Transcript Connecting Health and Health Care

May 23, 2013
Denver Medical Study Group
Connecting Health
and Health Care
From n=1 to n=7 x 109
Jeff Selberg
Executive Vice
President and COO
Overview
Institute for Healthcare Improvement
Overview
What Problem Are We Trying To Solve?
Disruptive Innovation
Connecting Health and Health Care
Courageous Adaptive Leadership
IHI Overview
IHI Background
Founded by Don Berwick and colleagues
Current President and CEO: Maureen Bisognano
Grew out of National Demonstration Project on Quality
Improvement in Health Care (NDP)
First National Forum was the NDP Summit
Incorporated in 1991
From 4 employees to now 135
Office in Cambridge, Massachusetts
Remote employees in many other locations
Some of Our Groundbreaking
Initiatives Are:
100,000 and 5 Million Lives Campaigns
IHI Open School for Health Professions
o 135,581 students and residents, 578 chapters, 59 countries
The IHI Triple Aim
The Improvement Map & Passport
STAAR (STate Action on Avoidable Rehospitalizations)
Safer Patients Initiative (UK)
Scottish Patient Safety Programme
Chronic Care Initiative (Indian Health Service)
WIHI
Our Mission
To improve health and health care worldwide.
Our Vision
Everyone has the best care and health possible.
Who We Are
IHI is a leading innovator in health and health care improvement worldwide,
joining forces with the IHI community to spark bold, inventive ways to
improve the health of individuals and populations.
What We Want to Accomplish
Together with our ever-growing community of visionaries, leaders and frontline practitioners around
the world, we seek and achieve vital science-based improvements in health and health care.
Where We Work
We work globally because
countries are interdependent in
terms of health and health care,
innovations can arise anywhere,
and everyone has something to
teach and something to learn.
How We Work
(Will, Ideas, Execution)
With the IHI community, we
motivate and build the will for
change, identify and test
innovative models of care, and
ensure the broadest possible
adoption of proven practices
that improve individual and
population health.
The Platform for Improvement
Will, hope, and optimism
Transparency: All Teach – All Learn
Safe and just environment
Innovation and improvement science
Integrated results oriented teams
Designing care with the patient involved
Courageous adaptive leadership
New IOM Framework
Type of Care
g
ttin
u
c
ss ons
Cro ensi
Dim
Components of
Quality Care
Preventive
Care
Acute
Treatment
Effectiveness
Safety
E
Q
U
I
T
Y
V
A
L
U
E
Timeliness
Patient/family-centeredness
Access
Efficiency
Care Coordination
Health Systems Infrastructure Capabilities
Chronic condition
management
Five Areas of Focus
Improvement Capability
Patient Safety
Person- and Family-Centered Care
Quality, Cost, and Value
The Triple Aim for Populations
How We Work
Goal: Build reach and will
to accelerate the pace of
improvement worldwide
Goal: Offer programming
to transfer knowledge and
build improvement capability
Goal: Harvest, create,
and test bold, innovative
ideas and new models
of care that support our
strategic initiatives
Goal: Leverage strategic
partnerships and key initiatives
to achieve ambitious
improvement goals
How will we know whether the approaches and the changes result in improvement?
Health Care Settings/Populations
Innovation
Testing
Spread & Scale up
Big Dot
4. Outcomes/Performance
Kirkpatrick Level
US Neonatal Mortality
Related Dots*
3. Process/Culture
Implementation of changes to
reduce Neonatal Mortality
2. Learning
Knowledge of improvement methods
1. Experience
Excellent experience working with IHI
0
*We will see change at levels 1 to 3
much sooner than at level 4
V?
W?
Time (years)
X?
Y?
Z?
What Problem Are
We Trying To Solve?
Costs and Affordability
PROBLEM
$2.5 Trillion total spend in 2009
17.6% of the GDP
Overspend estimated at $572 billion (ESAW)
with 85% in outpatient services
Rate of growth slowing from 9.5% in 2002 to
3.9% in 2010.
Accounting for the Cost of U.S. health care,
McKinsey&Company, December 2011
PROBLEM
Accounting for the Cost of U.S.
health care, McKinsey&Company,
December 2011
HEALTHY LIVES
Mortality Amenable to Health Care
PROBLEM
Deaths per 100,000 population*
1997–98
150
2006–07
134
127
116
115
109
99
100
89
88
120
113
106
97
97
88
81
76
50
96
57
55
61
60
61
64
66
74
67
76
79
78
77
80
83
d
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nm
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* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.
See Appendix B for list of all conditions considered amenable to health care in the analysis.
Data: E. Nolte, RAND Europe, and M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health
Organization mortality files and CDC mortality data for U.S. (Nolte and McKee, 2011).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
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HEALTHY LIVES
Infant Mortality Rate, 2007
PROBLEM
6.8
5.1
4.0
2.0
2.5
en
nd
d
a
l
e
Ice
Sw
2.6
2.7
3.1
rk
ay
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an
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nd
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a
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Ja
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St
e
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ite
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U
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
18
