Transcript Hot Topics for Governing Boards

Hot Topics for
Governing Boards
James Conway
James Reinertsen
Denmark, April 2010
Hot Topics
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Patient/family engagement: getting started
Transparency: brave, or foolhardy?
Should someone be blamed for this error?
Quality, safety, and money: is there a
connection?
• Sentinel events
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Transparency Examples
• Dartmouth Hitchcock
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http://www.dhmc.org/webpage.cfm?site_id=2&org_id=459&gsec_id=0&sec_id=0&item_id=20534
• Beth Israel Deaconess
• http://www.bidmc.org/
• Mayo Clinic Florida
─ “I want that run chart up on the wall by 3 o’clock.”
• The Board’s role: “If you make a mistake by
being too transparent, we’ll support you. We
won’t be as forgiving if you make a mistake by
hiding things, or covering them up.”
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Were the
actions as
intended?
No
Yes
No
Were the
consequences
as intended?
Unauthorized
substance?
No
Knowingly
violate safe
operating
procedures?
Yes
Yes
Medical
condition?
Were procedures
available,
workable,
intelligible and
correct?
Yes
No
Pass
substitution
test?
No
Yes
No
Deficiencies in
training &
selection or
inexperience?
No
No
Yes
Yes
Yes
Sabotage,
malevolent
damage,
suicide, etc.
Substance
abuse
without
mitigation
Substance
abuse with
mitigation
Possible
reckless
violation
History
of unsafe
acts?
Systeminduced
violation
Possible
negligent
error
Systeminduced
error
Yes
Blameless
error but
corrective
training,
counseling
needed
No
Blameless
error
Diminishing
culpability
Decision Tree for Determining Culpability of Unsafe Acts
Reason, J: Managing the Risk of
Reason, J., Managing the Risks of Organizational Accidents
Organizational Accidents
A good resource: National Patient Safety
Agency Incident Decision Tree
• http://www.npsa.nhs.uk/nrls/improvingpati
entsafety/patient-safety-tools-andguidance/incidentdecisiontree/?locale=en
Strategies for Reducing Per Unit Cost
(Pugh)
Traditional
Strategy:
Control Inputs
Direct Inputs
•Supplies
•Labor
Indirect Inputs
•Structure
•Technology
Quality
Strategy:
Remove Waste*
from Production
Clinical
Processes
Support
Processes
*waste = unintended variation,
rework, error, valueless care,
needless complexity, etc.
Big Dots
•Financial
•Clinical
•Patient Experience
Reliable care costs less (Premier)
One link between higher quality and lower cost: LOS
Iowa Urban Hospitals:
CMS Quality Measures for Pneumonia vs.
Hospital Length of Stay 2005
1.4
64.2%
1.3
82.2%
Observed/
Expected LOS
1.2
63.3%
68.8%
80.3%
67.5%
1.1
86.3%
71.8%
1
77.3%
85.7%
83.2%
81.7%
82.7%
77.0%
84.3%
87.0%
0.9
86.8%
86.3%
0.8
0.7
50.0%
89.2%
87.8%
87.5%
60.0%
70.0%
80.0%
CMS Quality
90.0%
100.0%
Another link: safety “defects”
and higher costs to payers
1.
2.
3.
4.
5.
6.
7.
Object left in after surgery ($63, 631)
Air embolism ($71,636)
Blood incompatibility ($50,455)
Catheter-associated urinary tract infections ($44,043)
Pressure ulcers ($43,182)
Vascular catheter associated infections ($103,027)
Surgical site infection—mediastinitis after CABG
($299,237)
8. Surgical site infection after spine, neck, shoulder, elbow
($63,135) and gastric bypass surgery ($180,142)
9. Hospital acquired injuries ($33,894)
10. Uncontrolled diabetes ($42,974)
11. Deep vein thrombosis after TKA or THA ($50,937)
One hospital’s data
2008
Future
Future
Future
Project impact of $2,068,259 for FY 2009
excluding Pneumothorax, C-Dif,Dollar
and
VAP.
Figures obtained from CMS 2008
Resource
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Centers for Medicare & Medicaid Services (2006). Eliminating serious, preventable, and costly
medical errors - never events. Retrieved February 4, 2009, from
http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863
Future
Centers for Medicare & Medicaid Services (2008). CMS proposes additions to list of hospitalacquired conditions for fiscal year 2009. Retrieved February 4, 2009, from
http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3042&intNumPerPage=10&ch
eckDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&
chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date
Centers for Disease Control and Prevention: Press Release, March 2000. Available at:
http://www.cdc.gov/od/oc/media/pressrel/r2k0306b.htm.
Centers for Medicare & Medicaid Services (2008). Hospital-acquired condition (Present on
admission indicator). Retrieved February 4, 2009, from http://www.cms.hhs.gov/HospitalAcqCond/
Klevens et al. 2007. Estimating Health Care-Associated Infections and
Deaths in U.S. Hospitals, 2002. Public Health Reports. March-April
2007. Volume 122.
Mattie, A. S. (2008). Centers for Medicare and Medicaid Services’ Never Events: An Analysis and
Recommendations to Hospitals. Health Care Manager, 27(4), 338-349. Retrieved from
Journals@Ovid
Framework for Moving Forward
Noriaki Kano’s Three Levers for
Improving Value
Historic focus in healthcare
1
Eliminate quality problems that arise because
customers’ (patients’) expectations are not met
2
Reduce costs (waste) significantly while
maintaining or improving quality
3
Expand customers’ (patients’) expectations by
providing products and services (care delivery)
perceived as unusually high in value
Kano N. Quality in the year 2000: Downsize through reengineering and upsize through attractive quality creation. Paper
presented at: American Society for Quality Control conference; May 24, 1994; Las Vegas, NV.
HIGH
VERY LOW
VERY HIGH
Kano 1: Eliminate quality problems that arise because
customers’ (patients’) expectations are not met
• Many of the safety and clinical improvement
projects underway fall into this category
─ Patients expect to receive evidence-based care…
─ Patients do not expect to fall…
─ Patients do not expect to have an unplanned
admission to the ICU…
─ Patients do expect that they will get the right
medications…
─ Patients do not expect to get an infection…
• Eliminating safety events will improve financial
performance
Losses Attributable to CLABs in Two ICUs at
Hospital of the University of Pennsylvania
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Average Payments: $64,894
Average Expense: $91,733
Average Loss from Operations: -$26,839
Total Loss from Operations:-$1,449,306
In only 4 cases the hospital made money
The cost of the additional care averaged 43% of
the total costs of care.
• Average LOS: 28 days (7-137)
• Only three patients were discharged to home.
Hospital of the University of Pennsylvania
Reduction in HAI in CCU/MICU:
Return on Investment
• Total Operating Improvements
CLAB= $1,235,765 (2 years)
VAP= $1,003,162 (1 year)
MRSA= $ 295,342 (1 year)
• Highmark PFP = $3,100,000 (2 years)
• HAI elimination Initiatives = +$5,634,269
• Investment = $85,607
• 388 additional ICU admissions
• 57 lives saved
Quality and Cost: Standard Work
The Ventilator Acquired Pneumonia Bundle
• VAP Cases
• Cost in Millions
40
1.6
40
1.4
35
1.2
30
1
25
20
1.6
2000
2003
2006
14
15
0.8
2000
2003
2006
0.6
0.6
0.4
10
3
5
0.2
0
0
0.1
Estimated Cost in Millions
Cases
Mortality Rate: 14% rate
*Data complete through August 2006
•© 2008 Virginia Mason Medical Center. Used with permission.
All rights reserved. No further use of these materials is permitted without the express
consent of Virginia Mason Medical Center.
Kano 2 Reduce costs (waste) significantly
while maintaining or improving quality
• Primary drivers
─ Staffing
─ Flow
─ Supply Chain
─ Mismatched Services
Kano 2 Reduce costs (waste) significantly
while maintaining or improving quality
• Marks of success
─ Link waste reduction with operational and
financial systems
─ Understand hospital operations
─ Outline overall savings potential
─Set waste reduction goals for all areas
─ Track dark green dollars
“Nursing Cells” – Results > 90 days
RN time available for patient care = 90%!
Before
• RN # of steps = 5,818
• PCT # of steps = 2,664
• Time to complete am cycle of work = 240’
• Patients dissatisfaction = 21%
• RN time spent in indirect care = 68%
• PCT time spent in indirect care = 30%
• Call light on from 7a-11a = 5.5%
• Time spent gathering supplies = 20’
•© 2008 Virginia Mason Medical Center. Used with permission.
All rights reserved. No further use of these materials is permitted without the express
consent of Virginia Mason Medical Center.
After
846
1256
126’
0%
10%
16%
0%
11’
RN Time at the Bedside
•© 2008 Virginia Mason Medical Center. Used with permission. All rights reserved.
•No further use of these materials is permitted without the express consent of Virginia Mason
Medical Center.
A common barrier
• “Why don’t you put in the flow-metered
urinary catheter in the first place, if you
know the patient is going to wind up in an
ICU bed?”
• “Those catheters cost a lot, and it comes
out of the ER’s budget.”
A Balanced Strategy of Initiatives
Kano Aim #2
Kano Aims #1 & #3
Aim: Reduce waste
and associated cost
by 1-3% of operating
budget year on year.
Aim: Raise the bar on…
Clinical
Service &
Work
Care
Systems
Environment
-
•Start with the dark
green dollars and
design portfolio
Business Case Management
Systems
Reinvestment strategy
Clinical
Care
Service &
Systems
Great Work
Environment
IT / HR
Bottom Line
Selected Bibliography
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Donald Berwick, MD: Connecting finance and quality [hfm Q&A]. Healthc Financ Manage.
2008;62(10):52-55.
Chip Caldwell & Associates: Lean-Six Sigma: tools for rapid cycle cost reduction. Healthc Financ
Manage. 2006;60(10):96-98.
DiGioia A, Greenhouse P, Levison T. Patient and family-centered collaborative care: An orthopaedic
model. Clin Orthop Relat Res. 2007;463:13-19.
Kano N. Quality in the year 2000: Downsize through reengineering and upsize through attractive quality
creation. Paper presented at: American Society for Quality Control conference; May 24, 1994; Las
Vegas, NV.
Litvak E, Buerhaus PI, Davidoff F, Long MC, McManus ML, Berwick DM. Managing unnecessary
variability in patient demand to reduce nursing stress and improve patient safety. Jt Comm J Qual
Patient Saf. 2005;31(6):330-338. Available at:
http://www.ihi.org/IHI/Topics/Flow/PatientFlow/Literature/ManagingUnnecessaryVariabilityinPatientDem
and.htm
McManus ML, Long MC, Cooper A, Mandell J, Berwick DM, Pagano M, Variability in surgical caseload
and access to intensive care services. Anesthesiology. 2003;98(6):1491-1496.
Nolan T, Bisognano M. Finding the balance between quality and cost. Healthc Financ Manage.
2006;60(4):66-72.
Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level
Improvement in Health Care (Second Edition). IHI Innovation Series white paper. Cambridge, MA:
Institute for Healthcare Improvement; 2008. Available at:
http://www.ihi.org/IHI/Results/WhitePapers/SevenLeadershipLeveragePointsWhitePaper.htm
Sentinel Event – In Summary
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The Board is part of the system that produces sentinel events like this
─ What you permit, you promote
─ The Board owns the credentialing system, even if it doesn’t operate it
─ Having a policy is not enough—the board must know that it is being followed
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Universal Protocol / Time Out
Fair and Just Environment
Physician Performance Failures
Stop the line at any level
Policies, Procedures, Systems should be in place when bad things happen
─ Disclosure
─ Crisis Management
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The Board should expect that these procedures are followed 100% of the time
─ Starting with Board
─ RED RULES
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If a serious event occurs…
─ Board is notified proactively and fully
 consistent with carefully considered norms by the Board
─ Rapid, comprehensive, system level review
─ Board understands its role in assuring learning and improvement
─ Performance failures addressed promptly, respectfully & effectively
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Never lose sight of the patient and family