Connecting the Dots for Quality and Safety: Broadening Our Perspective and Potential

1. Destination Health:10th Annual Transforming Health Symposium Connecting the Dots for Quality and Safety: Broadening Our Perspective and Potential Laura Adams President and CEO, Rhode Island Quality Institute Faculty, Institute for Healthcare Improvement, Boston, MA Oversight Council, Massachusetts Center for Health Information & Analysis, Boston, MA @LAdamsRIQuality April 12 , 2017

2. Disclosures Principal at Laura Adams Consulting

3. From: Seth Goldenberg, founder and CEO of IP.21 Studios and Alex Jadad, MD, Founder of the Centre for Global eHealth Innovation , University of Toronto and University Health Network; Canada Research Chair in eHealth Innovation. $2.9T $1.3T

4. An Epidemic of Error Medical Error: 3rd Leading Cause of Death in the U.S. Martin A Makary, MD; Michael Daniel, MD Medical error—the third leading cause of death in the US. BMJ 2016;353:i2139; DOI: 10.1136/bmj.i2139 (open access)

5. Two Key Drivers of U.S. Healthcare’s High Cost and Relatively Poor Overall Quality • How care is financed (what’s paid for, by whom and at what price) • How care is designed (a “sick care” system when what we need is a health care system)

6. The Prevalent (and Toxic) Financing System • Payment to providers is on a “piecework” basis—the more pieces produced, the greater their reimbursement. Quality isn’t often figured into the payment—the worst cardiac surgeon, primary care doctor, etc., gets paid the same as the best. • Market forces (e.g. competition) don’t work in healthcare – the more MRI machines, the more MRI’s; the more doctors per capita, the more tests and procedures per capita, regardless of need (Wennberg, et.al.). • Little incentive to produce efficient, effective care—in fact— providers are still often harmed financially if they improve quality and safety.

7. 2012 Bipartisan Policy Center Report: Lots to Lose: How America’s Health and Obesity Crisis Threatens our Economic Future 2012 Bipartisan Policy Center Report: Lots to Lose: How America’s Health and Obesity Crisis Threatens our Economic Future

8. Enter New Payment Models

9. New Payment Models – Necessary, but Not Sufficient Dept. of Health Dept. of Health ACO ACO Hospitals, LTCs, BH /SA Facilities, etc. Hospitals, LTCs, BH /SA Facilities, etc. Hospitals, LTCs, BH /SA Facilities, etc. Public Health Public Health Public Health Primary Care Physicians (Incl. BH/SA Professionals, CHCs , Free Clinics, etc.) Primary Care Physicians (Incl. BH/SA Professionals, CHCs , Free Clinics, etc.) Primary Care Physicians (Incl. BH/SA Professionals, CHCs , Free Clinics, etc.) Laboratories Laboratories Laboratories Pharmacies Pharmacies Pharmacies Dept. of Health Patients and Families Patients and Families Patients and Families Specialty Physicians Specialty Physicians Specialty Physicians ACO Payers Payers Payers Ambulatory Centers (e.g. imaging centers) Ambulatory Centers (e.g. imaging centers) Ambulatory Centers (e.g. imaging centers)

10. With the current design of our delivery system, (decidedly not patient/consumer-focused) what are our chances of success under new payment models rewarding value not volume?

11. Fragmented Patient Data Resulting in Poorly Coordinated Care, Errors and Inefficiency Hospitals, LTCs, BH /SA Facilities, etc. Dept. of Health Public Health Laboratories Primary Care (incl. Behavioral Health/Substance Abuse, CHCs, Free Clinics, etc.) Pharmacies Patients and Families Specialty Physicians Payers Ambulatory Centers (e.g. imaging centers) Adapted from: Indiana Health Information Exchange 11

12. HIE in Rhode Island Health Information Exchange in Rhode Island Public Health Hospitals, LTCs, BH /SA Facilities, etc. Primary Care (incl. Behavioral Health and Substance Abuse, CHCs, Free Clinics, etc.) Laboratories Consumers; Patients and Families Pharmacies Specialty Physicians Payers Ambulatory Centers (e.g. imaging centers)

13. What Does This Mean for Healthcare Leaders? Take Away #1: -Collaboration may be the most important survival (and reliability) strategy for your organization and for your patients -The enemy is disease, error and waste… not each other.

