Steven M. Berkowitz, MD SMB Health Consulting Austin, TX steve@smbhealthconsulting

1. Superior Quality and Safety through Reform… … What Successful Organizations Must Accomplish Despite whatever happens, or does NOT happen in Washington… or Bismarck Steven M. Berkowitz, MD SMB Health Consulting Austin, TX steve@smbhealthconsulting.com 512-415-6095

2. 2012- 2013 Clients- Two Lessons Learned Every System is unique. But… Every System is dealing withthe same issues.

3. So What’s New in Health Care Reform? Same old wine in a brand new bottle?

4. So What’s New in Health Care Reform?

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

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

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

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

9. The Evolution of Health Care Reform 1990’s-- Market Correction 2013-- Market Reconfiguration

10. Remember, It’s Not Nice to Fool Mother Nature Health care must follow the same market rules as all other industries

11. 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 !!

12. 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 !!

13. Value Based Purchasing The increasingly informed consumer will make health care decisions on the basis of VALUE VALUE= Outcomes + Satisfaction Cost The CONSUMER ultimately determines which of the above elements constitute VALUE

14. Read all about it !! April 2005

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

16. Pennsylvania Coronary Artery Bypass Surgery 2008 - 2009 Released: May 2011

18. CABG Mortality in Pennsylvania Results !!

19. The New York State CABG Experience Chassin, 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% )

20. Wisconsin QualityCounts Report on the Safety of Hospital Care Released January 2003

22. Data Transparency 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

23. Core Measures: Heart Attack Heart Failure Pneumonia Surgical Care Improvement HCAHPS

24. CMS Core Measures– the Top Decile

25. Core Measures: Heart Attack Heart Failure Pneumonia Surgical Care Improvement HCAHPS Goal: 100% Compliance !! Standard of Care ? !!

26. Data Transparency and Accountability Transparency is the best thing that’s happened to quality since antibiotics... …by decreasing variance and improving results

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

28. 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 Change

29. Data Transparency and Accountability Transparency is the best thing that’s happened to quality since antibiotics... …by decreasing variance and improving results As transparency matures, it will rewrite the book on: Who is your competitor?

30. The Role of Transparency Price Transparency Quality Transparency

31. The Role of Transparency Quality Transparency Price Transparency

32. System Strategic Planning Who is Your Competitor…. The role of Transparency Stage IV The whole world ?? Increasing Transparency Stage III The entire nation ? Stage II All hospitals in North Dakota Stage I The “other guy”

33. Steve’s Three Rules of Data 1. The data is significant, whether it is significant or not. 2. A low score almost always points to a real issue. 3. The biggest gain in performance improvement occurs when going from NO data to ANY data. Involve ALL stakeholders in the performance improvement process

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

35. 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.

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

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

38. The Role of Transparency Quality Transparency: Improved performance Decreased variance Quality Transparency Price Transparency

39. The Role of Transparency Price Transparency: ??? ??? Price Transparency Quality Transparency

40. Reflections on Price Transparency Steve has a URI symptoms and feels bad!Steve has great insurance but a $3,000 deductible What does he do? Treatment Options:Approximate*: Out of Pocket Wait • Emergency Department $ 300 2-3 hrs • Urgent Care 150 1 hr • PCP visit 120 1 hr (if available) • Local Pharmacy 80 30 min • Self Treat.. rest, OTC meds... 10 ? none * The actual cost may not be known until the evaluation is completed

41. What Steve Does Not Need to Know • The physician’s reimbursement for the visit • The nurses reimbursement for the visit • The cost of his treatment to the institution • Any other contractual relationships • Physicians • Vendors • Any other arrangements with the insurance company Just tell me: How Much Do I Need to Pay !!

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

43. 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

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

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

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 Don’t DEVIATE from the guidelines !!

48. Degani and Weiner 1993 What Can we Learn from the Airline Industry ? Elimination of Ambiguity “the eliminationofambiguityis consistently cited as a key factor in protocol success and safety” 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”

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….”