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Patient Safety and Quality: The Unfinished Agenda

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Title: Patient Safety and Quality: The Unfinished Agenda


1
Patient Safety and QualityThe Unfinished Agenda
  • Harvey V. Fineberg, M.D., Ph.D.
  • Syracuse Healthcare Quality Forum
  • 22 April 2009

2
IOM Study of Medical Errors
2000
3
Response To IOM Errors Report
  • 51 of the American public closely followed the
    media coverage (Kaiser Family Foundation, 2000)
  • Congress appropriated 50 million for AHRQ
    patient safety center
  • President Clintons call to action (DHHS Quality
    Interagency Coordinating Committee)
  • Leapfrog Group reinforced and energized
  • National Academy for State Health Policy
  • Many national associations taking action

4
IOM Study of Health Care Quality
2001
5
Dimensions of Quality of Care
  • Health care should be
  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable

6
Dimensions of Quality of Care
  • Health care should be
  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable

7
Quality, Efficiency, and Value
  • Meaning and measurement of efficiency
  • Relationship between efficiency and quality
  • Examples and reasons for inefficiency in health
    care
  • Strategies and examples to improve efficiency,
    quality and value

8
Meanings of Efficiency
  • Technical
  • Production
  • Allocative
  • Market
  • Health

9
Technical Efficiency
  • When no greater output can be achieved for a
    given level of resource input. Production occurs
    on the technical production possibility
    frontier.

10
Technical Efficiency
  • When no greater output can be achieved for a
    given level of resource input. Production occurs
    on the technical production possibility
    frontier.

Input A
Input B
11
Technical Efficiency
  • When no greater output can be achieved for a
    given level of resource input. Production occurs
    on the technical production possibility
    frontier.

Input A
Input B
12
Technical Efficiency
  • When no greater output can be achieved for a
    given level of resource input. Production occurs
    on the technical production possibility
    frontier.

13
Production Efficiency
  • Optimal combination of resource inputs (labor,
    equipment, supplies, etc.) to achieve a given
    output. Production is efficient if a given level
    of output is achieved at the lowest resource
    cost.

14
Production Efficiency
  • Optimal combination of resource inputs (labor,
    equipment, supplies, etc.) to achieve a given
    output. Production is efficient if a given level
    of output is achieved at the lowest resource
    cost.

Input A
Input B
15
Production Efficiency
  • Optimal combination of resource inputs (labor,
    equipment, supplies, etc.) to achieve a given
    output. Production is efficient if a given level
    of output is achieved at the lowest resource
    cost.

Ratio of Input Costs
Input A
Input B
16
Allocative Efficiency
  • Resources are allocated so as to optimize
    benefit to a population
  • Market Efficiency
  • Distribution of goods according to individual
    preferences
  • Competitive market marginal cost marginal
    price
  • Health Efficiency
  • Distribution of health resources to maximize the
    level of health in the population

17
Allocative Efficiency
  • When would market efficiency equal health
    efficiency? Among the assumptions
  • Complete and accurate information
  • No barriers to market access and exchange
  • Personal preferences (utilities) for health
    expenditures coincide with health improvements
  • Equivalent purchasing power across purchasers

18
Measuring Efficiency
  • Identifying all inputs
  • Pricing (resource cost) of each input
  • Identifying relevant outputs
  • Valuing the outputs (outcomes)

19
Outputs of Interest in Health
  • Element of service
  • Episode of illness or health condition
  • Management of disease over a period of time
  • Overall health of an individual
  • Health of a community or society

20
Efficiency is not about
  • Just cutting costs
  • Enhancing revenues
  • Making the doctors life easier (rather than the
    patients life better)
  • Achieving justice

21
Quality and Efficiency
  • Efficiency, in terms of eliminating waste, is one
    dimension of quality in health care.
  • Quality, in terms of net benefits to health, is
    half of the equation for health efficiency.

