Transcript The 100000 Lives Campaign: A Model for

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
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)
Gaps/Variation in Outcomes and
Performance Nationally &
Internationally
A Very Ugly Story
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%
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
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
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
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
Gaps and Performance Variation in
Infection Control:
Methicillin-Resistant
Staphylococcus aureus (MRSA)
Methicillin (oxacillin)-resistant
Staphylococcus aureus (MRSA) in U.S.
Intensive Care Units, 1995-2004
Percent Resistance
70
60
50
40
30
20
10
20
04
20
03
20
02
20
01
20
00
19
99
19
98
19
97
19
96
19
95
0
Year
Source: National Nosocomial Infections Surveillance (NNIS) System
Equally Grave MRSA Problem
in the United Kingdom…
Methicillin-resistant Staphylococcus aureus in
Europe, 1999–2002
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
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
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
Reliability is failure free operation
over time from the viewpoint of
the patient
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
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
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)
Reliability requires knowledge about key evidencebased 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)
Applying Reliability Science,
Evidence, and Quality
Improvement to Dramatically
Reduce Central Venous Catheter
Infections
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?
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”
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
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 CVLassociated infections) in graphic format
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
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
MRSA Bundle
• High reliability hand hygiene for all
• High reliability MRSA screening (elective highrisk 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
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)
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
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
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
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)
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)
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 postdischarge
• Discharge “contract”
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
Tips for Getting Started on
Transition Planning
• Involve case managers; focus on CHF at admission
• Use a discharge checklist with nursepatient/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
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.
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
Current
Average
Primary Care
Practices
Best
Practice
Results
25%-30%
0
20%
CCHMC
Inpatient Outpatient
71%
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
Health Status
Would you say that in general your health is excellent, very good, good, fair, or poor?
Results are stratified by annual household income (2001)
$25,000$49,999
$15,000<$15,000 $24,999
≥$50,000
Sample Average
10%
14.3%
15%
17.2%
22.1% 23.6%
20%
25%
34.0%
30%
35%
Percent of Adults Who Self-Rated Their Health Status Excellent
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”
40%
Hospital Standardized Mortality Ratio (HSMR)
2004
Top Decile
2004
US Average
HealthPartners
2000
US Average
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)
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)
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
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.
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)
Segmentation
• Age
• Chronic illness
• Region
Driver Diagram for Triple Aim
Primary Drivers
Secondary Drivers
Measurement that is
transparent
Evidence based care
Improved dissemination and uptake of medical knowledge
Collaboration on standardization of definitions
Trusted body to assemble evidence
Education
Community outreach
Government regulation
City planning design and redesign
.
Public health
interventions
1.
2.
3.
Individual’s
Healthcare Experience
Population Health
Per Capita Cost
Design and
coordination of care
at the patient level
Universal access to
care
Financial
management system
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
What are the Triple Aim Toyota
Specs for Louisiana?
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
Site A
Site B
Site C
Site D
Site E
Site F
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
Probability of developing
NBSI
Adjusted Nosocomial Bloodstream
Infection Rates (Including Only Patientrelated Variables as Covariates)
Length of stay (days)
Variation in parenteral nutrition
utilization
100
90
80
Percent
70
60
50
40
30
20
10
0
Day 1
Day 3
Day 14
0.35
0.3
Site A
0.25
Site B
0.2
Site C
0.15
Site D
0.1
Site E
Site F
0.05
0
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
Probability of developing
NBSI
Adjusted Bloodstream Infection Rates
(Including Patient- and Treatment-related
Variables as Covariates)
Length of stay (days)
10-1 Performance:
Intent, Vigilance and Hard Work
•
•
•
•
Exhortation to work harder
Awareness, education and training
Audit and feedback of compliance data
Personal check lists
10-2 Performance
Emphasis on Systems
• Sophisticated failure prevention,
identification, and mitigation systems
– Decision aids and reminders built into the
system
– Desired action the default (based on evidence)
– Redundant processes
– Taking advantage of habits and patterns
– Standardization of process with clear
specification and articulation
CVC Infections are not a right of
passage
Dramatic improvement is possible
Some ICUs have gone months without a
CVC infection
Institute for
Healthcare
Improvement