QUALITY: SAFE CARE
EXHIBIT 16
Medical, Medication, and Lab Errors, Among Sicker Adults, 2008
Percent of adults reported medical mistake, medication error, or lab error in past two years
PROBLEM
40
32
30
20
26
16
18
19
FRA
GER
22
23
UK
NZ
28
10
0
NETH
CAN
AUS
US
Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or
had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New
Zealand; UK=United Kingdom; US=United States.
Data: 2008 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
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McKinsey Commentary
“…the combination of a reimbursement system
that pays for value over volume and a population
of consumers that make value based buying
decisions could drive improved performance within
the system.”
“…it remains to be seen how quickly and
effectively industry stakeholders will navigate the
messy transition of incentives, behaviors, and
business models.”
Accounting for the Cost of U.S. health care,
McKinsey&Company, December 2011
Affordable Care Act: A Summary
Restructure payments to Medicare Advantage (MA)
plans
Reduce annual market basket updates for care and
adjust for productivity
Establish an Independent Payment Advisory Board
to propose recommendations for reducing per capita
growth rates
Allow shared savings for Accountable Care
Organizations
Create an Innovation Center within CMS
Affordable Care Act: A Summary
Reduce Medicare payments for readmissions and
hospital acquired conditions
Reduce aggregate Medicaid DSH allotments
Establish national Medicare pilot program to develop
and evaluate bundled payment
Create Independent at Home demonstration project
for high-need beneficiaries
Establish hospital value-based purchasing program
Improve care coordination for dual eligibles
Source: Health and Health Care in 2032: Report from the
RWJF Futures Symposium
Source: Health and Health Care in 2032: Report from the
RWJF Futures Symposium
Health and Health Care in 2032
U.S. Economy
Society and Culture
Government
Definition of Health
Health Threats
Medical Advances
Health Care Delivery
Health Insurance Coverage (50.7m uninsured in 2011)
Health Information Technology
National Health Care Spending in 2032 as Percentage
of GDP
Source: Health and Health Care in 2032: Report from the
RWJF Futures Symposium
Disruptive Innovation
Jason Hwang, M.D., M.B.A
The Innovator’s
Prescription:
How Disruptive Innovation
Can Fix Health Care
Centralization followed by decentralization in computing
Jason Hwang, Innosight
The decentralization that follows centralization
is only beginning in health care
Surgical
suites
Specialty care
Jason Hwang, Innosight
The ReEngineered Discharge
Reducing 30 Day All Cause
Rehospitalization Rates
Faculty & Fellowship Seminar
Institute for Healthcare Improvement
Cambridge, MA 02138
March 11, 2013
Brian Jack, MD
Professor and Chair
Department of Family Medicine /
Boston University School of Medicine
Boston Medical Center
Can Health IT assist with
providing a comprehensive
discharge?
Using Health IT to Overcome
Challenge of Clinician Time
Virtual Patient Advocates
• Emulate face-to-face communication
• Develop therapeutic alliance-empathy, gaze, posture, gesture
• Teach AHCP
• Tailored
• Do “Teach Back”
• Can drill down
• Print Reports
• High Risk Meds
Lovenox
Insulin
Characters: Louise (L) and Elizabeth (R)
Studies of Nurse-Patient
Interaction
Who Would You Rather Receive
Discharge Instructions From?
36% prefer Louise
48% neutral
16% prefer doc or nurse
“I prefer Louise, she’s better
than a doctor, she explains
more, and doctors are always
in a hurry.”
“It was just like a nurse,
actually better, because
sometimes a nurse just gives
you the paper and says ‘Here
you go.’ Elizabeth explains
everything.”
1=definitely prefer doc, 4=neutral, 7=definitely prefer agent
Twice as Many Pts Prefer
Louise than RN/MD
“It was just like a nurse,
actually better, because
sometimes a nurse just
gives you the paper and
says ‘Here you go.’ Louise
explains everything.”
“I prefer Louise, she’s
better than a doctor, she
explains more, and
doctors are always in a
hurry.”
Bickmore TW, Jack B, et al. Journal of Health Communication 2010:15:197-210
Source: The Right to World Class Healthcare: A Model for Response to Health
Crisis in Developing Countries,
Ernest C. Madu, MD, FACC, FRCP, April 2013
MIT Media Lab
John Moore, M.D.
The doctor-patient relationship is deteriorating.
Today’s information technology solutions are
exacerbating the problem by perpetuating
paternalistic decision-making and episodic care.
CollaboRhythm is a technology platform that
enables a new paradigm of healthcare delivery;
one where patients are empowered to become
active participants and where doctors and other
health professionals are transformed into realtime coaches. We believe that this radical shift in
thinking is necessary to dramatically reduce
healthcare costs, increase quality, and improve
health outcomes.
The Patient’s Health Record
Cloud Infrastructure
Financial
Services
Fitness
Center
Home
Telemetry
Grocery
Store
Pharmacy
Home Health
Care
Primary
Care
Long Term
Care
Specialist
Hospitals
Connecting Health
and Health Care
Where are you in the Model Life Cycle?
Viability
Optimizing the
Current Model
Technical Leadership:
• Problem solving through
expertise
Transforming the
Organization
Inflection
Point
Adaptive Leadership
•
•
•
Adaptive
Leadership
Technical
Leadership
New beliefs & behaviors
New relationships
New customers
Clinical Model
Episodic Care

