Improving Population Health: Reliability, “Toyota Specifications,” and the “Triple Aim”

1. Improving Population Health:Reliability, “Toyota Specifications,” and the “Triple Aim” Don Goldmann, MD Senior Vice President Institute for Healthcare Improvement Professor of Pediatrics Harvard Medical School

2. Institute of Medicine’s 6 Key Quality Improvement Aims Health care should be: • Safe • Effective (providing services based on scientific knowledge to all who could benefit and not providing services to those not likely to benefit) • Patient-centered • Timely (reducing waits and potentially harmful delays) • Efficient (avoiding waste of equipment, supplies, ideas, energy) • Equitable (regardless of gender, ethnicity, geography, socioeconomic status)

3. Gaps/Variation in Outcomes and Performance Nationally & Internationally A Very Ugly Story

4. For those who only have time for the NEJM and JAMA…. • McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-45 (recently confirmed in NEJM) • 439 indicators of clinical quality of care • 30 acute and chronic conditions, plus prevention • Participants had received 54.9% of scientifically indicated care • acute: 53.5%; chronic: 56.1%; preventive: 54.9% Conclusion: The “Defect Rate” in the technical quality of American health care is approximately 45%

5. More Comprehensive Sources of Information on Quality Gaps and Variation • AHRQ National Quality Report • Commonwealth Fund Chart Books • Commission on a High Performance Health System (available on the Web or in Health Affairs) • Dartmouth Atlas

6. Some Highlights • US ranking v. other countries • 15/19 in preventable deaths prior to age 75 • death rate 40% higher than top countries (France, Japan, Spain) • Tied for last in life expectancy prior to age 60 • Last of 23 in infant mortality • Enormous variability by region and state • Low ranks for adults with health-related limitations in daily activities, children missing >11 days of school due to illness or injury Commonwealth Commission

7. More Selected Highlights • 49% of adults get recommended screening and prevention • 50% of patients discharged from hospital with CHF get written instructions/materials • Enormous disparities by race, ethnicity, SES, and insurance status for many outcomes and processes of care • Even in managed care systems Commonwealth Commission

8. Resource Use at the End-of-Life • US average during the last 6 months of life • 13.9 hospital days • 3.6 ICU days • 33.5 physician visits • 32.8% patients seeing 10 or more physicians • Half of visits to specialists rather than primary care • 20.1% of deaths during an ICU admission Dartmouth Atlas

9. Gaps and Performance Variation in Infection Control:Methicillin-Resistant Staphylococcus aureus (MRSA)

10. Methicillin (oxacillin)-resistant Staphylococcus aureus (MRSA) in U.S. Intensive Care Units, 1995-2004 Source: National Nosocomial Infections Surveillance (NNIS) System

11. Equally Grave MRSA Problem in the United Kingdom…

12. Methicillin-resistant Staphylococcus aureus in Europe, 1999–2002

13. Is this remarkable variation due to: • Transmissibility and virulence of distinct strains (genotypes)? • Size, design, or type of hospital? • Sicker, more complex patients? • Practice variation? • Compliance with known, measurable evidence based practices? • Less tangible features, such as culture and organization of an intensive care unit? • Are nosocomial infections an “expected” consequences of caring for very sick, complex patients, or intolerable, potentially preventable adverse events

14. A Modest Proposal… • Improve reliability of basic procedures • “Defect rates” of 60-80% are not tolerable • Isolation Procedures • Hand hygiene • Ventilator and central venous catheter care • Screening cultures

15. Reliability Science Health care is riddled with defects 40% compliance (60% defects) with hand hygiene!!?? From the patient’s point of view, it’s “all or nothing” Reliability science offers effective approaches to reducing defects and harm in health care

16. Reliability is failure free operation over time from the viewpoint of the patient

17. Defects in outpatient prevention and CHF care Defects in hospital care CHF requiring admission: Admission through discharge Defects in outpatient CHF care management Years/Months Days Years/Months Defect free care overtime from the patient’s viewpoint