22
Efficiency in Health
  • Efficiency is a relationship of value how much
    output of value (health benefit) per input of
    value (resource cost)
  • Focus on efficiency forces consideration of both
    sides of the value proposition benefits and
    costs
  • EFFICIENCY

23
An estimated thirty to forty cents of every
dollar spent on health care a half trillion
dollars a year is spent on costs associated
with overuse, underuse, misuse, duplication,
system failures and inefficiency.
2005
24
Expected Quality and CostsEfficient Producer
Quality
Cost
25
Expected Quality and CostsEfficient Producer
Quality
Cost
26
Expected Quality and CostsEfficient Producer
Increasing Production Efficiency
Quality
Cost
27
Expected Quality and CostsSmart Consumer
Quality
Cost
28
Expected Quality and CostsSmart Consumer
Quality
Cost
29
Health Consumption Observed Quality and Costs
30
Episode Treatment GroupTM Analysis
Presented by E. McGlynn, RAND
31
Episode Treatment GroupTM Analysis
Presented by E. McGlynn, RAND
32
Why is Health Care Inefficient?
  • Payment for wrong outputs (units of service
    rather than care of illness, quality of care, or
    health outcome)
  • Financial incentives reward inefficiency
    (complications or re-admission)
  • Lack of price incentives to patients
  • Providers indifferent to induced costs

33
Why is Health Care Inefficient?
  • Insufficient attention to prevention and
    long-term results
  • Fragmented and uncoordinated delivery system
  • Lack of information on performance and quality
  • Dysfunctional competition rather than value-based
    competition

34
Making Anesthesia Better
  • Deaths from anesthesia decline
  • Early 1980s 1 per 10,000
  • Today 1 per 200,000
  • Malpractice claims, judgments, and fees decline
  • Proportion of malpractice claims targeting
    anesthesiologists 19727.9 20013.8
  • Proportion of malpractice claims closed with
    payment 1970s64 1990s45

35
Making Anesthesia Better
  • 1985 Anesthesia Patient Safety Foundation
  • Forum for health professionals, device
    manufacturers, regulatory bodies, and others
  • Patient safety newsletter
  • Seed grants in safety research
  • New technology
  • Pulse oximeter and capnometer
  • Redesigned machines, standardized practice
    guidelines, improved training programs, hospital
    safety committees

36
St. Johns Hospital
  • 866-bed, not-for-profit hospital and trauma
    center in Springfield, Missouri
  • 32 operating rooms and 45-room trauma center
  • 29,000 surgical procedures in 2005
  • 74,000 emergency department visits in 2005, 22
    of whom are admitted and comprise 20 of the
    surgical load

37
St. Johns Hospital
  • Problems (2002 analysis by E. Litvak)
  • Lack of flexibility in scheduling elective
    surgeries that produced unpredictable and
    excessive use of overtime
  • Mid-week peaks in surgery and resulting backup in
    admissions that often made it impossible for
    patients to have a bed on the appropriate floor
    and receive optimal post-surgical care

38
St. Johns Hospital
  • Solution (peak-flow management techniques
    operations research)
  • Set aside a single OR for overflowboth elective
    and unplannedsurgeries
  • Smooth the scheduling of elective surgeries
    across the five weekdays

39
St. Johns Hospital
  • Results
  • After smoothing elective surgery, the capacity
    for ED admissions rose from 647 (October 2004) to
    1100 (October 2005)
  • Excluding ICU, a 59 increase in inpatient
    capacity was realized without adding additional
    inpatient nursing beds
  • The number of OR rooms needed after 3 p.m.
    dropped by 45, and OR overtime declined to a
    record low level of 2.9

40
St. Johns Hospital
  • Results (continued)
  • Since 2003, surgical volume has increased by 33,
    and trauma surgeons experienced a 4.6 increase
    in revenue
  • Waiting time for emergent and urgent surgical
    cases after 3 p.m. was reduced by 45
  • Prior to smoothing, the rate of patient placement
    into the appropriate bed for orthopedic patients
    was 83 after smoothing, the rate of appropriate
    placement rose to 96

41
Strategies to Increase Efficiency
  • Improve outcomes (health benefits) without
    raising costs (i.e., without consuming more
    resources) or while saving resources

42
Strategies to Increase Efficiency
  • Improve outcomes (health benefits) without
    raising costs (i.e., without consuming more
    resources) or while saving resources
  • OR
  • Reduce costs without reducing benefits (health
    outcomes) or while improving health outcomes

43
Strategies to Increase Efficiency
  • Improve outcomes (health benefits) without
    raising costs (i.e., without consuming more
    resources) or while saving resources
  • OR
  • Reduce costs without reducing benefits (health
    outcomes) or while improving health outcomes
  • Get more value from every health care dollar

