Fundamentals of Health System ReformRetention ‐Nurse Turnover yProblem: nurse turnover on liver transplant unit goes from 5% to 12% in one year y“Peeling the onion” for nurses:

© Pittsburgh Regional Health Initiative 2011 1

Moving the Big Needle:

Fundamentals of Health System Reform

Karen Wolk Feinstein,PhDPresident & Chief Executive Officer

July 21, 2011

Pittsburgh, PASpreading Quality, Containing Costs.


History of the Jewish Healthcare Foundation (JHF)

The Foundation was established following the sale of Montefiore Hospital to Presbyterian Hospital (the forerunner to UPMC Health System)

JHF maintains two seats on the UPMC Health System Board

Functions as a Public Charity (formerly a Private Foundation)


Staff and Functions

ThinkResearchersData analystsCommunications, media, writersPolicy analystsEvaluators

GiveProgram officersGrant managersFiscal agents for HIV/AIDS fundsAccounting

DoProgram directorsEvent plannersTrainers Grant writersWeb designersPublic relations

TrainCurriculum developersCoaches and trainers

40+ Staff


Jewish Healthcare Foundation

Had a VISION in 1997 for a High-Performing Healthcare System that was safer, more reliable, efficient and compassionate


What and Why: PRHI

Pittsburgh Regional Health Initiative (PRHI) A not-for-profit, regional, multi-stakeholder coalition formed in 1997 An initiative of a business group, the Allegheny Conference on Community Development

PRHI’s messageDramatic quality improvement (approaching zero deficiencies) is the best cost-containment strategy for health care


Formed in 1997

Before IOM Reports:To Err is Human: Building a Safer Health SystemCrossing Quality Chasm: A New Health System for the 21stCenturyMichael Porter’s Defining Competition in Markets: Why and How?

By Pittsburgh’s leading corporate CEO entity:The Allegheny Conference on Community Development

To create in the Pittsburgh region the highest value delivery system


PRHI’s Prescription for Transformation

Services That Add Value All Services Add Value

Preventable Complications

Unnecessary Treatments

Inefficiencies

Errors

100% Value

60% Value

40% Waste

NOW FUTURE


The Problem Was Worse Than We Thought

How Does the U.S. Measure Up Globally?

Source: Commonwealth Fund Commission on a High Performance Health

Australia Canada Germany NetherlandsNew

ZealandUnited Kingdom

United States

OVERALL RANKING (2010)

Quality Care

Effective Care

Safe Care

Coordinated Care

Patient‐Centered Care

Access

Cost‐Related Problem

Timeliness of Care

Efficiency

Equity

Long, Healthy, Productive Lives

Health Expenditures/ Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290

Country Rankings Excellent Fair Poor


Additional Grim Statistics

Source: Elizabeth A. McGlynn and Robert H. Brook, Rand, June 2003

55%45%

Percent of Americans receiving recommended care for preventive, chronic and acute conditions

Receive recommended careDo not receive recommended care

Just over 50% of Americans receive recommended care. Why?

What gets in the way of recommended care being provided 100% of the time?


The Persistence of Medical Errors in U.S.

Adapted from Milliman: The Economic Measurement of Medical Errors, June 2010

Error Type% of

Injuries that are Errors

Count of Errors (2008)

Total Cost per

Error

Total Cost of Error

(millions)

Pressure Ulcer (Medicare Never Event) >90% 374,964 $10,288 $3,858

Postoperative Infection >90% 252,695 $14,548 $3,676

Infection due to Central Venous Catheter >90% 7,062 $83,365 $589

Catheter - Associated Urinary Tract Infection (Medicare Never Event) >90% 12,839 $26,793 $344

Object Left in Body (Medicare Never Event) >90% 11,690 $8,031 $94

Blood-Type Incompatibility (Medicare Never Event) >90% 6,350 $11,738 $75

Total Cost of all errors = $19.5 Billion per year


Consequences of sub‐optimal care:Diabetes: missed opportunity to identify and intervene with serious consequences of poor blood sugar control at an early stageHypertension: 68,000 preventable deaths annuallyPreventative care:

