Transcript Breaking News in Pay-4-Performance The

Surviving the No Outcome No Income Tsunami:
Pay-4-Performance – A Patient Safety Focus
Charles Denham, M.D.
Chairman, Texas Medical Institute of Technology
Chairman, Leapfrog NQF Safe Practices Program
© 2004 TMIT
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Surviving the No Outcome No Income Tsunami:
• Breaking News in Pay-4-Performance
• The “C-Suite” Perspective
• Building the Business Case
• Communicating to the “C-Suite”
© 2004 TMIT
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Mark McClellan, MD, PhD
“P-4-P and Patient Safety are major
priorities for me, the Secretary of
Health, and the President”
© 2004 TMIT
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© 2004 TMIT
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© 2004 TMIT
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© 2004 TMIT
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© 2004 TMIT
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© 2004 TMIT
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© 2003 TMIT
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27 NQF Safe Practices Weighting Results
Enterprise-wide System
#
Practice
Final Weighting out of 1000 points
1
Create Safety Culture
263
3
Ensure Adequate Nursing Workforce
119
SUBTOTAL
382
Enterprise-wide Process
6
Verbal Order Readback
36
7
Standardized Abbrev./Doses
17
8
No Pt Care Summaries from Memory
17
9
Pt Care Info/Orders to all Providers
84
SUBTOTAL
TOTAL ENTERPRISE-WIDE
Clinical Care Setting or Function Specific
1000 Points Applied to
27 Practices
Weighted Individually
Hospitals Nationally
Ranked
154
536
5
Pharmacist Active in Med Use
10
Pt Readback of Informed Consent
11
Document Resusc./End of Life/ Directives
13
Prevention of Mislabeled Radiographs
14
Wrong-site/Wrong-patient Prevention
15
Prophylactic Beta Blockers for Elective Surgery
16
Pressure Ulcer Prevention
17
DVT/VTE- Risk Assessment & Prevention
27
18
Anticoagulation Services
39
19
Aspiration Prevention
24
20
Central Venous Line Sepsis Prevention
33
21
Surgical Site Infection/AB Prophylaxis
37
22
Contrast-induced Renal Failure Protocol
12
23
Malnutrition Prevention
12
24
Tourniquet—Ischemia/Thrombosis Prevention
9
25
Hand Washing
33
26
Flu Vaccination for HC Workers
11
27
Optimize Medication Workspaces
7
28
Optimize Med. Storage/Pkg/Labeling
22
29
I.D. High Alert Medications
21
30
Med. Unit Dosing/Unit-of-Use Dispensing
29
SUBTOTAL
© 2004 TMIT Leapfrog Survey 1.0.
32
9
12
16
30
23
28
465
12
11.17.03 1600 CT
27 NQF Safe Practices Weighting Results
Enterprise-wide System
#
Practice
Final Weighting out of 1000 points
1
Create Safety Culture
263
3
Ensure Adequate Nursing Workforce
119
SUBTOTAL
382
Enterprise-wide Process
6
Verbal Order Readback
36
7
Standardized Abbrev./Doses
17
8
No Pt Care Summaries from Memory
17
9
Pt Care Info/Orders to all Providers
84
SUBTOTAL
154
TOTAL ENTERPRISE-WIDE
536
© 2004 TMIT Leapfrog Survey 1.0.
13
11.17.03 1600 CT
27 NQF Safe Practices Weighting Results
Clinical Care Setting or Function Specific
5
Pharmacist Active in Med Use
32
10
Pt Readback of Informed Consent
9
11
Document Resusc./End of Life/ Directives
12
13
Prevention of Mislabeled Radiographs
16
14
Wrong-site/Wrong-patient Prevention
30
15
Prophylactic Beta Blockers for Elective Surgery
23
16
Pressure Ulcer Prevention
28
17
DVT/VTE- Risk Assessment & Prevention
27
18
Anticoagulation Services
39
19
Aspiration Prevention
24
20
Central Venous Line Sepsis Prevention
33
© 2004 TMIT Leapfrog Survey 1.0.
14
11.17.03 1600 CT
27 NQF Safe Practices Weighting Results
Clinical Care Setting or Function Specific
21
Surgical Site Infection/AB Prophylaxis
37
22
Contrast-induced Renal Failure Protocol
12
23
Malnutrition Prevention
12
24
Tourniquet—Ischemia/Thrombosis Prevention
9
25
Hand Washing
33
26
Flu Vaccination for HC Workers
11
27
Optimize Medication Workspaces
7
28
Optimize Med. Storage/Pkg/Labeling
22
29
I.D. High Alert Medications
21
30
Med. Unit Dosing/Unit-of-Use Dispensing
29
SUBTOTAL
© 2004 TMIT Leapfrog Survey 1.0.
465
15
11.17.03 1600 CT
What Guiding Principles were used to design the 1.0 Survey Questions?
