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Experts believe that a stunning 20 to 40 percent of the $2.4 trillion America spends on health care in 2008 will be wasted on misuse (including harmful and fatal errors), overuse (care that’s unnecessary) or underuse ( effective care that’s not provided).
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Experts believe that a stunning 20 to 40 percent of the $2.4 trillion America spends on health care in 2008 will be wasted on misuse (including harmful and fatal errors), overuse (care that’s unnecessary) or underuse ( effective care that’s not provided). The Overuse and Misuse of Health Care Resources: Reduction of Bronchodilator Utilization in the Management of Acute Bronchiolitis in Children
Finding Value in Health Care’s : Our Escape Fire….. • The Five Domains of Value: • Access • Technical Quality • Functional Status • Service Satisfaction • Cost/price • Value (V) == A + TQ +FS + SS C
CoreConclusions of the IOM Report.. The problems come from poor systems…not badpeople • Every system is perfectly • designed to achieve exactly • the results it gets.
Changing the System….. • Redesign Care Based on Best Practices • Use Information Technology to Improve Access to Information and to Support Clinical Decision Making • Develop Effective Teams • Coordinate Care Among Services and Settings • Measure Performance and Outcomes
Bronchiolitis • A self-limited condition; viral mediated associated with URI symptoms, cough, and wheezing; most commonly dx age <2. • #1 discharge ICD-9 diagnosis, excluding birth • #2 in aggregate costs • incredible degree of variation • New evidence-based AAP guidelines
The Evidence From the American Academy of Pediatrics… • “Bronchodilators should not be used routinely for management. An optional trial of an - or ß-agonist should be continued only if objective evaluation indicates a clinical response. Most positive studies of bronchodilators for management of bronchiolitis show transient improvement of unclear clinical significance.”
Specific AIM:To reduce the utilization of bronchodilators for bronchiolitis by 20% when comparing 1st Q2010 data to 4th Q 2008 and 1st Q 2009 data in the Pediatric Inpatient Ward and in the Pediatric Emergency Room • Global Aims: • To Improve Effectiveness of Care (IOM)
Plan…… • Create the Team • Clinical Physicians: Pediatric Hospitalists; Pediatric ED Physicians, Community Pediatricians, and Pediatric Pulmonologists • Respiratory Therapists • Nurse Managers from the Inpatient and Pediatric ED • Physician Liaison to IS Department (order set creation)
) Do: The Intervention An Objective Respiratory Acuity Scoring Tool
Do: The InterventionA Standardized Bronchiolitis Order Setin ED and Inpatient settings IF Score is 4 or greater—trial of Racemic Epinephrine (evidence demonstrates some modest improvement in Resp Score—so will wait for scores to be clearly indicative of respiratory distress) IF one wants an Albuterol Trial ( should be based on primary FH of Atopy/Asthma)—must specify “Asthma Protocol with albuterol” (and albuterol will be given after a post suction score of 4) There will be 2 orders on the Bronchiolitis Order Set Bronchiolitis Protocol (start with Racemic Epinephrine) Bronchiolitis Protocol (start with Albuterol)
Do: The Intervention– Education and Changing Culture Town Hall Meetings • Bronchiolitis Protocol • Monday, October 12, 2009 @ 10:30am - 11:00am in the PEDS Conference Room • Wednesday, October 14, 2009 @ 7am - 7:30am • in the Playroom
ACT LESSONS LEARNED NEXT STEPS “Every system isperfectly designed to get the resultsit gets. If we want different results, we must change the system” “Culture eats strategy for lunch.” “Effective leaders help others to understand the necessity of change and to accept a common vision of the desired outcome” Monitor Control Charts for next 3 months to ensure stable process Sustaining Change Integrate in to Physician Report Cards Development of a Balanced Score EBM Lunch Series (CME)