14. Steve Jobs on Creativity and Connecting the Dots Creativity is just connecting things. When you ask creative people how they did something, they feel a little guilty because they didn’t really do it, they just saw something that seemed obvious to them.

15. “That’s because they were able to connect experiences they’ve had and synthesize new things—because they have had more experiences than other people.”

16. Unfortunately, that’s too rare a commodity. A lot of people haven’t had very diverse experiences. So they don’t have enough dots to connect, and they end up with very linear solutions without a broad perspective on the problem.

17. What Does this Mean for Healthcare Transformation? We can only connect the dots we collect The broader the understanding of the human experience of health and healthcare, the better design we can create.

18. What Does This Mean for Healthcare Leaders? Take Away #2: -The future lies not in “engaging patients”--but instead--engaging in the lives of patients. -More “dots to connect” emerge and so do much better ideas for care delivery redesign.

19. A Limited Perspective: Some of My Early Lessons in “Patient-Centered” Health Care • A pain pill • The Breast Center

20. My Early Lessons in “Patient-Centered” Health Care (cont’d) • A 7-year old child • The birth of my son Ben

21. What Does This Mean for Healthcare Leaders? Take Away #3: Mine your personal experiences—and that of your family and your friends—for inspiration and guidance about how to redesign care and make it more reliable.

22. Just to be clear…

23. The Course of Events… • So there’s a chance…? • Mammogram; Ultrasound; Right breast biopsy

24. The Course of Events…(cont’d) • So there’s a chance…? • Definitive diagnosis on right side – the left side is still in question • 5 different care locations in a span of 20 days

25. The Course of Events…(cont’d) • “Mom, I feel guilty…” – The Silver Linings List begun

26. The Course of Events, cont’d • Prognosis– inconclusive due to concerns about the left side • Stereotactic biopsy of left breast – inconclusive • Surgical biopsy of the left breast - Just as the anesthesia mask is lowered… • Left side – no cancer!! • The Surgery • Pre-op on Friday – An “Elaine” experience • Sentinel node biopsy

27. The Course of Events, cont’d • Reconstructive Surgeon’s Office • The clipboard (again!) • Follow-up • How to prevent this from happening again?

28. What Does This Mean for Healthcare Leaders? Take Away #4: Think about what you could do within your area of influence to assure that patients and families are always regarded as part of the care team AND the quality improvement team.

29. Patients’ Response to the Concept of “Engaging the Patient”

30. Creating Health • Being ready for “teachable moments” will be crucial. • “Come and get it care” won’t move the critical metrics for which we’re are now being paid. It’s going to take connecting a community – the healthcare system can’t do it alone. • People are already in control of their own health – and more capable of managing it than we think.

31. Creating Health (cont’d) • There’s some data/information that only the patient or family can provide, e.g. advance directives, functional health status, pain levels, in-home monitoring data, etc. • If we expect to manage population health, we’re going to have to engage in their lives – and technology can play a huge role.

32. I Want to Say Just One Word to You…

33. HIE in Rhode Island Health Information Exchange’s Potential Public Health Hospitals, LTCs, BH /SA Facilities, etc. Primary Care (incl. Behavioral Health and Substance Abuse, CHCs, Free Clinics, etc.) Laboratories Consumers; Patients and Families Pharmacies Specialty Physicians Payers Ambulatory Centers (e.g. imaging centers)

34. Poorly Coordinated Care, Errors and Inefficiency Provides a longitudinal view to improve quality, safety and value Primary Care (incl. Beh. Health/ Substance Abuse, CHCs, etc.) Hospitals, Long-Term Care, Behavioral Health /Substance Abuse Facilities, etc. Social Determinants of Health Laboratories Pharmacies Ambulatory Centers (e.g. imaging centers) Specialty Physicians Patient and Family-supplied data

35. What Does This Mean for Healthcare Leaders? Take Away #5: In the information age, commitment to “the data following the patient” –including data the patient supplies – is one of the highest standards of professional conduct. And a hallmark of a genuine understanding of high reliability…

36. Personal Goals: The Most Important? Amy Berman, RN, Senior Program Officer John A. Hartford Foundation Amy at TedMed 2013

37. Remember… We can only connect the dots we collect

38. Laura Adams, President & CEO Rhode Island Quality Institute 50 Holden Street, Suite 300 Providence, Rhode Island, 02908 ladams@riqi.org 401-276-9141 x 271 @LAdamsRIQuality