1. Compliment the NQF Safe Practices Report (May 2003): The survey,
weighting system, and ranking system designs are explicitly tied to the problem
areas and practices defined by the NQF report. Recognizing the challenges of
tying standards, measures, or practices to a report that is written at a snapshot
in time, the survey, weighting, and ranking systems take into account that new
evidence and refinement of performance improvement methods are being
generated all the time. Patient safety is an emerging science and is constantly
evolving. Therefore, the guiding principles included focus on the excellent list of
safety problems being targeted by NQF practices and apply the “4 A
Framework” below. The “4 A Framework” provides real flexibility of interpretation
and provides a means of providing partial credit for partial progress and partial
credit for commitment to progress. Although the survey will undergo refinement
through public review and optimization by our subject matter experts, the design
will be kept intact in order to make the survey fair and reasonable. The goal is to
neutralize the challenges of explicitly tying questions to specific language of
practices that are evolving while staying well within the scope of the NQF report.
2. Partial Credit for Partial Progress: The questions were designed using a
“select any that apply” response giving hospitals numerous opportunities for
partial credit. Once significant public input is provided, a set of FAQs will be
provided for each question to assure that respondents will have clarity regarding
what will qualify for credit on a question specific basis.
3. Partial Credit for Commitment: Many of the questions provide partial credit to
organizations that make substantial commitment to get started. This will help
those that may be “behind the safety curve”. The intent is to provide a clear
roadmap to organizations that have heretofore not prioritized safety. These
questions are also intended to provide fairness in areas where patient safety
issues have not been well publicized.
4. Systematic Application of 4A Framework : The 4A framework recognizes the
sequential and interdependent nature of awareness of our performance
opportunities, accountability of leadership, the ability to employ practices, and
measurable action towards closing performance gaps. This “4A Framework”
(updated from a 3 A framework published by C. Denham in 2001) was used as
an organizational structure to allow systematic customization of survey
questions.
 Awareness: Clearly, the leaders of an organization must be aware of
performance problems before they can make any impact on them. The
concept of THE problem or performance opportunity addresses the
awareness by hospitals that there is evidence to support a common
problem across all hospitals. The concept of OUR problem addresses
awareness of the frequency and severity of adverse events to our patient
population within our organization and recognition of the impact that
practices or performance improvement methods can have on those
adverse events. Awareness of THE performance opportunities and OUR
performance opportunities are addressed in a relatively standardized
manner in each survey question, however they were customized to each
problem depending on the current state of awareness in the community.
 Accountability: A critical success factor to patient safety is
accountability of the leadership to performance. Whether the
mechanisms of personal performance reviews or performance
compensation incentives are used, sustained gains in patient safety
frequently do not occur without personal accountability of the leaders.
This issue was addressed in a relatively standardized way throughout
the survey, however the questions were fine tuned to the scope or
care setting addressed by the practice.
 Ability: An organization may be aware of THE problem – a
performance gap common to most hospitals. In fact they may be
aware of OUR problem (their own) with clear evidence of frequency
and severity of adverse events in their own patient population. They
may even have awareness of the impact of a given practice, however
if they do not invest in education or skill development and more
importantly allocate real protected staff time and dollars to a given
problem, the impact on safety is modest at best. Adding a patient
safety responsibility to an already overloaded employee without
carving out the time and providing them the necessary financial
resources to make an impact sends a clear message to the
organization. The “ability” related survey questions employ a
graduated set of investment levels ranging from investment in
education, skill development (training regarding the application of
practices or performance improvement methods), dedicated HR, and
dedicated line item budget allocations.
 Actions: Action activities were tied to the NQF cited best practices
language as appropriate. Where there have been great strides in best
practices, the survey questions provide latitude for activities
deserving credit. A set of FAQs will be tied to each survey question
that will provide guidance as to what activities may qualify for credit,
especially if certain developments in patient safety have been
substantiated in the literature after publication of the NQF report.
Performance Improvement programs and project actions were given
high emphasis, as such, these programs will require thorough
literature reviews and examination of readily available practices be
undertaken. Such initiatives would include but not limited to the NQF
practices especially if there were new high impact actions that target
the problems listed in the NQF report. Far more important than
attestations of compliance to procedures, policies, and protocols are
ongoing programs that have regular measurement and process
improvement elements.
5. Sensitivity to use of the word “Problem”: Risk managers at hospital
organizations have expressed concern over the use of the word “problem”,
therefore wherever possible the term “performance opportunity” was used in
the survey in place of the word “problem”. That is not to say the word
problem is not used appropriately in the NQF report. It is.
1. Compliment the NQF Safe Practices Report (May 2003):
• The survey, weighting system, and ranking system designs
are explicitly tied to the problem areas and practices
defined by the NQF report.
•
Recognizing the challenges of tying standards, measures,
or practices to a report that is written at a snapshot in time,
the survey, weighting, and ranking systems take into
account that new evidence and refinement of
performance improvement methods are being
generated all the time.
•
Patient safety is an emerging science and is constantly
evolving. The goal is to neutralize the challenges of
explicitly tying questions to specific language of
practices that are evolving while staying well within the
scope of the NQF report.
