unique.

But… Every System is dealing withthe same issues.

slide3

So What’s New in Health Care Reform?

Same old wine in a brand new bottle?

slide5

You can always count on Americans to do the right thing…

  • …after they’ve exhausted all the other possibilities !!”
  • Winston Churchill
slide6

People do not change until the pain of staying the same…

… exceeds the pain of changing.

Anonymous

slide7

The Health Care Team

Medicine is a Team effort….

…..Why do we insist on playing Solo!

slide8

The Health Care Team

Medicine is a Team effort….

…..Why do we insist on playing Silo!

slide9

The Evolution of Health Care Reform

1990’s-- Market Correction

2013-- Market Reconfiguration

slide10

Remember, It’s Not Nice to Fool Mother Nature

Health care must follow the same market rules as all other industries

quality challenges for a ticket to the game
Quality Challenges for a Ticket to the Game

1. Embrace Data Transparency

  • Implement Evidence-based practices
  • Excel at Pay for Performance

4. Add the Secret Sauce !!

quality challenges for a ticket to the game1
Quality Challenges for a Ticket to the Game

1. Embrace Data Transparency

  • Implement Evidence-based practices
  • Excel at Pay for Performance

4. Add the Secret Sauce !!

slide13

Value Based Purchasing

The increasingly informed consumer will make health care decisions on the basis of VALUE

VALUE= Outcomes + Satisfaction

Cost

The CONSUMER ultimately determines which of the above elements constitute VALUE

slide15

This is Your Life !!

Data Transparency in Action

Data Transparency

slide16

Pennsylvania

Coronary Artery Bypass Surgery

2008 - 2009

Released: May 2011

slide19

The New York State CABG Experience

Chassin, Health Affairs, 2002

41% reduction in mortality in first four years

Mortality higher in facilities with low volumes

  • Reduction in hospitals doing CABG
  • Reduction in physicians performing procedures
    • 27 surgeons ceased operations in NY

Their combined mortality was 11.9%

( NY stateaverage 3.1% )

slide20

Wisconsin

QualityCounts

Report on the Safety

of Hospital Care

Released January 2003

slide22

Data Transparency

That which is measured, tends to improve.

That which is measured publicly, tends to improvefaster.

“What we concluded was that even when hospitals know their performance is not good, that's not sufficient motivation for them to do something. Making it public made a big difference in motivating them to improve.”

Judith Hibbard, Health Affairs 2003

slide23

Core Measures:

Heart Attack

Heart Failure

Pneumonia

Surgical Care Improvement

HCAHPS

slide25

Core Measures:

Heart Attack

Heart Failure

Pneumonia

Surgical Care Improvement

HCAHPS

Goal:

100% Compliance !!

Standard of Care ? !!

slide26

Data Transparency and Accountability

Transparency is the best thing that’s happened to quality since antibiotics...

…by decreasing variance and improving results

percent who saw and acted upon the information choice of hospitals
Percent Who Saw and Acted Upon the InformationChoice of Hospitals

Exposure to and Use of Quality Information

Kaiser Family Foundation, October 2008

slide28

If the other guy’s getting better, then you’d better be getting better faster than that other guy’s getting better…

…Or you’re getting worse.

Tom Peters

Change

slide29

Data Transparency and Accountability

Transparency is the best thing that’s happened to quality since antibiotics...

…by decreasing variance and improving results

As transparency matures, it will rewrite the book on:

Who is your competitor?

slide30

The Role of Transparency

Price Transparency

Quality

Transparency

slide31

The Role of Transparency

Quality

Transparency

Price Transparency

slide32

System Strategic Planning

Who is Your Competitor…. The role of Transparency

Stage IV

The whole world ??

Increasing Transparency

Stage III

The entire nation ?

Stage II

All hospitals in North Dakota

Stage I

The “other guy”

slide33

Steve’s Three Rules of Data

1. The data is significant, whether it is significant or not.

2. A low score almost always points to a real issue.

3. The biggest gain in performance improvement occurs when going from NO data to ANY data.

Involve ALL stakeholders in the performance improvement process

slide34

Hospitals and Physicians Working as a Team

Share the Data !

Decreasethe Variance !

slide35

Hospitals and Physicians Working as a Team

Large variances continue to exist amongst physicians and hospitals.

Variances can and do lead to differences in management, treatment, and outcomesfor the patient.

slide36

Hospitals and Physicians Working as a Team

Data, not an Indictment !!

Data isNOTDiagnostic !!

slide37

Hospitals and Physicians Working as a Team

The great majority of “outlying” physicians are good, caring physicians who have developed a particular style of practice which can be improved!

slide38

The Role of Transparency

Quality Transparency:

Improved performance

Decreased variance

Quality

Transparency

Price Transparency

slide39

The Role of Transparency

Price Transparency:

???

???

Price

Transparency

Quality

Transparency

reflections on price transparency
Reflections on Price Transparency

Steve has a URI symptoms and feels bad!Steve has great insurance but a $3,000 deductible

What does he do?

Treatment Options:Approximate*:

Out of Pocket Wait

  • Emergency Department $ 300 2-3 hrs
  • Urgent Care 150 1 hr
  • PCP visit 120 1 hr (if available)
  • Local Pharmacy 80 30 min
  • Self Treat.. rest, OTC meds... 10 ? none

* The actual cost may not be known until the evaluation is completed

what steve does not need to know
What Steve Does Not Need to Know
  • The physician’s reimbursement for the visit
  • The nurses reimbursement for the visit
  • The cost of his treatment to the institution
  • Any other contractual relationships
    • Physicians
    • Vendors
    • Any other arrangements with the insurance company

Just tell me: How Much Do I Need to Pay !!

slide42

Questions for the Leadership Team

Does your organization…

… embrace data transparency ?

quality challenges for a ticket to the game2
Quality Challenges for a Ticket to the Game

1. Embrace Data Transparency

2. Implement Evidence-based practices

  • Excel at Pay for Performance
  • The Secret Sauce
slide44

Implementing Evidence-Based Medicine

What Can we Learn from the Airline Industry ?

slide46

Where Do We Find the Best Practices ?Examine Your Own Specialty Literature

Implement the Guidelines Recommended

by your OWN Specialty Society

slide47

Guidelines for Guidelines

There will be MORE guidelines in clinical medicine

Guidelines wereNEVERintended to apply to all patients and do NOT

take the place of individual physician judgment

Expect physicians to occasionally deviate from guidelines in the daily

practice of prudent medical care

When so…

… DOCUMENTIn the medical recordthat:

The patient was seen and evaluated

The options were thoughtfully considered

The best clinical judgment was used

Discussed with the patient

Don’t DEVIATE from the guidelines !!

degani and weiner 1993
Degani and Weiner 1993

What Can we Learn from the Airline Industry ?

Elimination of Ambiguity

“the eliminationofambiguityis consistently cited

as a key factor in protocol success and safety”

Most medical guidelines are based upon ambiguity as a guiding principle of protocol development

oxytocin treatment guidelines acog 2006 compendium

Example

Oxytocin Treatment GuidelinesACOG 2006 Compendium

“Any of the low or high dose regimens

outlined in table 2 are appropriate”

(0.5 – 6 mU/min every 15-40 min)

“Each hospital’s OB/Gyn department should develop guidelines for preparation and administration of oxytocin”

“The uterine contractions and fetal heart rate should be monitored closely”

postdates guidelines acog 2006 compendium

Example

Postdates GuidelinesACOG 2006 Compendium

“ Women with post-term gestations who

have unfavorable cervices can either

undergo labor induction or be managed expectantly”

“Delivery should be effected if there is evidence of fetal compromise….”

slide51

How to Land a 747 in a Strong Cross Wind *

*( Had it been Written by ACOG)

  • Use any settings of the plane’s

instruments you feel like

  • Every airline and pilot can do it

differently

  • Be really careful as you get close to

the ground Steve Clark, MD

slide52

Do Guidelines Help or Hurt?

“Yeah, but Pilots do not have to worry about Malpractice Suits”

Obstetrician, Texas

slide53

Adverse

Outcomes

evidence based

guidelines

Adverse

Outcomes

Do Guidelines Help or Hurt?

  • We keep missing the point….. Simply put…

Evidence-based guidelines:

reduceadverse outcomes !

improve patient care!

slide54

Questions for the Leadership Team

Does your organization…

…implement best practices ?

quality challenges for a ticket to the game3
Quality Challenges for a Ticket to the Game

1. Embrace Data Transparency

2. Promote Evidence-based practices

  • Excel at Pay for Performance
  • Add the Secret Sauce !!
job one
Job One !!

There will be a focus on Cost Control like we have NEVER seen before in our careers

slide57

Enterprise Wide Cost Reduction

Job One !!

Today’s Health Care Costs

Admin

Cost Reductions

Post- Reform Health Care Costs

Other

?????

Rx

Any decrease in health care expenditures is a paycut for somebody in health care !!

Hospital

Physician

goal 20 total cost reduction

Total Cost of Care- Hospitals

Goal: >20 % Total Cost Reduction

Maximum opportunity !

