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Connecting Health and Health Care

May 23, 2013. Denver Medical Study Group. Jeff Selberg Executive Vice President and COO. Connecting Health and Health Care. From n=1 to n=7 x 10 9. Overview. Institute for Healthcare Improvement Overview What Problem Are We Trying To Solve? Disruptive Innovation

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Connecting Health and Health Care

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  1. May 23, 2013 Denver Medical Study Group Jeff Selberg Executive Vice President and COO Connecting Health and Health Care From n=1 to n=7 x 109

  2. Overview • Institute for Healthcare Improvement Overview • What Problem Are We Trying To Solve? • Disruptive Innovation • Connecting Health and Health Care • Courageous Adaptive Leadership

  3. IHI Overview

  4. 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

  5. Some of Our Groundbreaking Initiatives Are: • 100,000 and 5 Million Lives Campaigns • IHI Open School for Health Professions 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

  6. Our MissionTo 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. 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. 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.

  7. 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

  8. New IOM Framework

  9. Five Areas of Focus • Improvement Capability • Patient Safety • Person- and Family-Centered Care • Quality, Cost, and Value • The Triple Aim for Populations

  10. How We Work Goal: Harvest, create, and test bold, innovative ideas and new models of care that support our strategic initiatives Goal: Build reach and will to accelerate the pace of improvement worldwide Goal: Leverage strategic partnerships and key initiatives to achieve ambitious improvement goals Goal: Offer programming to transfer knowledge and build improvement capability

  11. How will we know whether the approaches and the changes result in improvement? Health Care Settings/Populations Innovation Testing Spread & Scale up Big Dot Outcomes/Performance US Neonatal Mortality Related Dots* Kirkpatrick Level Process/Culture Implementation of changes to reduce Neonatal Mortality LearningKnowledge of improvement methods ExperienceExcellent experience working with IHI 0 V? W? X? Y? Z? *We will see change at levels 1 to 3 much sooner than at level 4 Time (years)

  12. What Problem Are We Trying To Solve?

  13. 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

  14. PROBLEM Accounting for the Cost of U.S. health care, McKinsey&Company, December 2011

  15. HEALTHY LIVES Mortality Amenable to Health Care Deaths per 100,000 population* PROBLEM * 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). 17 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

  16. HEALTHY LIVES Infant Mortality Rate, 2007 PROBLEM 18 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

  17. QUALITY: SAFE CARE 19 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 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 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.

  18. 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

  19. 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

  20. 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

  21. Source: Health and Health Care in 2032: Report from the RWJF Futures Symposium

  22. Source: Health and Health Care in 2032: Report from the RWJF Futures Symposium

  23. Source: Health and Health Care in 2032: Report from the RWJF Futures Symposium

  24. Disruptive Innovation

  25. Jason Hwang, M.D., M.B.A The Innovator’s Prescription: How Disruptive Innovation Can Fix Health Care

  26. Centralization followed by decentralization in computing Jason Hwang, Innosight

  27. The decentralization that follows centralization is only beginning in health care Specialty care Laboratory services Imaging services Clinical research and training Data collection and warehousing Surgical suites Jason Hwang, Innosight

  28. The ReEngineeredDischargeReducing 30 Day All Cause Rehospitalization Rates Brian Jack, MD Professor and Chair Department of Family Medicine / Boston University School of Medicine Boston Medical Center Faculty & Fellowship Seminar Institute for Healthcare Improvement Cambridge, MA 02138 March 11, 2013

  29. Can Health IT assist with providing a comprehensive discharge?

  30. Characters: Louise (L) and Elizabeth (R) 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

  31. Studies of Nurse-Patient Interaction

  32. 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

  33. 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

  34. 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

  35. 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 real-time coaches. We believe that this radical shift in thinking is necessary to dramatically reduce healthcare costs, increase quality, and improve health outcomes.

  36. The Patient’s Health RecordCloud Infrastructure Fitness Center Home Telemetry Financial Services Grocery Store Pharmacy Home Health Care Primary Care Long Term Care Specialist Hospitals

  37. Connecting Health and Health Care

  38. 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 • New beliefs & behaviors • New relationships • New customers Adaptive Leadership Technical Leadership Models Adapted from: The Second Curve, I. Morrison, 1996 The Innovator’s Prescription, C. Christensen, 2008 Adaptive Design, J. Kenagy, 2009

  39. The Health and Health Care Continuum Alan Morris Intensive Care Optimal Functionality Full Cycle of Care Diagnosis Hospital Care Emory Orthopedic and Spinal Hospital (Clinical) Total Health Tony DiGioia (Clinical + Social) Hospital • Care Oregon • Kaiser Permanente Long Term Care Ambulatory Social Service Prevention

  40. 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

  41. 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.

  42. A Case Study From University of Pittsburgh Medical Center (UPMC) Aims in redesigning care for patients undergoing total joint replacement 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 Family-centered Collaborative Care: An Orthopaedic Model”. Clinical Orthopaedics and Related Research. 2007: 463; pp: 13-19.

  43. Better Care for Individuals • Better Health for Populations • Lower Per Capita Costs

  44. 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 • New beliefs & behaviors • New relationships • New customers Adaptive Leadership Technical Leadership Models Adapted from: The Second Curve, I. Morrison, 1996 The Innovator’s Prescription, C. Christensen, 2008 Adaptive Design, J. Kenagy, 2009

  45. Where are you in the Model Life Cycle? Transforming the Organization Viability • Adaptive Leadership • New beliefs & behaviors • New relationships • New customers Optimizing the Current Model • Technical Leadership: • Problem solving through expertise Patient Inflection Point Adaptive Leadership Technical Leadership Models Adapted from: The Second Curve, I. Morrison, 1996 The Innovator’s Prescription, C. Christensen, 2008 Adaptive Design, J. Kenagy, 2009

  46. The True Disruptors Christian Gilbert

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