© 2004 TMIT Leapfrog Survey 1.0
16
11.17.03 1600 CT
What Guiding Principles were used to design the 1.0 Survey Questions?
1. Compliment the NQF Safe Practices Report (May 2003): The survey,
weighting system, and ranking system designs are explicitly tied to the problem
areas and practices defined by the NQF report. Recognizing the challenges of
tying standards, measures, or practices to a report that is written at a snapshot
in time, the survey, weighting, and ranking systems take into account that new
evidence and refinement of performance improvement methods are being
generated all the time. Patient safety is an emerging science and is constantly
evolving. Therefore, the guiding principles included focus on the excellent list of
safety problems being targeted by NQF practices and apply the “4 A
Framework” below. The “4 A Framework” provides real flexibility of interpretation
and provides a means of providing partial credit for partial progress and partial
credit for commitment to progress. Although the survey will undergo refinement
through public review and optimization by our subject matter experts, the design
will be kept intact in order to make the survey fair and reasonable. The goal is to
neutralize the challenges of explicitly tying questions to specific language of
practices that are evolving while staying well within the scope of the NQF report.
2. Partial Credit for Partial Progress: The questions were designed using a
“select any that apply” response giving hospitals numerous opportunities for
partial credit. Once significant public input is provided, a set of FAQs will be
provided for each question to assure that respondents will have clarity regarding
what will qualify for credit on a question specific basis.
3. Partial Credit for Commitment: Many of the questions provide partial credit to
organizations that make substantial commitment to get started. This will help
those that may be “behind the safety curve”. The intent is to provide a clear
roadmap to organizations that have heretofore not prioritized safety. These
questions are also intended to provide fairness in areas where patient safety
issues have not been well publicized.
4. Systematic Application of 4A Framework : The 4A framework recognizes the
sequential and interdependent nature of awareness of our performance
opportunities, accountability of leadership, the ability to employ practices, and
measurable action towards closing performance gaps. This “4A Framework”
(updated from a 3 A framework published by C. Denham in 2001) was used as
an organizational structure to allow systematic customization of survey
questions.
 Awareness: Clearly, the leaders of an organization must be aware of
performance problems before they can make any impact on them. The
concept of THE problem or performance opportunity addresses the
awareness by hospitals that there is evidence to support a common
problem across all hospitals. The concept of OUR problem addresses
awareness of the frequency and severity of adverse events to our patient
population within our organization and recognition of the impact that
practices or performance improvement methods can have on those
adverse events. Awareness of THE performance opportunities and OUR
performance opportunities are addressed in a relatively standardized
manner in each survey question, however they were customized to each
problem depending on the current state of awareness in the community.
 Accountability: A critical success factor to patient safety is
accountability of the leadership to performance. Whether the
mechanisms of personal performance reviews or performance
compensation incentives are used, sustained gains in patient safety
frequently do not occur without personal accountability of the leaders.
This issue was addressed in a relatively standardized way throughout
the survey, however the questions were fine tuned to the scope or
care setting addressed by the practice.
 Ability: An organization may be aware of THE problem – a
performance gap common to most hospitals. In fact they may be
aware of OUR problem (their own) with clear evidence of frequency
and severity of adverse events in their own patient population. They
may even have awareness of the impact of a given practice, however
if they do not invest in education or skill development and more
importantly allocate real protected staff time and dollars to a given
problem, the impact on safety is modest at best. Adding a patient
safety responsibility to an already overloaded employee without
carving out the time and providing them the necessary financial
resources to make an impact sends a clear message to the
organization. The “ability” related survey questions employ a
graduated set of investment levels ranging from investment in
education, skill development (training regarding the application of
practices or performance improvement methods), dedicated HR, and
dedicated line item budget allocations.
 Actions: Action activities were tied to the NQF cited best practices
language as appropriate. Where there have been great strides in best
practices, the survey questions provide latitude for activities
deserving credit. A set of FAQs will be tied to each survey question
that will provide guidance as to what activities may qualify for credit,
especially if certain developments in patient safety have been
substantiated in the literature after publication of the NQF report.
Performance Improvement programs and project actions were given
high emphasis, as such, these programs will require thorough
literature reviews and examination of readily available practices be
undertaken. Such initiatives would include but not limited to the NQF
practices especially if there were new high impact actions that target
the problems listed in the NQF report. Far more important than
attestations of compliance to procedures, policies, and protocols are
ongoing programs that have regular measurement and process
improvement elements.
5. Sensitivity to use of the word “Problem”: Risk managers at hospital
organizations have expressed concern over the use of the word “problem”,
therefore wherever possible the term “performance opportunity” was used in
the survey in place of the word “problem”. That is not to say the word
problem is not used appropriately in the NQF report. It is.
2. Partial Credit for Partial Progress:
• The questions were designed using a “select any that
apply” response giving hospitals numerous
opportunities for partial credit. Once significant public
input is provided, a set of FAQs will be provided for each
question to assure that respondents will have clarity
regarding what will qualify for credit on a question specific
basis.