18. Levels of Reliability • Chaotic process: Failure in greater than 20% of opportunities • 10-1: 90 percent success: 1 or 2 failures out of 10 opportunities (no consistent articulated process) • education, exhortation, audit and feedback • 10-2: 1 failure or fewer out of 100 opportunities (process is articulated by front line) • Systems-oriented prevention, detection, mitigation • 10-3: 1 failure or fewer out of 1000 opportunities • 10-4: 1 failure or fewer out of 10,000 opportunities Blood banking and anesthesiology alone achieve the higher levels of reliability in medicine

19. Reliability in Healthcare • Remember, it’s “all or nothing” – not compliance with each individual component of “best practice” • Most institutions do fairly well with individual components of evidence-based practice, but performance drops dramatically when the standard is “all or nothing” • We are trying to decrease the “defect rate” and to achieve a reliability of performance to the 10-2 level (95-99% compliance with the entire package of evidence-based practice)

20. Reliability requires knowledge about key evidence-based interventions AND Proactive risk assessment to identify critical control points (hazard points) where failures in key evidence-based practices may occur and not be detected/mitigated • Hazard analysis critical control point (HACCP) and failure mode effects analysis (FMEA)

21. Applying Reliability Science, Evidence, and Quality Improvement to Dramatically Reduce Central Venous Catheter Infections

22. Guidelines v. Bundles (Intervention Packages) • Guidelines tend to be long, all-inclusive, and confusing • Many potential interventions are supported by some evidence • Guidelines are difficult to translate into action and often are ignored by clinicians • What if just a few key, actionable interventions, supported by strong evidence, were culled from the guidelines?

23. What Is a Bundle? • A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement • The science behind the bundle is so well established that it should be considered standard of care • Bundle elements are dichotomous and compliance can be measured: yes/no answers • All components of the bundle must be performed – it’s “all or nothing”

24. Central Venous Catheter Bundle • Hand hygiene before inserting a catheter • Subclavian vein as the preferred insertion site • Maximal barrier precautions for line insertion • Hand hygiene • Non-sterile cap and mask • Sterile gown and gloves • Large sterile drape • Antiseptic prep used for catheter insertion as per hospital protocol • 2% chlorhexidine supported by evidence

25. Quality Improvement for Catheter Insertion • Train all who will insert catheters and check competency • Put all needed supplies in a standard, readily available pack on a cart • Use a checklist to insure all components are completed correctly • Empower nurse to stop procedure if mistakes are made (“matron’s charter”) • Feed back data (e.g., days between CVL-associated infections) in graphic format

26. Central line-associated bloodstream infection rate in 66 ICUs, Southwestern Pennsylvania, April 2001-March 2005 CDC Pronovost et al.,N Engl J Med; 2006;355:2725 Decrease from 7.7 to 1.4 per 1000 catheter days in 103 ICUs

27. A Hand Hygiene Bundle • Staff knowledge • Staff competency • Alcohol and gloves available at the point of care • Operational, full dispensers providing correct volume of rub • At least 2 sizes of gloves • Correct performance of hand hygiene + gloves worn for standard precautions

28. MRSA Bundle • High reliability hand hygiene for all • High reliability MRSA screening (elective high-risk surgical patients, high risk microsystems) • ? preemptive barrier precautions pending screening culture results • Isolation/Cohorting for infected and colonized patients • Environment/fomite disinfection • Compliance with central venous catheter and ventilator bundles

29. Six Changes That Save Lives • Rapid response teams • Evidence-based care for acute myocardial infarction • Prevention of adverse drug events (medication reconciliation) • Prevention of central line infections (Central Line Bundle) • Prevention of surgical site infections (correct perioperative antibiotics at the proper time and other elements of the Surgical Infection Bundle) • Prevention of ventilator-associated pneumonia (Ventilator Bundle)

30. 5 Million Lives Campaign The Platform • Reduce Surgical Complications – Adopt “SCIP” • Prevent Harm from High Alert Medications • Prevent MRSA Infections • Reduce Readmissions in patients with Congestive Heart Failure • Prevent Pressure Ulcers • Get Boards on Board

