The Design of Health Care System Transformation

Panas Jesadaporn, MD, MS

Department of Internal Medicine,

Faculty of Medicine, Chiang Mai University

OUTLINE

• Health care delivery system and health care value

• Quality of care and measurement

• Cost and waste in healthcare system

• Quality improvement programs

• Care redesign

Health care delivery system

Jt Comm J Qual Patient Saf 2007 Nov;33(11 Suppl):3-6.

Environments

:Markets, Payers, Regulators, and

Consumers

People

Physical settings

Technologies

Care processes

Organization

:Rules, Structure, Information systems ,

Communication , Rewards, Workflow,

and Culture

System design research

(redesign, reinvent)

• Use tools for examining

interactions to improve care

value

Jt Comm J Qual Patient Saf 2006 Nov;32(11):599-611.

HEALTH CARE VALUE

↑ Quality

↓, ↔ Cost

↑ Care Value

↔, ↑ Quality

↓ Waste

QUALITY OF CARE

“The extent to

which health care

services provided

to individuals and

patient populations

improve desired

health outcomes”

WHO

• Safe

• Effective

• Patient-centered

• Timely

• Efficient

• Equitable

IOMFACCT

• Staying Healthy

• Getting Better

• Living with

Illness or

Disability

• Coping with the

End of Life

FROM PATIENT SAFETY TO SYSTEM REDESIGN

To Err Is

Human:

Building a

Safer Health System (1999)

Patient safety

Crossing the

Quality Chasm: A

New Health System

for the 21st Century

(2001)

How the health system

can be reinvented to

foster innovation and

improve the delivery of

care

CROSSING THE QUALITY CHASM

Crossing the Quality Chasm: A New Health System for the 21st Century.

Washington, D.C.: National Academy Press, 2001.

Included

• Six Aims for

Improvement and four

levels to address them

• Ten Rules for Redesign

Six Aims for Improvement

• Reducing the likelihood that patients are harmed by medical errors1. Safe

• Avoiding over and underuse of resources and services2. Effectiveness

• Customer service and to considering and accommodating individual patient needs when making care decisions3. Patient centeredness

• Reducing wait times4. Timeliness

• Reducing waste and total cost of care5. Efficiency

• Closing racial and income gaps in health care6. Equity

Four levels to address six aims

Level D: Legal, financial, and educational

environment

Level C: Organizations that house and support care-

giving microsystems

Level B: Care-giving microsystems

Level A: Patient experiences

• Financing, regulations, accreditation, litigation, workforce education, and social policy

• Better systems, ICT, training, team & care coordination, and measurement

• 3 principle: Knowledge-based, Patient-centric, and System-minded

• 10 simple rules

• Clear, comprehensive, and bold goals for quality improvement

Small groups of

people

Information system(s)

Client population

Processes

MICROCOSM (mai·krow·kaa·zm)

Level B: Care-giving microsystems

Ten Simples Rules for Microsystems Redesign

CURRENT NEW

1. Care is based primarily on visits. Care is based on continuous healing relationships.

2. Professional autonomy drives variability. Care is customized according to patients’ needs and

values.

3. Professionals control care. The patient is the source of control.

4. Information is a record. Knowledge is shared freely.

5. Decision making is based on training and

experience.

Decision making is based on evidence.

6. “Do no harm” is an individual responsibility. Safety is a system property.

7. Secrecy is necessary. Transparency is necessary.

8. The system reacts to needs. Needs are anticipated.

9 Cost reduction is sought. Waste is continuously decreased.

10. Preference is given to professional roles

over the system.

Cooperation among clinicians is a priority.

Why Measuring Healthcare Outcomes Is Important

Quadruple Aim

1. Improve the

patient

experience of

care.

2. Improve the

health of

populations.

3. Reduce the per

capita cost of

healthcare.

4. Reduce

clinician and staff

burnout.

The Top Seven Healthcare Outcome Measures by CMS

www.medicare.gov/hospitalcompare/About/What-Is-HOS.html

Measure CategoryWeight Used in

Calculation (%)

1. Mortality 22

2. Safety 22

3. Readmission 22

4. Patient Experience 22

5. Effectiveness of Care 4

6. Timeliness of Care 4

7. Efficient Use of Medical Imaging 4

Impact of Star Rating by Category

Understanding total care delivery costs

Source: Courtesy of Dr. Davia A. Burton, Intermoutain Healthcare

COST OF QUALITY

Buthmann, A. (2010). Cost of Quality: Not Only Failure Costs.

www.slideshare.net/raviupadhye/cost-of-quality-66451300

Estimating waste in frontline health care worker activities

Journal of Evaluation in Clinical Practice 14 (2008) 178–180

Journal of Evaluation in Clinical Practice 14 (2008) 178–180

Activity class Definition/description/examples

1. Operations Bedside caregivers: time spent with patients or family performing direct care.

Non-bedside staff: job-specific activity (e.g. phlebotomist drawing blood, scrub tech

assisting surgeon).

2. Clarifying Communication of information about work processes, including meetings, reports,

rounds, teaching, ‘huddles’, perusing medical records, locating information, paging or

telephoning.

3. Error/defect Mistakes or interruptions in work that require a corrective response. Errors included

planning failures, wrong actions or plans, and medication errors. Defects involved

equipment- (including computers) or supply related problems.

4. Processing Redundant work or activities that do not fundamentally change service delivery,

including documentation,

paperwork and preparation time.

5. Motion Inventory/stocking supplies, travelling, waiting, and locating missing items or people.

6. Other

• Interruptions

• Location

changes

All other activities not categorized above (e.g. talking to the observer).

Unanticipated external (to the worker) requests from people or other events that divert

attention from work.

Movement from one work area to another requiring more than 10 steps.

PROBLEMS

15

10

17

22

36

Miscellaneous other problems

Errors

Waiting and redundant work

Missing information

Supply- or equipment-related problems

• 2 problems per hour.

• 86% of problems

disrupted workflow

• 5% disrupted therapy.

HOW: Quality Improvement Programs

HSR: Health Services Research 43:5, Part II (October 2008)

Employee Recognition Programs

Benchmarking

Employee Suggestion Systems

100K Lives Campaign

Cross Functional Teams

Balanced Scorecard

PDCA

5 Millions Lives Campaign

FOCUS PDSA

Studer or StuderlikeProgram

Pay Bonus Plans

Lean Management

Supply Chain Management (SCM)

Customer Relationship

Management (CRM)

Internal Quality Programs

Voice of the Customer (VOC)

Six Sigma

Statistical Process Control (SPC)

Malcom Baldridge Award

External Awards

Quality Function Deployment (QFD)

Nobody Wants a Waiting Room

: transform the patient experience by

eliminating waiting rooms

Nobody Wants a Waiting Room: transform the patient experience by eliminating waiting rooms

Integrated Practice Units (IPUs)

• Built small-scale prototypes, then full-scale prototypes

• Agile

• Sprint

• Scrum

• Level D: Value-Based Model

• Level C: Design Institute for Health• Dell Medical School

• College of Fine Arts

• Level B,A:• Service model

• Physical layout of the clinic

www.catalyst.nejm.org/nobody-wants-waiting-room/

www.gv.com/sprint/