3. Partial Credit for Commitment:
• Many of the questions provide partial credit to
organizations that make substantial commitment to
get started. This will help those that may be “behind the
safety curve”. The intent is to provide a clear roadmap to
organizations that have heretofore not prioritized safety.
These questions are also intended to provide fairness in
areas where patient safety issues have not been well
publicized.
© 2004 TMIT Leapfrog Survey 1.0
17
11.17.03 1600 CT
What Guiding Principles were used to design the 1.0 Survey Questions?
1. Compliment the NQF Safe Practices Report (May 2003): The survey,
weighting system, and ranking system designs are explicitly tied to the problem
areas and practices defined by the NQF report. Recognizing the challenges of
tying standards, measures, or practices to a report that is written at a snapshot
in time, the survey, weighting, and ranking systems take into account that new
evidence and refinement of performance improvement methods are being
generated all the time. Patient safety is an emerging science and is constantly
evolving. Therefore, the guiding principles included focus on the excellent list of
safety problems being targeted by NQF practices and apply the “4 A
Framework” below. The “4 A Framework” provides real flexibility of interpretation
and provides a means of providing partial credit for partial progress and partial
credit for commitment to progress. Although the survey will undergo refinement
through public review and optimization by our subject matter experts, the design
will be kept intact in order to make the survey fair and reasonable. The goal is to
neutralize the challenges of explicitly tying questions to specific language of
practices that are evolving while staying well within the scope of the NQF report.
2. Partial Credit for Partial Progress: The questions were designed using a
“select any that apply” response giving hospitals numerous opportunities for
partial credit. Once significant public input is provided, a set of FAQs will be
provided for each question to assure that respondents will have clarity regarding
what will qualify for credit on a question specific basis.
3. Partial Credit for Commitment: Many of the questions provide partial credit to
organizations that make substantial commitment to get started. This will help
those that may be “behind the safety curve”. The intent is to provide a clear
roadmap to organizations that have heretofore not prioritized safety. These
questions are also intended to provide fairness in areas where patient safety
issues have not been well publicized.
4. Systematic Application of 4A Framework : The 4A framework recognizes the
sequential and interdependent nature of awareness of our performance
opportunities, accountability of leadership, the ability to employ practices, and
measurable action towards closing performance gaps. This “4A Framework”
(updated from a 3 A framework published by C. Denham in 2001) was used as
an organizational structure to allow systematic customization of survey
questions.
 Awareness: Clearly, the leaders of an organization must be aware of
performance problems before they can make any impact on them. The
concept of THE problem or performance opportunity addresses the
awareness by hospitals that there is evidence to support a common
problem across all hospitals. The concept of OUR problem addresses
awareness of the frequency and severity of adverse events to our patient
population within our organization and recognition of the impact that
practices or performance improvement methods can have on those
adverse events. Awareness of THE performance opportunities and OUR
performance opportunities are addressed in a relatively standardized
manner in each survey question, however they were customized to each
problem depending on the current state of awareness in the community.
 Accountability: A critical success factor to patient safety is
accountability of the leadership to performance. Whether the
mechanisms of personal performance reviews or performance
compensation incentives are used, sustained gains in patient safety
frequently do not occur without personal accountability of the leaders.
This issue was addressed in a relatively standardized way throughout
the survey, however the questions were fine tuned to the scope or
care setting addressed by the practice.
 Ability: An organization may be aware of THE problem – a
performance gap common to most hospitals. In fact they may be
aware of OUR problem (their own) with clear evidence of frequency
and severity of adverse events in their own patient population. They
may even have awareness of the impact of a given practice, however
if they do not invest in education or skill development and more
importantly allocate real protected staff time and dollars to a given
problem, the impact on safety is modest at best. Adding a patient
safety responsibility to an already overloaded employee without
carving out the time and providing them the necessary financial
resources to make an impact sends a clear message to the
organization. The “ability” related survey questions employ a
graduated set of investment levels ranging from investment in
education, skill development (training regarding the application of
practices or performance improvement methods), dedicated HR, and
dedicated line item budget allocations.
 Actions: Action activities were tied to the NQF cited best practices
language as appropriate. Where there have been great strides in best
practices, the survey questions provide latitude for activities
deserving credit. A set of FAQs will be tied to each survey question
that will provide guidance as to what activities may qualify for credit,
especially if certain developments in patient safety have been
substantiated in the literature after publication of the NQF report.
Performance Improvement programs and project actions were given
high emphasis, as such, these programs will require thorough
literature reviews and examination of readily available practices be
undertaken. Such initiatives would include but not limited to the NQF
practices especially if there were new high impact actions that target
the problems listed in the NQF report. Far more important than
attestations of compliance to procedures, policies, and protocols are
ongoing programs that have regular measurement and process
improvement elements.
5. Sensitivity to use of the word “Problem”: Risk managers at hospital
organizations have expressed concern over the use of the word “problem”,
therefore wherever possible the term “performance opportunity” was used in
the survey in place of the word “problem”. That is not to say the word
problem is not used appropriately in the NQF report. It is.