10,000 preventable deaths from pneumonia9,600 preventable deaths from colorectal cancer

McGlynn et al, 2003

The System is Not Working Well For Patients


Reforming Health Care

Five phases of reform to achieve transformation:Phase 1 – Defining a Vision and Strategy to Deliver Value

Vision: perfect care = efficient + safe + best practiceStrategy: focus on the frontline, aim for ambitious targets, leadership support of continuous improvement

Phase 2 – The MethodDeveloped Perfecting Patient CareSM (PPC) and enlisted Champions of Reform

Phase 3 – Demonstrating the Value of PPC PPC tested in various settings


Reforming Health Care (contd.)

Five phases of reform to achieve transformation (contd.):Phase 4 – Aligning Incentives

Create climate and infrastructure for change, and reward teamworkChange policy and regulations, and reform payment systemsUse good data to allow for credible transparency

Phase 5 – Spread and Stabilization Knowledge networks spread quality and contain costQuality management tools support quality Champions


The Original Vision


Where Value Derives

THE PATIENT

• Outcomes of Care• Efficiency of Care• Zero Defects

Value begins at the front linewhere patients receive care


Toyota Lean Production Thinking: The Basics

Problems identified and solvedRapid root cause analysisOrganized work areasConcise communicationActive involvement of managers

“Go and see”On the floor

Intense respect for the employee:Every employee has what they need, when they need it to succeedCareer development

Team problem solving to meet customer need


What We Observe in Health Care

W. Edwards Deming, PhD: “Where Art Thou?”

ChaosUncertaintyRandom BehaviorsWork‐AroundsConfusionDisorderErrorsHigh TurnoverSecrecy


QI Inhibitors:The Cycle of Despair

+

No Education about High Performance

Low Aspirations

No QI Structure

Powerless Customers / Patients

Powerful Interests Resisting Change

Perverse Payment

Low Aspirations


Our Method: Perfecting Patient CareSM

PRHI’s Unique Brand of Quality Improvement

Adapted from LeanPatient-focused systems redesignCan be applied in the course of everyday workThe ultimate goal is perfection


Our Method:What is Unique About Perfecting Patient CareSM (PPC)?

One universal improvement method

Meeting patient need is the focus of all work

Frontline clinical teams apply daily problem‐solving methods and work process improvement techniques

Research occurs and is performed at the frontline

Focus is clinical care improvement


It’s Not Working Well for Providers, Either

2009 study in Annals of Internal Medicine reveals:• 53.1% of surveyed physicians reported time pressures during office visits

• 48.1% said their work pace is chaotic• 78.4% report low control over their work

• Strong association between “unfavorable organizational culture”and low physician satisfaction, high stress, burnout, and intent to leave

• Linzer et al, 2009


The Champion Role in Transformation

PPC empowers frontline staff…and more

Nurse Navigators

Nurse Managers

Team LeadersSalk Fellows

Patient Safety Fellows

Physician Champions

Clinical Pharmacists

Long‐term Care Workers

Librarians

Hospital Trustees

Emergency Medical Technicians

Caregivers


Retention ‐ Nurse Turnover

Problem: nurse turnover on liver transplant unit goes from 5% to 12% in one year“Peeling the onion” for nurses:Gives nurses a voiceLevels work loadEncourages nurses to ask for, and render, help

Nurse Navigator Christopher Saunders, MSN, RN


Nurse Turnover


Nurse Turnover


Nurse Turnover


Results

RN turnover rates on abdominal transplant unitYear RN Resignations

2003 3

2004 12 (12%)

