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The Business Case for Quality How Some Have Created Systems for Rapid and Effective Change

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The Business Case for Quality How Some Have Created Systems for Rapid and Effective Change

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    1. The Business Case for Quality How Some Have Created Systems for Rapid and Effective Change Maureen Bisognano Scottish Patient Safety Programme Masterclass 28 September 2009 Edinburgh

    2. Tom Nolan and I Were Curious to Know Could we find organizations that were excellent in multiple measures? Could some organizations move more than one system level measure in a year, and year on year? What is their method for improvement? What are their leadership processes?

    4. Framework: Leadership for Improvement

    5. Measures of System Performance Actual HCAHPS questions: “Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?” (Q21) “Would you recommend this hospital to your friends and family?” (Q22) Actual HCAHPS questions: “Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?” (Q21) “Would you recommend this hospital to your friends and family?” (Q22)

    8. Mercy Medical Center Location: Cedar Rapids, IA Timothy Charles EVP/COO of Mercy Medical Center and President of Mercy Care Management in July 2003 President & CEO of entire organization since 2007 305 staffed beds 1,751 FTE’s 5% Medicaid admissions

    10. Mercy Medical Center Aaa “gilt edged” Aa1 Aa2 high grade Aa3 A1 A2 upper-medium grade A3 Baa1 Baa2 medium-grade Baa3

    11. Patient-Centeredness at Mercy All rooms are private and all rooms are universal Open visiting hours Liberalized diet with 24-hour room service menu Patient-centeredness is “an obsession, from the Board to the front-line, and the family is part of the system”

    13. Lean All rooms are same-sided; equipment and supplies are in the same place in every patient room Flow and zones for caregivers, patients, and families are clear and built into the designs

    15. Multidisciplinary Team Rounds (Monday through Friday) with the physicians, nurses, dieticians, social workers, palliative team, pastoral care, and therapists Team-based care on all units Dieticians and quality and outcome research staff are located on the unit

    17. System Connections Patient flow and care design built from pre-hospital through recovery period Door-to-balloon time decreased from 128 minutes to 48 minutes Length-of-stay for joint replacements = about 2 days Palliative care with community includes new hospice

    18. Technology Effectively used to support front-line staff (nurses at the bedside) Links physicians and staff remotely for direct patient visual and vital-sign monitoring

    20. Predictions Mission-driven, cohesive executive team Strategic plan focused on quality, value, and financial stewardship Strong relationships among administration, nursing, and medical staff Investment of time by senior people to lead initiatives emerging from the strategic plan

    21. Predictions: Mostly Accurate Mission-driven, cohesive executive team Strategic plan focused on quality, value, and financial stewardship Strong relationships among administration, nursing, and medical staff Investment of time by senior people to lead initiatives emerging from the strategic plan

    22. What We Found Relative to Predictions Surprises All but one are part of larger hospital systems Boards very involved in quality measurement, aim-setting, and implementation Focused on the work, not the improvement methods Addition of hospitalists and/or intensivists was associated with discrete improvement in HSMR Standardization through the use of guidelines and protocols has been integral to success Bold aims, awareness of the data, and general dissatisfaction with performance Fast tempo for review of quality data and a strong bias toward action — “we meet, evaluate, decide, and do” Multidisciplinary approach at all sites on all problems Do these show up anywhere now?? - Finance and operations are linked - The physical environment matters Do these show up anywhere now?? - Finance and operations are linked - The physical environment matters

    23. Today’s Reality “Several months ago, I wrote about what it is like to construct a budget for a hospital like ours. Well, all that careful planning goes out the window when the economy tanks the way we have seen in the last few months.” (Paul Levy, Running a Hospital;http://runningahospital.blogspot.com/)

    24. Drivers for Urgent Attention to the Business Case for Quality Care

    25. Changes in the US Payment Environment Recent reimbursement changes at Centers for Medicare and Medicaid Services (CMS) dictate that certain preventable conditions, when not present on admission, are not eligible for reimbursement: Object left in surgery Air embolism Blood incompatibility Catheter-associated urinary tract infections Pressure ulcers (decubitus ulcers) Vascular catheter-associated infections Mediastinitis (surgical-site infection between the lungs after CABG surgery) Injuries from falls and other “external causes” (e.g., fractures, dislocations, intracranial injuries, crushing injuries and burns) Surgical-site infections following certain orthopedic surgeries and bariatric surgery Extreme blood sugar derangement Deep vein thrombosis / pulmonary embolism

    26. National Priorities Partnership Waste Driver Diagram

    27. Waste Reduction Targets for National Priorities Partnership* *A partnership between the National Quality Forum and 28 other organizations