4. Systematic Application of 4 A Framework:
•
© 2004 TMIT Leapfrog Survey 1.0
The 4A framework recognizes the sequential and
interdependent nature of awareness of our
performance opportunities, accountability of
leadership, the ability to employ practices, and
measurable action towards closing performance
gaps. This “4A Framework” (updated from a 3 A
framework published by C. Denham in 2001) was
used as an organizational structure to allow
systematic customization of survey questions.
18
11.17.03 1600 CT
AWARENESS
4 A Framework
ACCOUNTABILITY
OUR PROBLEM
In Strategic/Ops
Plan
Commit To
Strategic/Ops Plan
Measured Events
with Opportunity
Report To Admin
Commitment
To Measure and
Report To Admin
THE PROBLEM
Evidence
Of Education
Commitment
to Educate
• The 4 A Framework provides a graduated scale of
options for to Awareness, Accountability, Ability,
and Action.
BOARD
• The survey design was intended to deliver partial
credit for partial progress in each of the 4 A
categories.
CEO
Commitment to
Report Board
Commitment to
CEO Accountability
• Partial credit for commitment is provided not only to
help stratify the respondents but to create a
Hawthorne effect: to encourage commitment
through participation in the survey and recognition
that a hospital organization could increase its score
by making a commitment at the time of survey
response.
SR. EXECs
Commitment to
Exec.s Accountability
DEPT HEAD
Commitment to
Dept. Head Accountability
• The Rural Hospital Task Force will apply the 4 A
Framework to the first 3 Leapfrog Leaps. The
objective is to create a fair and reasonable set of
survey questions to address the unique
characteristics of rural hospitals.
ABILITY
ACTION
Enterprise-wide PI
Program OR Rigorous
Practice Implementation
Line Item
Budget
Commit to
Budget
Dedicated
HR
Clinical Functional Unit
wide, Department-wide
Service Line wide PI
Program
Commit to
Dedicated HR
Invest in
Skills
Intermediate Level of
Practice Actions
Commit to
Invest in Skills
Commit to Enterprise-wide
PI Program OR Rigorous
Practice Implementation
Commit to Clinical Functional
Unit wide, Department-wide
Service Line wide PI Program
Commit to
Invest in Skills
Invest in
Education
Basic Level of
Practice Actions
Commit to
Invest in
Education
Commit to Performance
Improvement Program
Confidential – Not to be distributed
© 2004 HCC Corporation
19
hccarchive\fdtncomp\communication\tools\
template\topdown.pot
AWARENESS
AWARENESS
ACCOUNTABILITY
OUR PROBLEM
OUR
PROBLEM
In Strategic/Ops
BOARD
Plan
In Strategic/Ops
Commit To
Plan Strategic/Ops Plan
Measured Events
with Opportunity
Report To Admin
Commitment
Measured Events
To Measure and
Report To Admin
with Opportunity
THE PROBLEM
Report
Evidence To Admin
Of Education
THE PROBLEM
Commitment
to Educate
Commitment to
Report Board
CEO
Commit To
Strategic/Ops Plan
Commitment to
CEO Accountability
SR. EXECs
Commitment to
Exec.s Accountability
Commitment
To Measure and
Report To Admin
DEPT HEAD
Commitment to
Dept. Head Accountability
Evidence
Of Education
Commitment
to Educate
ABILITY
ACTION
Enterprise-wide PI
Program OR Rigorous
Practice Implementation
Line Item
Budget
Commit to
Budget
Dedicated
HR
Clinical Functional Unit
wide, Department-wide
Service Line wide PI
Program
Commit to
Dedicated HR
Invest in
Skills
Intermediate Level of
Practice Actions
Commit to
Invest in Skills
Commit to Clinical Functional
Unit wide, Department-wide
Service Line wide PI Program
Commit to
Invest in Skills
Invest in
Education
Basic Level of
Practice Actions
Commit to
Invest in
Education
© 2004 HCC Corporation
Commit to Enterprise-wide
PI Program OR Rigorous
Practice Implementation
Commit to Performance
Improvement Program
20
hccarchive\fdtncomp\communication\tools\
template\topdown.pot
ACCOUNTABILITY
AWARENESS
OUR PROBLEM
In Strategic/Ops
Plan
BOARD
Commit To
Strategic/Ops Plan
Commitment to
Report Board
Measured Events
with Opportunity
Report To Admin
CEO
Commitment
To Measure and
Report To Admin
THE PROBLEM
Evidence
Of Education
SR. EXECs
Commitment to
CEO
Accountability
Commitment to
Exec.s Accountability
Commitment
to Educate
DEPT HEAD
Commitment to
Dept. Head
ACTION
Accountability
ABILITY
Enterprise-wide PI
Program OR Rigorous
Practice Implementation
Line Item
Budget
Commit to
Budget
Dedicated
HR