Coordinated Care

Patient Directed-Population Based
Business Model
Fee for Service

Bundled Payment/Capitation

Disruptive Innovation?
Infrastructure
Segmented

Integrated

Cloud
Adapted from:
The Second Curve, I. Morrison, 1996
The Innovator’s Prescription, C. Christensen, 2008
Adaptive Design, J. Kenagy, 2009
Models
The Health and Health Care
Continuum
Intensive Care
Alan Morris
Hospital Care
Emory Orthopedic and
Spinal Hospital
Tony DiGioia
Diagnosis
Full Cycle of Care
Optimal
Functionality
(Clinical)
•
•
Care Oregon
Kaiser Permanente
Total Health
Prevention
Ambulatory
Hospital
(Clinical + Social)
Long Term Care
Social Service
Alan Morris
Dr. Alan Morris led a project to smooth out variation in
ventilator settings for patients with acute respiratory
distress syndrome at LDS Hospital.
Dr. Morris blended an evidence-based clinical guideline into
the flow of work (checklists, order sets, clinical flow
sheets) to make it a normative default.
In a group of the most acutely ill patients, the rate of
guideline variances went from 59 percent to 6 percent;
patient survival went from 9.5 percent to 44 percent;
physicians’ time commitment fell by half; and the total
cost of care was reduced by 25 percent.
Source: James B. Savitz L. “How Intermountain Trimmed Health Care Costs Through Robust
Quality Improvement Efforts.” Health Affairs. June 2011. 30:6
Tony DiGioia
Dr. Anthony M. DiGioia III, orthopedic surgeon and
developer of the patient- and family-centered care
program for UPMC, in his office at Magee-Womens
Hospital in Oakland.
A Case Study From University of Pittsburgh
Medical Center (UPMC)
Aims in redesigning care for patients undergoing total joint
replacement
1.
2.
3.
4.
5.
6.
7.
8.
Patient and family education
Less invasive techniques
Multimodal anesthesia and pain management techniques
Rapid rehabilitation protocols
Rapid outcomes feedback (from the patients’ and the
providers’ perspectives
Creating a learning environment and culture
Developing a sense of community, competition and teamwork
among patients and between patients, caregivers and staff
Promoting a wellness (rather than sickness) approach to
recovery
DiGioia A, Greenhouse P, Levison T. “Patient and Familycentered Collaborative Care: An Orthopaedic Model”. Clinical
Orthopaedics and Related Research. 2007: 463; pp: 13-19.
Better Care for Individuals
Better Health for Populations
Lower Per Capita Costs
Where are you in the Model Life Cycle?
Viability
Optimizing the
Current Model
Technical Leadership:
• Problem solving through
expertise
Transforming the
Organization
Inflection
Point
Adaptive Leadership
•
•
•
Adaptive
Leadership
Technical
Leadership
New beliefs & behaviors
New relationships
New customers
Clinical Model
Episodic Care