31. Reduce Re-admissions from Congestive Heart Failure (CHF) The Goal: Reduce the 30-day re-admission rate of patients discharged with the diagnosis of CHF by 50% by December 2008

32. Why is this a Campaign Plank? • One of the nation’s leading causes of hospitalization and re-hospitalization, especially among the elderly • 12-15 millions office visits, 6.5 million hospitalizations • One of the leading causes of re-hospitalization (27% within 1 month of discharge, 47% within 3 months) • $27-56 billion in direct costs annually • Campaign is focusing on in-hospital care of CHF Additional interventions to improve the hospital’s hand-off of patients to the community will follow in the Spring

33. Seven Key Interventions • Left ventricular systolic (LVS) heart function assessment (CMS,JCAHO,ACC,AHA) • ACE inhibitor or ARB at discharge for CHF patients with systolic dysfunction (LVEF<40) (CMS,JCAHO,ACC,AHA) • Anticoagulant at discharge for CHF patients with chronic/recurrent atrial fibrillation (ACC,AHA)

34. Seven Key Interventions • Influenza immunization (ACIP) • Pneumococcal immunization (ACIP) • Smoking cessation counseling (CMS,JCAHO,ACC,AHA) • Discharge instructions that address all of the following: activity level, diet, discharge medications, follow-up appointments, weight monitoring, and what to do if symptoms worsen (CMS,JCAHO,ACC,AHA)

35. Other Interventions to Consider • Beta blocker therapy for patients who have minimal or no evidence of fluid overload or volume depletion (AHA,ACC) • Well supported by randomized controlled trials • If started at discharge (as recommended by AHA Get With The Guidelines-HF): • Insures patient is started on therapy and hastens attainment of therapeutic levels • Requires close monitoring and follow-up post-discharge • Discharge “contract”

36. Tips for Getting Started • Form a multi-disciplinary improvement team • Include hospitalist, nurse, nurse educator, case manager, QI representative, patient, cardiology and emergency department opinion leaders, and others involved in the system of care • Segment – pick a segment to work on first • Patients being discharged directly to home • Patients not needing ICU care • Standardize • Use nurse-driven protocols (ordering LVS function testing, smoking cessation instruction, immunizations) • Link ACE inhibitor/ARB orders directly to interpretation of LVS function testing • Give patients a standard discharge instruction booklet (in appropriate language) at admission or when diagnosis is made, and reinforce throughout stay

37. Tips for Getting Started on Transition Planning • Involve case managers; focus on CHF at admission • Use a discharge checklist with nurse-patient/family/caregiver face time • Respect health literacy; use teach back to insure comprehension; use “Ask-Me-3” • Reconcile medications; insure understanding of purpose, regimen, and side effects • Provide real-time information transfer for next provider(s) • Speak with emergency contact for high risk patients • Schedule follow-up phone calls to patient/family to occur within 48 hours and physician visit within 1 week for average risk patients • Schedule, before patient leaves, follow-up visit (home or office) for high risk patients to occur within 48 hours after discharge • Discharge high risk patients to multi-disciplinary case management

38. Toyota Specifications • “Toyota” Specifications • Measures were selected primarily from IHI’s Whole System Measures, which are aligned with the IOM Six Dimensions. • The on each scale indicates the “Toyota” performance specification. • The specifications were based on the best results seen by IHI, top-decile performance, or best-practice results in other industries.