Clinical Functional Unit
wide, Department-wide
Service Line wide PI
Program
Commit to
Dedicated HR
Invest in
Skills
Intermediate Level of
Practice Actions
Commit to
Invest in Skills
Commit to Clinical Functional
Unit wide, Department-wide
Service Line wide PI Program
Commit to
Invest in Skills
Invest in
Education
Basic Level of
Practice Actions
Commit to
Invest in
Education
© 2004 HCC Corporation
Commit to Enterprise-wide
PI Program OR Rigorous
Practice Implementation
Commit to Performance
Improvement Program
21
hccarchive\fdtncomp\communication\tools\
template\topdown.pot
AWARENESS
ACCOUNTABILITY
OUR PROBLEM
In Strategic/Ops
Plan
Commitment to
Report Board
Commit To
Strategic/Ops Plan
Measured Events
with Opportunity
Report To Admin
THE PROBLEM
Commitment to
CEO Accountability
Commitment
To Measure and
Report To Admin
Commitment to
Exec.s Accountability
Evidence
Of Education
Commitment to
Dept. Head Accountability
Commitment
ABILITY
to Educate
Line Item
Budget
Dedicated
HR
Invest in
Skills
Invest in
Education
© 2004 HCC Corporation
ACTION
Commit to
Budget
Enterprise-wide PI
Program OR Rigorous
Practice Implementation
Commit to
Dedicated HR
Clinical Functional Unit
wide, Department-wide
Service Line wide PI
Program
Intermediate Level of
Practice Actions
Commit to
Invest in Skills
Commit to Enterprise-wide
PI Program OR Rigorous
Practice Implementation
Commit to Clinical Functional
Unit wide, Department-wide
Service Line wide PI Program
Commit to
Invest in Skills
Basic Level of
Practice Actions
Commit to Performance
Improvement Program
Commit to Invest
in Education
22
hccarchive\fdtncomp\communication\tools\
template\topdown.pot
AWARENESS
ACCOUNTABILITY
OUR PROBLEM
In Strategic/Ops
Plan
Commitment to
Report Board
Commit To
Strategic/Ops Plan
Measured Events
with Opportunity
Report To Admin
Commitment to
CEO Accountability
Commitment
To Measure and
Report To Admin
THE PROBLEM
Commitment to
Exec.s Accountability
Evidence
Of Education
Commitment
to Educate
Line Item
Budget
Commit to
Budget
Dedicated
HR
ACTION
Enterprise-wide PI
Program OR Rigorous
Practice Implementation
ABILITY
Commit to
Dedicated HR
Invest in
Skills
Commit to
Invest in Skills
Invest in
Education
Commit to
Invest in
Education
Clinical Functional Unit
wide, Department-wide
Service Line wide PI
Program
Intermediate Level of
Practice Actions
Basic Level of
Practice Actions
Confidential – Not to be distributed
© 2004 HCC Corporation
Commitment to
Dept. Head Accountability
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Commit to Enterprise-wide
PI Program OR Rigorous
Practice Implementation
Commit to Clinical Functional
Unit wide, Department-wide
Service Line wide PI Program
Commit to
Invest in Skills
Commit to Performance
Improvement Program
hccarchive\fdtncomp\communication\tools\
template\topdown.pot
24
www.SafetyLeaders.org
Submitter’s Toolbox
Five Stages for Submission:
Prepare
Plan
Collect
Assess
Submit
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© 2004 TMIT
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TMIT
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Surviving the No Outcome No Income Tsunami:
• Breaking News in Pay-4-Performance
• The “C-Suite” Perspective
• Building the Business Case
• Communicating to the “C-Suite”
© 2004 TMIT
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Chris Olivia MD, MBA
CEO
Cooper Healthcare Before:
Facing bankruptcy
Major turnaround over 24 months
Unfavorable payer mix
Poor reimbursement
After a Focus on Quality:
Major Financial Reversal
Upgraded Bond Rating
Now Starting a new medical school
© 2004 TMIT
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Warren Buffett
“The chains of habit
are too light to be
noticed until they are
too heavy to be
broken.”
© 2004 TMIT
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Surviving the No Outcome No Income Tsunami:
• Breaking News in Pay-4-Performance
• The “C-Suite” Perspective
• Building the Business Case
• Communicating to the “C-Suite”
© 2004 TMIT
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Business Case Design
Revenue – Cost = Margin
ProForma
• Givens, Assumptions, and Variables:
• Format: Typical Comprehensive Investment
• Time: ( ex. 3 years )
• Metrics: ( ex. cost per discharge )
1.Additional L.O.S.
