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Creating ‘Real Change’ in the Emergency Department with ‘Pay for Performance’

Creating ‘Real Change’ in the Emergency Department with ‘Pay for Performance’. CEO Forum Kananaskis, Alberta February 16, 2009 Les Vertesi. Imagine .…. A Conversation with Government … If you could solve ONE problem in health what would it be? Would you willing to PAY to do it?

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Creating ‘Real Change’ in the Emergency Department with ‘Pay for Performance’

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  1. Creating ‘Real Change’ in the Emergency Department with ‘Pay for Performance’ CEO Forum Kananaskis, Alberta February 16, 2009 Les Vertesi

  2. Imagine .…. • A Conversation with Government … • If you could solve ONE problem in health what would it be? • Would you willing to PAY to do it? • No? Why not? • Under what circumstances would you be willing to PAY to get there?

  3. Changing the Question WHAT if you only had to pay for SUCCESS … and didn’t have to pay for FAILURE?

  4. The Result • An Emergency Department Improvement Initiative started in Four Vancouver Area Hospitals • Purpose: • to improve access to patients in the ED and work to eliminate ED congestion • To gain experience with the best ways to use money to improve quality • Part of a $100m innovation fund (F2007-08) announced by BC Ministry of Finance • Implementation started in October 2007

  5. Key Points • Source of new $ was Ministry of Finance (not MoH) • New money ($16.5m for 4 hospitals) dedicated to improving Emergency Congestion • Not for monthly targets: • Pay is for each patient that meets targets • This is a competitive model, so • Money must go to the Hospital • Not to individuals • Not to the Health Authority • Money must be earned before it is paid

  6. Necessary First Steps • Agree on a Definition and the best Measure of ED Crowding • Establish the “Rules” for P4P funding • Anticipate and Monitor for unintended consequences to patient flow • Make it fair --- not starting from same place • Minimize possibilities for gaming • Anticipate up-front vs. ongoing investment needs • Establish tracking & information systems • Attaching money makes it “serious”

  7. Target: Total Time in ED Why Total Transit Time? Why Three Separate Targets? • $600 for Admitted Patients • to Ward Within 10 hrs ($600) • $100 for Non-Admitted Hi Acuity • (CTAS 1-2-3) (within 4 hrs) • $100 for Non-Admitted Low Acuity • (CTAS 4-5) within 2 hrs Payment is for EACH patient that meets targets It Doesn’t Have to be Perfect … Definition of “Complete Success`` = 80% meeting targets

  8. What is a “Floor”? Each hospital has their own “funding floor” based on their historical performance • Each new patient (above that floor) that meets the P4P guidelines for TT in department has the same $ value • Implies some recognition for previous investments in access • But the go-forward rules and $ amounts are the same for all hospitals • Makes both Volume and Quality (access) count

  9. The Results • Results 1: Changes We Can Measure • Improved access times for Three Streams • Admitted Patients - • All Admitted Patients (10 hr transit time) • Discharged Patients • High Acuity (4 hr transit time) • Low Acuity (2 hr transit time)

  10. Time Period: Oct-07 thru Jan-09 Baseline (P6) = average performance for 1st six periods of FY2007/08

  11. Fighting a Headwind Improvements in performance have come in spite of significant increases in workload and acuity

  12. Changes more difficult to measure • About Working Faster? • About Better investment? • About Using Data & Information? • About Value? • About Front-line Commitment? What Are We Learning?

  13. About Working Faster • We do not expect people to work faster in real time • But we CAN expect people: • to pay more attention to time-related decisions in their work • to stop doing things that are not helpful • DE-SEQUENCING: • Finding things that are done in sequence • How many can be done in parallel? • How many don’t need to be done at all?

  14. About Better Investment Sound Investments are Key to Improvements: P4P creates a climate for Better Investment Choices by: • Local Empowerment and Control of Decisions • Shortening the Plan, Assess, Re-plan Cycle Time • Funding based on What You EARN instead of on What you Spend • Conventional fixed funding methods encourage “high ask” and “spend it or lose it” behaviors

  15. About Value • There is a Moral Commitment to the need to ensure reasonable access to both ED and in-hospital acute care • Until now, has been no FINANCIAL consequences for hospitals that allow admitted patients to be boarded in ED stretchers • Placing a $ Value on ED access aligns the financial objectives of a hospital with the moral ones

  16. Using Data & Information What Do You Believe? • Two Kinds of Information: • Those with NO consequences • Those WITH consequences • Adding the $$ Sign: • Correct • Relevant • Timely

  17. Personal Commitment • Staff are our most important asset • Staff become alienated when: • No sense of control • No sense of recognition for effort • No sense of common purpose • No sense of achievement • It’s not about the Money • P4P uses $$ as a surrogate for Feedback about Quality and what is being valued

  18. Example of Daily Posting(from Richmond Hospital)

  19. Staff Morale and Motivation Highlights of Staff Survey at VCH Emergency Departments(June 2008) • The majority of staff believe the initiatives at their site have been quite successful. 45% rated success a score of 4 out of a possible 5. • An overwhelming majority of respondents believe the project benefited patients. 91% of surveyors rated success a 3 or higher (out of a possible 5). • Some people felt that implementation of the initiatives was rushed and that more time was necessary to make the changes. • 87% of respondents say they received sufficient information about EDP initiatives to do their job. • A key concern from staff noted that it is difficult to change the work culture and that many staff aren’t aware of the benefits of the initiatives. • All staff that responded to the survey were aware of at least one to five project initiatives. • Staff believe the Rapid Assessment Zone (RAZ) and Medical Assessment Unit (MAU) were the most successful projects. • Some staff suggest that the rest of the hospital should have more involvement in the project.

  20. Does P4P Really Work as an Agent of Positive Change? • No, it doesn’t always work • But it CAN work if done right • This is a CULTURAL CHANGE • There is a LEARNING CURVE in getting it right

  21. Some Tips on Getting it Right • No one keeps any of the money, so reward comes from local empowerment and sense of ownership • You need a very clear definition of what you want to achieve (and pay for) and how to measure it • Need control andflexibility of the rules for funding • Targets that have no consequences are not taken seriously • Constant (daily) feedback and reinforcement are powerful tools • Competition and Cooperation can co-exist Total $ Spent in 1st year: about $11m of $16m

  22. Spreading the Gospel • As of October 2008, funding source for ED-P4P has been assumed by LMIIF • Confirmed for expansion to 4 Fraser Health Hospitals as of January 2009 • Next Steps: (depend on new sources of $) • Expansion to other FHA hospitals • Include other major ED’s in province

  23. Questions?

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