Minimal

Opportunity

More

Opportunity

slide59

The Goal: Drive from Point A to Point B

Cost Reduction Strategies

Road – 200 miles

Point B

Point A

Variables:

1. The cost of gas

2. The cost of the car

3. The cost of lunch on the way

Cost Reduction Strategy:

Negotiate better gas price

Get a cheaper car with better MPG

Eat at a fast food place

slide60

The Goal: Drive from Point A to Point B

What We Did NOT Consider

Road – 200 miles

Point B

Different Road – 100 miles

Point A

Variables:

1. The cost of gas

2. The cost of the car

3. The cost of lunch on the way

Cost Reduction Strategy:

Half the amount of gas needed

Get a cheaper car with better MPG

Arrive before lunch

slide61

The Goal: Drive from Point A to Point B

Maybe We Can’t Get There from Here

Road – 200 miles

Point B

Different Road – 100 miles

Point A

The best solution for cost reduction may be to get a better process, not necessarily reduce each individual unit cost of the existing process

slide62

CMS Pay for Performance

CMS Pay for Performance

Hospitals

Physicians

slide63

CMS Pay for Performance

What Pay for Performance is NOT:

  • A increase in revenue
  • A break-even with revenue

What Pay for Performance IS:

  • A way to partially recoup some of the REDUCTIONS we will see in revenue
slide64

CMS Pay for Performance

What Pay for Performance is NOT:

  • A increase in revenue
  • A break-even with revenue

What Pay for Performance IS:

  • A way to partially recoup some of the REDUCTIONS we will see in revenue

Core Measures

HCAHPS

Re-admissions

Hospital Acquired Conditions

Meaningful Use

slide65

CMS Pay for Performance

What Pay for Performance is NOT:

  • A increase in revenue
  • A break-even with revenue

What Pay for Performance IS:

  • A way to partially recoup some of the REDUCTIONS we will see in revenue

5 – 10 % of Total Medicare…

Or more !!

Core Measures

HCAHPS

Re-admissions

Hospital Acquired Conditions

Meaningful Use

slide66

CMS Pay for Performance- Physicians

  • In 2015, CMS will begin applying a value modifier under the Medicare Physician Fee Schedule
    • Quality
    • Cost
    • Value of Care
  • By 2017, this modifier will be applied to all physicians who bill medicare for services
  • 1.5% at risk in 2015
  • 2% in 2016 and beyond
reasonably preventable an example from the auto repair shop
Reasonably PreventableAn Example from the Auto Repair Shop

You take your car in to get the brakes fixed.

While fixing the brakes, the repairman accidentally punctures the tire with the tire iron.

You now receive the following bill:

Bill for Services:

Fixing Brakes: $ 300

Repairing Tire: $ 200

Total Due: $ 500

Pay for Performance

the lake wobegon paradox pay for performance
The Lake Wobegon ParadoxPay for Performance

Can all hospitals in the U.S. be in the top decile?

Can we all be 5-stars?

What do we do?

hospital acquired conditions
Hospital Acquired Conditions

Going from knowncomplication…..

….. to known complication.

NO

Pay for Performance

slide71

Surgical Consent Form….

Death

Stroke

Heart Attack

Emergency Surgery

Infection

Bleeding

Allergic Reaction

Nerve Damage

Renal Failure ….

perfection is unattainable but if we chase it we can catch excellence vince lombardi
Perfection is unattainable. But if we chase it,

we can catch excellence.

Vince Lombardi

Change

Change

slide73

Questions for the Leadership Team

Will your organization…

…excel at pay for performance?

quality challenges for a ticket to the game4
Quality Challenges for a Ticket to the Game

1. Embrace Data Transparency

2. Promote Evidence-based practices

3. Prioritize Communication Skills

4. Add the Secret Sauce !!

slide75

Mapping

Hardwiring

Manufacturing

Process

The Disconnect between Process and Outcome

What’s Missing ?

Outcome

slide76

Mapping

Hardwiring

The Disconnect between Process and Outcome

What’s Missing ?

X

Clinical

Process

Outcome

slide77

Mapping

Hardwiring

The Disconnect between Process and Outcome

What’s Missing ?

X

Clinical

Process

Outcome

What’s Missing ??

slide78

Mapping

Hardwiring

The Disconnect between Process and Outcome

What’s Missing ?

X

Clinical

Process

Outcome

Patients are NOT Toyotas !

slide79

Mapping

Hardwiring

The Disconnect between Process and Outcome

What’s Missing ?

Incomplete

Medical Knowledge

X

Clinical

Process

Outcome

(P) Poor Protoplasm

slide81

Mapping

Hardwiring

The Disconnect between Process and Outcome

What’s Missing ?

Incomplete

Medical Knowledge

X

Clinical

Process

Outcome

(P) Poor Protoplasm

slide82

Mapping

Hardwiring

The Disconnect between Process and Outcome

What’s Missing ?

Incomplete

Medical Knowledge

TheHUMAN

Element !!

X

Clinical

Process

Outcome

(P) Poor Protoplasm

the secret sauce the human element

TheHUMAN

Element !!