2.Measures of harm
3.NCC MERP
• Are There Trends? What is the trajectory of trends and what
might be the drivers
• Return on a Risk Management Program
© 2004 TMIT
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The Blunt and Sharp Ends
Blunt End
Organizations, Institutions,
Policies, Procedures, Regulations
Resources and
Constraints
Practitioner
Knowledge
Goals
Mindset
Sharp End
Errors and
Expertise
Monitored Process
© 2004 TMIT
*Adapted from Cook and Woods Tale of Two Stories
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SAFETY
INNOVATION
SAFETY
INNOVATION
SAFETY
INNOVATION
HUMAN FACTORS
PROCESS
REENGINEERING
SAFETY
CULTURE
© 2004 TMIT
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SAFETY
CHALLENGES
Traditional and New Technologies
Traditional and New
Technologies
Combined
Combined Performance Potential
Traditional
versus New
Performance Gap
Technical
Performance
Switching
Point
Traditional
Alone
New
Alone
Savings from Combining Traditional and
New Technologies
Effort (Elapsed Time, Cost)
Source: Thomke, Stefan, Enlightened Experimentation: The new Imperative for Innovation, Harvard Business Review, Feb 2001.
© 2004 TMIT
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Stages of Change Model
Time and Energy Required
Disaster
Failure
Ideal
1
2
Pre-contemplation
3
Contemplation
4
5
Preparation
Time
Source: VHA’s 2003 Research Series – The fusion of Technology and Work Force
Medscape
© 2004 TMIT
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Action
Maintenance
Recommendations for Business Case
Development
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
© 2004 TMIT
Keep it Simple
Frame the Issues and Decision
Use the Blunt End – Sharp End approach
Take an Enabling Solutions approach
Use a Revenue – Expense = Margin framework
Provide Compelling Evidence
Appeal to all Stakeholders
Preemptively Identify Concerns
Teach them to Fish – Don’t Give them a Fish
Never Accept Supplier Stories at Face Value
Take a Full Value approach to calculating impact
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PAST
Revenue – Cost = Margin
All Admissions are good
and all revenue is good
© 2004 TMIT
Cost takes care of
itself
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All admissions that
generate revenue
generate margin
PRESENT
Revenue – Cost = Margin
• Frequently revenue is
generated at greater cost
than payment. (margin
negative revenue)
• Safety is becoming a
discriminator for choice
by educated consumers.
• Cost pressures are
huge
• Adverse events
generate great cost.
• Greatest margin impact
will be through cost
reduction from optimal
clinical and operational
performance.
• Adverse events convert
THERE IS A BUSINESS
margin positive
CASE FOR SAFETY …..
admissions to margin
• Educated Consumers
negative admissions.
IT IS CALLED ECONOMIC
increasingly have portable
• Optimal outcomes are
SURVIVAL!
financial resources and
will reward best outcomes. generated at lower cost
AND
than worse outcomes.
• Employers are demanding
safety to award contracts • Spending (tech) wisely IT MUST BE MADE AT
now can save cost later THE STRATEGIC LEVEL
© 2004 TMIT
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Revenue – Cost = Margin
• Internal Operational Cost
• Ongoing Monitoring Costs
• Malpractice Claims Paid
• Opportunity Costs
• Malpractice Insurance
• Billable time of care givers
• Legal Fees
• Staff Back-fill, overtime
• Expert Witness Fees
• Paid administrative leave for the event
• Copies/depositions/transcripts
• Patient productivity loss, lost pay, lost
• Consultant Fees
employer administrative expenses
• Demonstrative Evidence
• Equipment down that requires
• Lost Productivity
cancellation of other volume
• Counseling + Staff support
• Lost recruitment costs
• Mock Trials
• Joint Commission and Regulatory Costs
• Focus Groups
such as NRC, state licensing boards,
• Cost of doing business for
medical boards, DEA
malpractice insurance company
• PR Counter Measures
• Cost to defend approx $35K
• Internal Legal and Support Costs
• Post suit defensive medicine
• Additional Length of Stay
• Stop-loss insurance cost
• Cost of outpatient care additional
• Added Diagnostic +Therapeutic costs rehab.
© 2004 TMIT
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Provider Options: Aggressive vs Passive Approach
Strategic
Initiatives
Performance Based
Payment
F
o
c
u
s
Transaction Based Payment
Time
© 2002 HCC, Inc.
Provider Options: Aggressive vs Passive Approach
Strategic
Initiatives
Performance Based
Payment
F
o
c
u
s
Transaction Based Payment
Time
© 2002 HCC, Inc.
Provider Options: Aggressive vs Passive Approach
Strategic
Purchasers Demand
Performance
Initiatives
Leapfrog & CMS (HCFA)
Performance Based
Payment
Shift market share to
reward performance
F
o
c
u
s
Transaction Based Payment
Time
© 2002 HCC, Inc.
Provider Options: Aggressive vs Passive Approach
Strategic
Purchasers Demand
Performance
Initiatives
Leapfrog & CMS (HCFA)
Performance Based
Payment
Shift market share to
reward performance
F
o
c
u
s
No Change Option
Transaction Based Payment
Time
© 2002 HCC, Inc.
Provider Options: Aggressive vs Passive Approach
Strategic
Purchasers Demand
Performance
Initiatives
Leapfrog & CMS (HCFA)
Performance Based
Payment
Shift market share to
reward performance
F
o
c
u
s
Performance
Option Now
Present
No Change Option
Transaction Based Payment
Time
© 2002 HCC, Inc.
