Enhancing Value in Health Care: Achieving System-Level Results

1. Enhancing Value in Health Care: Achieving System-Level Results

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3. 3 Some Concepts Based in Improvement Knowledge Every system is perfectly suited to produce the results it produces All improvement requires change, but all change is not improvement Under-use of intrinsic motivation inhibits unleashing the talents of individuals

4. Major Biomedical Successes 4 Acute Lymphoblastic Leukemia Coronary Heart Disease Acute Myocardial Infarction Diabetes Mellitus Asthma Organ Transplantation

5. Mortality Amenable to Health Care 5

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7. Aims Safety Effectiveness Patient-centeredness Timeliness Efficiency Equity 7

8. Preventing Central Line Infections Hand hygiene Maximal barrier precautions Chlorhexidine skin antisepsis Appropriate catheter site and administration system care Daily review of line necessity and prompt removal of unnecessary lines 8

9. Central Line Associated Bloodstream Infections (CLABs)(from Rick Shannon, MD, West Penn Allegheny Health System) 9

10. 10 Seton Family of HospitalsBirth Trauma Prevention

11. Palmetto Hospital Mortality Rates

12. What about cost? 12

13. Health Care Expenditure Out of GDP

14. The Dartmouth AtlasRegional Variation in Medicare Spending per Capita

15. 15 What Do Highest Quintile Cost Regions Get for $3000 Extra per Capita per Year? COSTS AND RESOURCE USE�. 32% more hospital beds per capita 65% more medical specialists 75% more internists More rapidly rising per capita resource use QUALITY AND RESULTS� Technically worse care No more major elective surgery More hospital stays, visits, specialist use, tests, and procedures Slightly higher mortality Same functional status Worse communication among physicians Worse continuity of care More barriers to quality of care Lower satisfaction with hospital care Less access to primary care Lower gains in survival

16. Premiums for employer-sponsored health insurance have risen from $5,791 in 1999 to $13,375 in 2009, with the amount paid by workers rising by 128%.Premiums for employer-sponsored health insurance have risen from $5,791 in 1999 to $13,375 in 2009, with the amount paid by workers rising by 128%.

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18. The Apparent Choice Spend More. Accomplish Less.

19. The Better Choice Spend More. Accomplish Less. Change the System.

20. Executing System Design Lead from a system perspective Eliminate waste and its associated cost Get everyone involved Build improvement capability in the line management 20

21. Lead from a System Perspective 21

22. Provincial Map 22

23. Constancy of Purpose:The �Triple Aim� 23

25. Design of a Triple Aim Enterprise

26. Eliminate Waste 26

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32. Cincinnati Children�s 32

33. Healthcare Navigation - Delivering 33

34. End-of-Life Care in La Crosse A community-wide advance care planning program Hospice and palliative care programs to assist patients with advanced diseases Coordination of these services by use of electronic medical records, which can be accessed by all medical professionals in the health system and region. Professional education: educating providers about advance directives has led to a high level of provider compliance with patients� treatment choices at all sites of care. 34

35. Medicare Expenses: La Crosse 35

36. Get Everyone Involved 36

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38. Our Measures for Heart Failure Show Great Results Heart Failure Core Measure (all or none bundle) at 100% Measure is the same value for all populations (white vs. of color) Readmission rate for CHF patients is low But Despite our great results, 10 case review shows another story for some individuals 38

39. Methodology Heart Failure patients with index inpatient stay during 2007 identified from claims data. 10 patients were selected randomly for medical record review (Average age= 61, min= 50, max = 70; Male = 6, Female = 4;White = 6, Black = 1, Asian = 1, Left blank = 2). From the 10 patients, three were selected for more detailed review. 39

40. Findings One patient called the nurse care line 23 times for various reasons Follow-up visits after hospital discharge are not always scheduled and/or completed (due to health and social issues) Within one year,10 patients had 27 inpatient admissions and 4 separate ED visits. Two of the patients had 8 admissions each Lack of coordination of care�multiple providers, specialties, and other health plans. 40

41. Patient Interview 54 year old male with recent hip replacement EKG done the day of surgery when had been done in internists office 2 days before surgery Sequential compression devices which kept falling off and did not ever seem to work Physical therapy continued walking the patient even after he was walking on his own without difficulty Portion sizes for meals continued to be large even though he requested smaller portions at least 3 times

42. Build Improvement Capability in Line Management 42

44. Sequential Building of Knowledge: Include a Wide Range of Conditions in the Sequence of Tests

45. Number with Moderate or High Capability

46. Development Options Train managers by helping them get clinical/business results Lead a project with help from a capable colleague or improvement advisor Lead an improvement workshop for those reporting to you Join an internal interest group/study group, for example safety Rotation into the improvement group for future leaders Attend seminars and conferences E-learning modules

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