39. Patient Experience “They give me exactly the help I want (and need) exactly when I want (and need) it…” Population includes adults in the “How’s Your Health?” database, aged 19-69 Best Practice Results Current Average Primary Care Practices CCHMC Inpatient Outpatient 25%-30% 71% 0 20% 40% 60% 80% 100% Percent of Patients Who Responded “Strongly Agree” to the Phrase Above Additional comments from John Wasson: Currently, about 25-30% of adults aged 19-69 will strongly agree. We find that in primary care practices the rate is about 40% and we are finding a group of practices with a average rate of about 60%. There is wide variance around these averages. Note: The phrasing above has been modified by John Wasson to read, “I receive exactly the care I want and need exactly when and how I want and need it.” Source: John Wasson, “How’s Your Health?” http://www.howsyourhealth.org

40. $25,000- $49,999 $15,000- $24,999 <$15,000 ≥$50,000 Sample Average 17.2% 14.3% 22.1% 23.6% 34.0% 15% 10% 25% 30% 35% 20% 40% Percent of Adults Who Self-Rated Their Health Status Excellent Health StatusWould you say that in general your health is excellent, very good, good, fair, or poor? Results are stratified by annual household income (2001) Source: Centers for Disease Control and Prevention (CDC) National Center for Chronic Disease Prevention and Health Promotion, Division of Adult and Community Health, “Health-Related Quality of Life Surveillance --- United States, 1993-2002”

41. Hospital Standardized Mortality Ratio (HSMR) 2004 Top Decile 2004 US Average 2000 US Average HealthPartners McLeod CCHMC PICU* 86 69 0 20 40 60 80 100 120 HSMR Source: Sir Brian Jarman, MedPar database *CCHMC data is Standardized PICU Mortality Ratio (# actual patient deaths / # expected deaths)

42. The Triple Aim • Optimize and balance • Patient experience over time • I get exactly the help I need and want exactly when I want it and need it (safe, effective, efficient, patient-centered, timely, equitable) • Population health • Self-perceived health status, quality of life/functional status, productive life years • Per capita cost (societal)

43. Problems • The healthcare system is fragmented and financially mal-aligned • Hospitals profit from increasing admissions and performing expensive, high-tech procedures. They have little incentive to decrease societal costs • Physicians and medical groups do not reap the financial benefit of improving health and reducing hospital visits/admissions • Payers seek to reduce per capita costs for the people they cover, but may not have their eye on the patient experience and population health • Little systems thinking or foreign competition • Tech explosion and increase in availability paradoxically increases demand

44. Promising Developments • Increased alignment of payment, evidence-based practice, measurement, and certification/re-certification requirements for physicians • Growing consensus among regulators, payers, and providers regarding a common set of metrics to evaluate quality of care and the impact of improvement efforts • Demonstration projects with “suspended rules” for payment (CMS) • Collaborative improvement initiatives (federal, regional, state, professional organizations) • Increasing promotion and use of information technology and inter-operable systems.

45. Integrator • Entity that is responsible for patient experience, population health, and cost • Companies (Hershey, QuadGraphics) • Visionary payers • Integrated health systems (Kaiser-Permanente) • Large health systems that own practices and hospitals and have a stable patient base • National/regional health systems (Jonkoping County, Sweden) • Visionary states/cities (Massachusetts, Oregon, ?Louisiana) • Government health systems (VA, Indian Health Service, CMS demonstration projects)

46. Segmentation • Age • Chronic illness • Region

47. Driver Diagram for Triple Aim Primary Drivers Secondary Drivers Evidence based care Improved dissemination and uptake of medical knowledge Collaboration on standardization of definitions Trusted body to assemble evidence . Measurement that is transparent Public health interventions Design and coordination of care at the patient level Universal access to care Financial management system Education Community outreach Government regulation City planning design and redesign • Individual’s Healthcare Experience • Population Health • Per Capita Cost Identification of provider responsible for coordination Handoff management Planning and execution of a shared treatment plan (all providers and patient and family) Information technology support Primary care access At least a minimally defined set of benefits for the population including secondary and tertiary care Incentives supporting design Operational Cost Capitol Expense Waste Reduction and coordination resources Appropriate use of technology and procedures Supply side management

48. What are the Triple Aim Toyota Specs for Louisiana?

49. Adjusted Nosocomial Bloodstream Infection Rates (Including Only Patient-related Variables as Covariates)

50. Variation in parenteral nutrition utilization