Provider Options: Aggressive vs Passive Approach
Strategic
Purchasers Demand
Performance
Initiatives
Leapfrog & CMS (HCFA)
Performance Based
Payment
Shift market share to
reward performance
F
o
c
u
s
Performance
Option Now
Present
Performance
Option Later
No Change Option
Transaction Based Payment
Time
© 2002 HCC, Inc.
Provider Options: Aggressive vs Passive Approach
Strategic
Purchasers Demand
Performance
Initiatives
Leapfrog & CMS (HCFA)
Performance Based
Payment
Shift market share to
reward performance
F
o
c
u
s
Performance
Option Now
Present
Performance
Option Later
No Change Option
Immediate Action Option
• Risk: Expense
• Benefit: Market Share
Transaction Based Payment
Time
© 2002 HCC, Inc.
Provider Options: Aggressive vs Passive Approach
Strategic
Purchasers Demand
Performance
Initiatives
Leapfrog & CMS (HCFA)
Performance Based
Payment
Shift market share to
reward performance
F
o
c
u
s
Performance
Option Now
Present
Immediate Action Option
• Risk: Expense
• Benefit: Market Share
Performance
Option Later
No Change Option
Delayed Action Option
• Risk: Lost Market Share and
loss of new opportunities.
• Benefit: Delayed Expense
Transaction Based Payment
Time
© 2002 HCC, Inc.
Provider Options: Aggressive vs Passive Approach
Strategic
Purchasers Demand
Performance
Initiatives
Leapfrog & CMS (HCFA)
Performance Based
Payment
Shift market share to
reward performance
F
o
c
u
s
Performance
Option Now
Present
Immediate Action Option
• Risk: Expense
• Benefit: Market Share
Performance
Option Later
No Change Option
Delayed Action Option
• Risk: Lost Market Share and
loss of new opportunities.
• Benefit: Delayed Expense
No Change Option
• Risk: High risk of lost
share & survival impact
• Benefit: No expense
Transaction Based Payment
Time
© 2002 HCC, Inc.
Communicating the Business Case
for Patient Safety to the “C-Suite”
• Breaking News in Pay-4-Performance
• The “C-Suite” Perspective
• Building the Business Case
• Communicating to the “C-Suite”
© 2004 TMIT
53
Financial ROI Calculation
Implementation Costs
Breakeven Years =
Annual Benefit – Carrying Costs
Source: Mark Smith CIO University of Pennsylvania Health System
© 2004 TMIT
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ExampleExample
ROI
ROI
(Ambulatory EMR)
Please Enter the following:
Description
Data
Number of Locations in department
1
Number of Providers (Physicians, PA)
4
Total Number of Visits Last Fiscal Year
12,000
Total Number of New Visits Last Fiscal Year
2,400
Total Charges Last Year
$1,980,000
Total Revenue Last Year
$1,000,000
Transcription Cost Last Year
$60,000
Average Annual Salary of a Med Rec Clerk
$25,000
Implementation Costs:
Implementation Team (10 weeks)
Abstraction (department Funded - TBD)
Software License
Server License
Site Hardware
PCs
Printers
Lab Printers
Scanners
Cabling
Total Implementation Costs
$78,645
$43,200
$60,000
Count
20
4
1
2
25
$48,000
$3,200
$1,500
$4,000
$7,500
--------------$246,045
Annual Carrying Costs:
Software Maintenance
Server Maintenance
Support Team Allocation (min 1/8 FTE)
$12,000
$6,000
$7,500
Total Annual Carrying Cost
$25,500
Direct Financial Benefits
Reduction in Transcription Costs
Increased Revenue from Charge Capture
Decreased Chart Creation Costs
Increased Support Staff Efficiencies
Total Annual Direct Financial Benefits
$51,000
$60,000
$8,400
$12,188
$131,588
Breakeven Analysis
Expect Breakeven (years)
© 2004 TMIT
Calculation:
2.3
Breakeven Years=Implementation
Costs/(Annual Benefit-Carrying Costs)
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ROI on PADE
• Estimated cost per preventable adverse drug event is
$4,685.
• Estimated preventable ADE is 5 per 1000 patient days.
• Published declines with CPOE range from 17% to 62%
decline depending on level of decision support
sophistication
• 100,000 patient days, 50% reduction = 250 avoided
• Potential annual savings of $1,171,250
Source: Mark Smith CIO University of Pennsylvania Health System
© 2004 TMIT
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Surviving the No Outcome No Income Tsunami:
• Breaking News in Pay-4-Performance
• The “C-Suite” Perspective
• Building the Business Case
• Communicating to the “C-Suite”
© 2004 TMIT
57
Winston Churchill
“Wait just a moment
while I review my
contemporaneous
comments”
© 2004 TMIT
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Gen. John R. Galvin
“Don’t bring me problems;
bring me solutions.”
NATO Supreme
Allied Commander
© 2004 TMIT
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