44
Strategies to Enhance Value
InnovationEvaluationDiffusionPerformance
45
Strategies to Enhance Value
  • Discover, design and invent technologies that
    provide more efficient solutions (direct savings
    and induced savings improved results)
  • Incentives for research and development of
    efficient technology and program design
  • Institutional innovation to bridge academic
    centers and technology creators and speed
    transition from research through prototype
    development and product availability
  • Payment for efficient solutions

46
Strategies to Enhance Value
  • Evaluate health outcomes and costs of
    technologies, care strategies, and providers
  • Assess resource costs and health outcomes as a
    routine part of care
  • Design information systems that serve patient
    records and can be used to evaluate patient
    outcomes and performance
  • Devise, test, and deploy evaluation alternatives
    to RCTs that are cheaper, faster and more
    directly relevant to different patient
    populations
  • Comparative Effectiveness research

47
Strategies to Enhance Value
  • Use evidence more effectively in decisions by
    care givers and patients ( appropriate use
    misuse and overuse)
  • Make information technology and decision-support
    systems more widely available
  • Develop uniform standards for health IT, provide
    financial resources to introduce and support IT
    systems, and mandate their use
  • Measure and make available to the public
    information on results and cost by physicians,
    hospitals, nursing homes, and health plans

48
Strategies to Enhance Value
  • Redesign care processes to reduce avoidable
    errors in care
  • Follow recommendations in series of IOM reports,
    from To Err is Human (1999) and Crossing the
    Quality Chasm (2001) to Preventing Medication
    Errors (2006)
  • Systems approach, with many interacting parts
  • Safer design, bar coding and labeling
  • Improve coordination of care

49
Strategies to Enhance Value
  • Train health professionals to improve quality and
    practice efficiently
  • Educate jointly across the several health
    professions to provide comprehensive care to
    patients
  • Regard as core professional competencies the
    ability to evaluate evidence and develop and use
    practice guidelines
  • Increase use of simulation training
  • Improve coordination of care

50
Strategies to Enhance Value
  • Enhance value-based competition for health care
    dollars
  • Reduce barriers to inter-state health insurance
    competition among health insurers
  • Pay for episodes of illness or periods of
    managing patients rather than for procedures
  • Provide feedback on performance to providers and
    to patients

51
Strategies to Enhance Value
  • Give providers financial incentives to increase
    value
  • Pay for performance and reward high-value
    providers
  • Pay for prevention
  • Pay for management of chronic conditions and
    coordination across hospital, nursing home, and
    community-based care
  • Couple payment to evaluation
  • Stop paying for hospital-acquired infection

52
Strategies to Enhance Value
  • Give patients financial incentives to increase
    value
  • Income-related co-payment and deductible
  • Reduce insurance premiums for healthy lifestyle
    choices
  • No deductible for preventive services
  • Lower co-payment and deductible for use of
    high-value providers

53
Strategies to Enhance Value
  • Use systems engineering methods to improve
    performance
  • Reduce variability
  • Optimize workflow
  • Enhance use of resources

54
Strategies to Enhance Value
  • Streamline administrative systems
  • Uniform insurance forms and procedures
  • Bulk purchasing cooperatives and competitive
    bidding
  • Reliance on information technology

55
Strategies to Enhance Value
  • Emphasize prevention of disease
  • Individual education and incentives
  • Community-based programs
  • Policies and payments that promote primary
    prevention of disease

56
Strategies to Enhance Value
  • Use information technology in a networked system
  • Personal medical records
  • Patient-centered communication (Patient-Patient
    Provider-Pt Pr-Pr)
  • Administration (billing, scheduling, inventory)
  • Enhance safety (pharmacy fulfillment)
  • Clinical decision support

57
Strategies to Enhance Value
  • Use information technology in a networked system
    (continued)
  • Quality assurance and improvement
  • Individual monitoring and population surveillance
  • Exploratory to comprehensive observational
    studies
  • Registries and clinical trials
  • Real-time clinical CME

58
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59
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60
Reframe the Culture of Medicine
  • Professionalism that embraces quality,
    efficiency, and value
  • Professionalism insulated from commercial
    conflict-of-interest
  • From autonomy to responsibility
  • From institution-centered to patient-centered
    care
  • From my patient to all patients

61
Toward Improved Health Care
Efficiency Outcome per Cost Value
Quality and Safety Performance
Use and Non-Use Practice
Standards Guidelines
Evidence Clinical Research
Opinion Personal experience
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