    28. Drivers for Urgent Attention to the Business Case for Quality Care

    29. New Ideas for the Senior Team Set a waste reduction target of 1-3% per year, year on year Develop new models of care that increase satisfaction, improve outcomes, and lower costs Use “disruptive innovations” to design care for new patient populations Develop new payment methods that provide “win-win” and emphasize value

    30. Noriaki Kano’s Three Levers for Improving Value

    31. (Kano 1) Case Study From Richard Shannon, MD, Chair-Department of Medicine Hospital of the University of Pennsylvania 37 year old video game programmer, father of 4, admitted with acute pancreatitis secondary to hypertriglyceridemia. Day 3: developed hypotension, and respiratory failure Day 6 : fever and blood cultures positive for MRSA secondary to a femoral vein catheter in place for 4 days. Multiple infectious complications requiring exploratory laparotomy and eventually tracheostomy Day 86: Discharged to nursing home

    32. The Losses Attributable to CLABs are Staggering Average Payments: $64,894 Average Expense: $91,733 Average Loss from Operations: -$26,839 Total Loss from Operations:-$1,449,306 In only 4 cases did the hospital make money! The cost of the additional care averaged 43% of the total costs of care Average LOS: 28 days (7-137) Only three patients were discharged to home. This summarizes our experience with respect to the economic impact of CLABs on our operating performance. This is just two ICUs!!This summarizes our experience with respect to the economic impact of CLABs on our operating performance. This is just two ICUs!!

    33. CCU/MICU and HAI A Big Return on Investment Total Operating Improvements CLAB= $1,235,765 (2 years) VAP= $1,003,162 (1 year) MRSA= $ 295,342 (1 year) Highmark PFP = $3,100,000 (2 years) HAI elimination Initiatives = +$5,634,269 Investment = $85,607 388 additional ICU admissions 57 lives saved To date in the CCU and MICU, we have saved $2.2 million by reduce CLABs and VAPs by 80-90%. We received a bonus payment from our largest payer for the work, meaning that The HAI effort in the CCU and MICU represents a $4.3 million improvement. The overall improvement has cost a mere $34,927! Thus, the HAI Elimination effort is now one of the most profitable cost centers in Medicine!To date in the CCU and MICU, we have saved $2.2 million by reduce CLABs and VAPs by 80-90%. We received a bonus payment from our largest payer for the work, meaning that The HAI effort in the CCU and MICU represents a $4.3 million improvement. The overall improvement has cost a mere $34,927! Thus, the HAI Elimination effort is now one of the most profitable cost centers in Medicine!

    34. Noriaki Kano’s Three Levers for Improving Value

    35. Inefficiency Waste Imagine two side-by-side processes with identical inputs, and identical outputs. Now imagine that one of the two processes uses fewer resources (more efficient). Which one would you use?

    36. Inefficiency Waste At Intermountain, quality, utilization, and efficiency (QUE) studies in six clinical areas revealed more than 100% cost differentials from one case to another. A protocol (process stablization) that reduced the time on a ventilator for patients recovering from open-heart surgery from an average of 25 hours to about 10 hours, revealed 60% inefficiency waste for use of the ventilator.

    37. Inefficiency Waste: Cost Savings The 60% reduction in ventilator time was associated with a 30% reduction in thoracic ICU LOS, which is in turn associated with a 15% reduction in the total costs of performing open-heart surgery (~$3,000 per patient; or net of $5.5 million per year, system-wide).

    38. What is Muda? Muda (??) is a Japanese term for anything that is wasteful and doesn't add value. It is also a key concept in the Toyota Production System. Waste reduction is an effective way to increase profitability. A process adds value by producing goods or providing a service. A process also consumes resources. Waste occurs when more resources are consumed than are necessary to produce the goods or provide the service.

    39. Six Categories of Waste (Muda) Delay: idle time spent waiting for something, such as utilization reviews, insurer payments, test results, patient bed assignments, OR prep, medical appointments. Re-work: performing the same task a second time, such as re-testing, re-scheduling, re-filing of lost claim forms, re-writing of patient demographic data, multiple bed moves. Overproduction: manufacturing of products or information that is not needed, such as precautionary “defensive” medical tests, surplus medications, excessive levels of paperwork.

    40. Movement: unnecessary transport of people, products or information, such as requiring patients to see a primary care provider before seeing a specialist who is clearly needed. Defects: design of goods that do not meet customer needs, such as medication errors, wrong side surgery, poor clinical outcomes. Waste of Spirit and Skill: failure to address the many hassles in our daily work, hunting and gathering, re-calling, the same things every day Six Categories of Waste (Muda)

    41. How Big is this Muda Problem? Estimates range as high as 40% of total expenditures are adding no value to patients or staff. For example: Patients may be transferred three to six times during a four day length of stay Wastes include: time, supplies, medications, information, even food.

