Making Healthcare Reform Work

1. Making Healthcare Reform Work by Turbo Charging Quality Steven M. Berkowitz, MD SMB Health Consulting Austin, TX steve@smbhealthconsulting.com 512-415-6095

2. What’s New with Health Care Reform?Same Old Wine in a Brand New Bottle ?

3. What’s New with Health Care Reform?

4. You can always count on Americans to do the right thing… …after they’ve exhausted all the other possibilities !!” Winston Churchill Change

5. Change People do not change until the pain of staying the same… … exceeds the pain of changing. Anonymous Change

6. The Health Care Team Medicine is a Team effort…. …..Why do we insist on playing Solo!

7. The Health Care Team Medicine is a Team effort…. …..Why do we insist on playing Silo!

8. 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 !!

9. 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 !!

10. Value-Based Purchasing The increasingly informed consumer will make health care decisions on the basis of VALUE VALUE = Outcomes + Satisfaction Cost

11. Read all about it !! April 2005 Data Transparency

12. This is Your Life !! Data Transparency in Action Data Transparency

13. This is Your Life !! Data Transparency in Action Data Transparency

14. Pennsylvania Coronary Artery Bypass Surgery 2008 - 2009 Released: May 2011 Data Transparency

15. Use of Public Performance ReportsA Survey of Patients Undergoing Cardiac SurgerySchneider, JAMA May 27, 1998 58% of patients probably or definitely would change surgeons if their doctor had a higher than expected mortality rate the previous year 1% knew the rating of their surgeon Data Transparency

16. CABG Mortality in Pennsylvania Results ! Data Transparency

17. The New York State CABG ExperienceChassin, 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% )

18. Wisconsin QualityCounts Report on the Safety of Hospital Care Released January 2003 Data Transparency

20. The Wisconsin Experience: 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 Data Transparency

21. Core Measures: Heart Attack Heart Failure Pneumonia Surgical Care Improvement HCAHPS Data Transparency

22. CMS Core Measures- 90th Percentile

23. Goal: 100% Compliance !! Core Measures: Heart Attack Heart Failure Pneumonia Surgical Care Improvement HCAHPS Data Transparency

24. Core Measures: Heart Attack Heart Failure Pneumonia Surgical Care Improvement HCAHPS Standard of Care ? !! Data Transparency

25. Data Transparency and Accountability Transparency is the best thing that’s happened to advance quality since antibiotics.. Data Transparency

26. Why are CMS Core Measures Important?Serving Multiple Masters Evidence-based  good for the patient Publicly available  marketing/ PR Effect reimbursement  dollars $$ Ultimately, SURVIVABILITYin Health Care Reform

27. Exposure to and Use of Quality InformationPercent Who Saw and Acted Upon the InformationChoice of Hospitals Kaiser Family Foundation, October 2008

28. Performance Data on Surgeons Kaiser Family Foundation, April 2011

29. Change Change 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 Data Transparency

30. Data Transparency and Accountability As transparency matures, it will redefine: “WHO is your competitor” How can your organization work together to improve ? Data Transparency

31. Steve’s Three Rules for Data 1. The data is significant, whether it is significant or not. 2. A low score almost always points to a real issue. • The biggest gain in performance improvement occurs when going from NO data to ANY data. Involve ALL stakeholders in the performance improvement process There is NO reason to blind the data !!

32. Hospitals and Physicians Working as a Team Share the Data ! Decreasethe Variance !

33. 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

34. Hospitals and Physicians Working as a Team Data, not an Indictment !! Data isNOTDiagnostic !!

35. Hospitals and Physicians Working as a Team The great majority of “outlying” physicians are good physicians who have developed a particular style of practice which can be improved!

36. The Future of TransparencyHealth Care, too !! Phase I Quality, Price Data Phase II Redefining Competition Phase III Accountable Care Organization The Way to do Business !!

37. Questions for the Leadership Team Does your organization… … embrace data transparency ?

38. 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

39. Implementing Evidence-Based Medicine What Can we Learn from the Airline Industry ?

40. What Can we Learn from the Airline Industry?Teamwork: GuidelinesandChecklists

41. Our Greatest Challenge in Clinical Medicine Eliminate the “DEADLY” Delay !!

42. 17 Years !! The Deadly Delay…From Clinical Trials to Clinical Practice…

43. Core Measures: Acute Myocardial Infarction Heart Failure Pneumonia Surgical Care Improvement HCAHPS

44. Core Measures: Acute Myocardial Infarction Heart Failure Pneumonia Surgical Care Improvement HCAHPS

45. Beta-Blocker for Acute MI The Evidence is Published 31 Years Ago !!

46. Where Do We Find the Best Practices ?Examine Your Own Specialty Literature Implement the Guidelines Recommended by your OWN Specialty Society

47. 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

48. What Can we Learn from the Airline Industry ? Elimination of Ambiguity “the eliminationofambiguityis consistently cited as a key factor in protocol success and safety” Degani and Weiner 1993 Most medical guidelines are based upon ambiguity as a guiding principle of protocol development

49. 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” Evidence-Based Medicine

50. 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….” Evidence-Based Medicine