The Secret Sauce:The Human Element

…More than HCAHPS (although a great start !)

…more than “touchy -- feelie”

…beyond Information Technology fixes

The Human Element

Communications

Relationships

Valuing the HUMAN side of Medicine

slide84

A Brief Digression….

1620- Somewhere in the Atlantic.…

questions for the leadership team
Questions for the Leadership Team

Does your organization…

…value the Human side of medicine?

TheHUMAN

Element !!

quality challenges for a ticket to the game5
Quality Challenges for a Ticket to the Game

1. Embrace Data Transparency

  • Implement Evidence-based practices
  • Excel at Pay for Performance

4. Add the Secret Sauce !!

who benefits
Who Benefits?

The Patient !!

slide88

Data Transparency

Evidence-Based

Medicine

Twelve Challenges for 2014

Pay for Performance

Put it all Together:

Are You Ready for the Game !!

slide89

Data Transparency

Evidence-Based

Medicine

Twelve Challenges for 2014

Pay for Performance

Put it all Together:

Are You Ready for the Game !!

We Still Have Time !!!

are you ready for the game twelve challenges for 2014
Are you Ready for the Game ??Twelve challenges for 2014
  • It’s the Cost, stupid !!
    • Cost control will be more critical than ever before
    • Any reduction in health care COST is a reduction in someone’s REVENUE
    • Can you be “cost-neutral” with Medicare/ Medicaid within 3 years?
are you ready for the game twelve challenges for 20141
Are you Ready for the Game ??Twelve challenges for 2014
  • Define and Excel in your Core Business
    • You cannot be all things to all people
    • Critical services and service lines must be defined
    • These must be prioritized on the basis of community need and operational feasibility
    • VALUE has to be demonstrated for each service area with public data
are you ready for the game twelve challenges for 20142
Are you Ready for the Game ??Twelve challenges for 2014
  • Turn data into useful information
    • The data is significant whether it is significant or not
    • A lower rating usually points to a real problem
    • Anticipate upcoming clinical measures and develop care improvement processes early
    • Clinical data is driven by physician documentation
      • A “good” doctor that does not document well is not a “good” doctor
are you ready for the game twelve challenges for 20143
Are you Ready for the Game ??Twelve challenges for 2014
  • Compliance with core measures is the StandardofCare
    • 100% compliance is to be expected
    • Variances are issues for peer review
are you ready for the game twelve challenges for 20144
Are you Ready for the Game ??Twelve challenges for 2014
  • Anticipate the continued growth of pay for performance
    • Complications considered preventable will be notbereimbursed
are you ready for the game twelve challenges for 20145
Are you Ready for the Game ??Twelve challenges for 2014
  • Go from Known Complication to NO Complication
    • View a hospital complication as industry views an industrial accident
    • Set a goal/ benchmark of ZERO
    • Never be “too old a DOG to learn a new trick!!”
are you ready for the game twelve challenges for 20146
Are you Ready for the Game ??Twelve challenges for 2014
  • Good information technology systems are essential
    • Every system must develop and execute an IT strategy
    • Successful systems must communicate
      • Hospitals
      • Physician to physician
      • Ancilliaries
    • Take full advantage of “Incentives” for “Meaningful Use”
are you ready for the game twelve challenges for 20147
Are you Ready for the Game ??Twelve challenges for 2014
  • Lose the “I don’t do cookbook medicine” mentality
    • Learn from the success of other industries
    • Evidence-based clinical guidelines improvecare
    • Guidelines were never intended to apply to all patients
are you ready for the game twelve challenges for 20148
Are you Ready for the Game ??Twelve challenges for 2014
  • There’s no more room for individual players !!
    • SYSTEM solutions trump INDIVIDUAL solutions
    • Successful organizations need to learn to manage some risk
are you ready for the game twelve challenges for 20149
Are you Ready for the Game ??Twelve challenges for 2014

10. Implement Best Practices in All Service Lines

  • Best practices decrease adverse outcomes
  • Avoid the temptation to “tweak” the guidelines
are you ready for the game twelve challenges for 201410
Are you Ready for the Game ??Twelve challenges for 2014

11. Excel at Pay for Performance

  • As much as 5-10% of all Medicare reimbursement can be at risk
  • Successful performance in P4P may be the ONLY way to remain profitable in Medicare/ Medicaid
are you ready for the game twelve challenges for 201411
Are you Ready for the Game ??Twelve challenges for 2014

12. Value the Human side of Medicine

  • You ARE the Mayflower !!
  • Demand SEAMLESS transitions of care
  • Emphasize communication and relationships

TheHUMAN

Element !!

to the world you may be just one person but to one person you may just be the world unknown
To the world you may be just one person,

But to one person you may just be the world.Unknown