    42. Intermountain Healthcare: study of caregivers’ use of time suggests 50% waste

    43. Waste Through Different Eyes

    44. Ideas for Seeing Waste Think in the categories Walk with the patient through a visit or care process Ask a nurse manager or department head where they see waste (usually because they are picking up from another department)

    45. Ideas for Seeing Waste Give the staff cameras and ask them to take pictures of hassles and waste Keep a “grrrrrrr list” on the wall to attract ideas from staff and physician hassles Use “spaghetti diagrams” to teach a process

    47. How is this different from traditional cost-cutting? Requires process literacy and redesign Holds quality the same or improves it Needs different ways to categorize costs and transparency Can unite people in a cause to control health care costs

    48. Our Vision is Strategic Waste Management From . . . Arbitrary, reactive cutting disconnected to the process of care delivery

    50. Noriaki Kano’s Three Levers for Improving Value

    51. New Models of Care UPMC orthopedics department Redesigned palliative care systems Disruptive innovations

    52. A Case Study From University of Pittsburgh Medical Center (UPMC) Aims in redesigning care for patients undergoing total joint replacement Patient and family education Less invasive techniques Multimodal anesthesia and pain management techniques Rapid rehabilitation protocols Rapid outcomes feedback (from the patients’ and the providers’ perspectives Creating a learning environment and culture Developing a sense of community, competition and teamwork among patients and between patients, caregivers and staff Promoting a wellness (rather than sickness) approach to recovery

    53. A Case Study From UPMC New Designs: Pre-op testing, teaching Coaching meetings with other patients Pre-surgery discharge planning Strong focus on complete pain management “Wellness” design in orthopedics unit

    54.

    55. Results Safe: Mortality rates: 0.1% (0.2% for TKA and 0% for THA) Infection rates: 0.3% (0% for TKA and 1.0% for THA) Zero dislocations SCIP compliance: 98% for antibiotics within one hour of surgery

    56. Results Effective: 91% of patients discharged without handheld assistance directly to home (national rates: 23-29%) 99% of patients reported that pain was not an impediment to physical therapy, including same-day-of-surgery physical therapy

    57. Results Patient-centered: Press-Ganey mean satisfaction score is 91.4% (99th national percentile ranking) with 99.7% positive responses to “Would you refer family and/or friends?” Efficient: Average length of stay: 2.8 days for TKA (national average is 3.9 days) 2.7 days for THA (national average is 5.0 days) One MD able to perform 8 joint replacements before 2:00pm

    58. Redesigned Palliative Care “ . . . more aggressive medical care was associated with worse patient quality of life . . . and higher risk of major depressive disorder in bereaved caregivers . . . whereas longer hospice stays were associated with better patient quality of life . . . Better patient quality of life was associated with better caregiver quality of life at follow-up . . . End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.” Paul Levy, President and CEO, Beth Israel Deaconness Medical Center - http://runningahospital.blogspot.com/

    59. Use Disruptive Innovation to Design for New Patient Populations QuadMed system of care Email care Electronic visits

    60. Disruptive Innovation: Quad/Med Integrator role with narrow network – almost all primary care in-house Employ internists, pediatricians, family practitioners, and some specialists; manage own labs, pharmacies, rehab centers; contacts for specialists and hospitals MD bonuses paid on satisfaction and clinical outcomes; all visits at least one half-hour Dramatically improved clinical outcomes Increases of (.75%) – 9% per year (less than 5% annually for last 5 years) Costs are 32% less than the Midwest average Now providing health care for other companies in Wisconsin and surrounding states

    61. Challenge: Ideas Using new technologies – Online Second Opinions and E-Visits: The Center for Connected Health* introduced several innovations utilizing new communication methods made possible by new technologies. *part of Partners Healthcare, Boston, MA USA

    62. Online Second Opinions Using a web-based system, patients have access to over 4000 specialists from leading hospitals (e.g., Massachusetts General Hospital). From their homes they can receive a qualified second opinion and can access resources related to their care. Analysis revealed that in 5% of these consultations, the diagnosis was changed. And in 90%, a change in the treatment plan was recommended.

    63. E-Visits A study was conducted to determine whether dermatology care could be effectively delivered remotely. The participating dermatologists responded to uploaded photos and a completed online questionnaire. They were able to prescribe new medications and be reimbursed for the (E-) visit. Study found that equivalent care can be delivered using E-visits rather than office visits. Over 90% of patients preferred E-visits. Patient satisfaction was very high and most physicians found the system efficient and user-friendly.

    64. Thank You! Maureen Bisognano Executive Vice President and COO Institute for Healthcare Improvement 20 University Road, 7th Floor Cambridge, MA mbisognano@ihi.org

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