2005 (Jan-Sept) 10

Jan 2006 (PPC innovations begun) to Dec 2006

0


68% Dropin CLABs in 34 regional hospitals

50% FewerReadmissionsw/ COPD focus

86% Reductionin medication errors

180 to Zero!Lost patient hours per

month due to ambulance diversions

Efficiency Increased 100%

in pathology lab

17% Dropin pediatric clinic

wait times

100% Reductionin nurse turnover

50% Reductionin pap smear

sampling defects

>20% DeclineNosocomialC. difficileinfections

35 to Zero!defective charts

100% Compliancew/guidelines & aspirinuse in a diabetes clinic

PRHI Stories of Success in Acute Care


Our Methods and Successes Have Attracted Attention


Key Media Placements

Health Affairs: Partnering Private Primary Care Practices with Federally Qualified Health Centers in the Care of Complex PatientsModern Healthcare: Reform CatalystsHealth Affairs Grant Watch Blog: Health Reform at the Retail Level: Community by Community, State by StateJournal of the American Medical Association: Health Care‐Associated Invasive MRSA Infections, 2005‐2008Hearst Newspapers: Dead by Mistake Follow‐upWashington Post: End‐of‐LifeHospital News of Western Pennsylvania: Monthly FeatureThe Role of Regional Health Improvement Collaboratives in HealthPolicy, USA; by Feinstein and Elster


“Bringing state‐of‐the‐art care to all will require a fundamental, sweeping redesign of the entire health system … merely making incremental improvements in current systems of care will not suffice.”

‐ The Institute of MedicineMarch 2001

The Bottom Line: Transformation of Organizations and Systems


PPC for Systems Transformation

PPC for Organizational Transformation

PPC for Repairs

An Early Vision for Perfecting Care

A Method for Perfecting Patient CareSM (PPC)

PPC in New Technologies and New Models

Moving Beyond Repair to Transformation


Global Vision

Culture of Quality and Safety

Quality Improvement Strategy

Targets and Measurement

Designated Champions and Teams

Training, Education and Coaching

Interdisciplinary/Transitional Collaborations

Research/Experimentation/Registries

Consumer and Purchaser Engagement

Information Technology

Public Reporting

Incentives for High Performance

Transforming Healthcare Organizations: Hit all the notes on the xylophone or no music


The Executive Role in Transformation

Paul O’Neill ‐ Alcoa Chairman, 1987‐1999

Corporate commitment to reduce workplace injury rate to zero

Imported Toyota Production System, manager accountability, real‐time data reporting to Alcoa; reduced workplace injuries by 90% over 12 years

Alcoa became the safest company in the world


Research Based Publications

The Complex Patient

HIV/AIDS End of Life

Skilled Nursing

Chronic Disease(COPD)

Behavioral Health and Substance Abuse

Multiple Conditions


Testing our Model:Reducing Preventable Hospitalizations — COPD

Our data mining identified chronic obstructive pulmonary disease (COPD) as a prominent cause of hospital admissions (4th highest) and readmissions (3rd highest)

Readmissions in Western PA, 2005-06

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

CHF Pneumonia Depression COPD KidneyFailure

AbnormalHeartbeat

Diabetes Asthma

Diagnosis at Initial Admission

# R

eadm

itted

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

% R

eadm

itted

# ReadmitsReadmit Rate


COPD Readmissions Reduction Results

By focusing on the transitions between care settings:30 readmissions prevented$160,000+ savedNet savings of $80,000+ after

cost of Care Manager44%

Reduction


The Second Systems Vision: Transforming the Care of Complex Patients

Care Mgt

Clinical Pharmacy

Patient Engagement

Health IT

QI Training

Payment Incentives

Collaboration and

Integration

Medication Reconciliation

Informed Activated Discerning Consumers

Data to Treat,

Measure, Evaluate

Perfect Patient Care

Rewardsfor

Collaboration

Hospice/Palliative

Long Term Care

Rehab

Hospital

Emergency Services

Specialty Care

Primary Care

Screening and Tx

Behavioral Health


Disruptive Innovations


“The challenge we face is not unique to health care. The transformational force that has brought value to other industries is disruptive innovation. The healthcare industry screams for disruption.”