Coordinated Care

Patient Directed-Population Based
Business Model
Fee for Service

Bundled Payment/Capitation

Disruptive Innovation?
Infrastructure
Segmented

Integrated

Cloud
Adapted from:
The Second Curve, I. Morrison, 1996
The Innovator’s Prescription, C. Christensen, 2008
Adaptive Design, J. Kenagy, 2009
Models
Viability
Where are you in the Model Life Cycle?
Transforming the
Organization
Adaptive Leadership
Optimizing the
Current Model
Technical Leadership:
• Problem solving through
expertise
•
•
•
New beliefs & behaviors
New relationships
New customers
Patient
Inflection
Point
Adaptive
Leadership
Technical
Leadership
Clinical Model
Episodic Care

Coordinated Care

Patient Directed-Population Based
Business Model
Fee for Service

Bundled Payment/Capitation

Disruptive Innovation?
Infrastructure
Segmented

Integrated

Cloud
Adapted from:
The Second Curve, I. Morrison, 1996
The Innovator’s Prescription, C. Christensen, 2008
Adaptive Design, J. Kenagy, 2009
Models
The True Disruptors
Gilbert
Christian
Leadership
The Four Leadership Questions
Do you know how good your hospitals are?
Do you know where your hospitals stand
relative to the best?
Do you know where the variation exists?
Do you know your hospital’s rate of
improvement over time?
The Four Leadership Questions
Do you know how good your community’s
health is?
Do you know where you community stands
relative to the best?
Do you know where the variation exists?
Do you know your community’s rate of
improvement over time?
Key Elements for Rapid Improvement
Executive leadership
Alignment with goals
Staff engagement
Improvement framework
Timely and reliable data
Deployment framework
Learning community
Performance based culture
Leading Is Not Tidy
Decisions are made and then reversed
Misunderstandings are frequent
Inconsistency is inevitable
Inside every solution are the needs of new
problems
Most of the time most things are out of hand
Nonaka and Takeuchi, The Wise Leader
Summary
Attention is the currency of leadership
Exercising leadership is risky and difficult
Articulating a vision begins with listening,
dialogue, and diagnosing
A powerful source of learning better
leadership is your/our own failures
One may lead perhaps with no more than a
question in hand
Adapted from Doug Bonacum
Vital Leadership Behaviors
Compliments of Heifetz
Role of the Leader
“Servant of what is.”
And,
“shaper of what might be.”
Nonaka and Takeuchi, The Wise Leader
Final Thoughts
Get patients involved
Increase improvement capability
Focus on reducing harm
Build capability to design, adhere to, and refine models
of care (full cycle)
Link Local Health System Performance with the IHI
Triple Aim*
*Rising to the Challenge: Results from a Scorecard on Local Health System Performance, 2012, The Commonwealth Fund
http://www.commonwealthfund.org/Publications/Fund-Reports/2012/Mar/Local-Scorecard.aspx
In The End
…it’s all about improvement.