‐ Clayton M. ChristensenThe Innovator’s Prescription: A Disruptive Solution for Health Care

Disruptive Innovations: System Transformations


Disruptive Innovations

1. Simple, less expensive, “upstream” innovations

2. Serve more with fewer features

Do not overshoot customer need

Show better understanding of customer need


“Training dosage had most important effect on measures of success. A combination of PPC training, additional training, and coaching were associated with improved outcomes. Social networking or on‐line technology can foster a virtual PPC community.”

‐ Donna O. Farley, PhDRAND: Results from the Retrospective Evaluation Effects of PPC University Training

The Technology Innovation


Why Tomorrow’s HealthCare™?

Spread best practices and lessons learned

Sustain quality improvement projects and staff learning

Improve team efficiency and communication

Achieve Pay-for-Performance objectives, reduce events that can lead to penalties

Train new employees quickly and reduce off-site training

A frontline learning and doing web-based tool that leverages the strengths of face-to face coaching


The Web‐based Solution: Tomorrow’s HealthCare™


How to Spread & Sustain TransformationTomorrow’s HealthCare™


Tomorrows HealthCare™: As a Management Tool

C‐Suite Dashboard – track progress of moving a full organization toward quality targets and transformation

Communications – establish groups of learners to foster open collaboration, share best practices and access coaching and networking tools

Lean Improvement A3 Tool – enables teams to:Review the steps of process improvementCreate a business caseDraw a current and target condition diagramsProduce an action plan detailing next steps in the improvement Automatically collect data and analyze outcome measures


The Current Agenda

For the Patient, it is care that is kind, competent, customized, comprehensive, safe and efficient; addressing the needs of vulnerable populations, including:

Seniors (Caregiver Champions) and Long Term Care ChampionsThe poor (Safety Net Medical Home Initiative)The chronically ill (Accountable Care Network)Those who are approaching End-of-Life (Closure)Persons living with behavioral health problems (AHRQ grant), and

persons living with HIV/AIDS (Readmissions Reductionproject)


The Current Agenda (cont’d)

For the Healthcare Worker, it means that care is:

Informed and supported (Regional Extension & Assistance Center for HIT)

Incentivized (Robert Wood Johnson Foundation payment reform grant and the Fine Awards)

Prepared by training and coaching (Perfecting Patient CareSM, Tomorrow’s HealthCareTM, PPC University, Fellowships and Champions Programs)


For Organizations and Systems, this focus includes:Training, coaching and leadership development (Perfecting Patient CareSM)

Comprehensive improvement and education tools (Tomorrow’s HealthCareTM)

Transformations and new models of care (Patient Centered MedicalHomes, Accountable Care Networks, Primary Care Resource Centers, Partners in Integrated Care)

Payment Reform (Robert Wood Johnson Foundation payment reform grant and the website The Center for Healthcare Quality and Payment Reform— www.chqpr.org)

The Current Agenda (cont’d)


Health Reform: An Historic Effort to Transform Health Care


Reforming Health Care

Five phases of reform to achieve transformation:Phase 1 – Defining a Vision and Strategy to Deliver Value

Vision: perfect care = efficient + safe + best practiceStrategy: focus on the frontline, aim for ambitious targets, leadership support of continuous improvement

Phase 2 – The MethodDeveloped Perfecting Patient CareSM (PPC) and enlisted Champions of Reform

Phase 3 – Demonstrating the Value of PPC PPC tested in various settings


Reforming Health Care (contd.)

Five phases of reform to achieve transformation (contd.):Phase 4 – Aligning Incentives

Create climate and infrastructure for change, and reward teamworkChange policy and regulations, and reform payment systemsUse good data to allow for credible transparency

Phase 5 – Spread and Stabilization Knowledge networks spread quality and contain costQuality management tools support quality Champions

Documents

Fundamentals of Health System ReformRetention ‐Nurse Turnover yProblem: nurse turnover on liver transplant unit goes from 5% to 12% in one year y“Peeling the onion” for nurses: