Improving Population Health: Reliability, Toyota Specifications, and the Triple Aim

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Improving Population HealthReliability, Toyota
Specifications, and the Triple Aim

• Don Goldmann, MD
• Senior Vice President
• Institute for Healthcare Improvement
• Professor of Pediatrics
• Harvard Medical School

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Institute of Medicines 6 Key Quality Improvement
Aims

• Health care should be
• Safe
• Effective (providing services based on scientific
  knowledge to all who could benefit and not
  providing services to those not likely to
  benefit)
• Patient-centered
• Timely (reducing waits and potentially harmful
  delays)
• Efficient (avoiding waste of equipment, supplies,
  ideas, energy)
• Equitable (regardless of gender, ethnicity,
  geography, socioeconomic status)

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Gaps/Variation in Outcomes and Performance
Nationally Internationally

• A Very Ugly Story

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For those who only have time for the NEJM and
JAMA.

• McGlynn, et al The quality of health care
  delivered to adults in the United States. NEJM
  2003 348 2635-45 (recently confirmed in NEJM)
• 439 indicators of clinical quality of care
• 30 acute and chronic conditions, plus prevention
• Participants had received 54.9 of scientifically
  indicated care
• acute 53.5 chronic 56.1 preventive 54.9
• Conclusion The Defect Rate in the technical
  quality of American health care is approximately
  45

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More Comprehensive Sources of Information on
Quality Gaps and Variation

• AHRQ National Quality Report
• Commonwealth Fund Chart Books
• Commission on a High Performance Health System
  (available on the Web or in Health Affairs)
• Dartmouth Atlas

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Some Highlights

• US ranking v. other countries
• 15/19 in preventable deaths prior to age 75
• death rate 40 higher than top countries (France,
  Japan, Spain)
• Tied for last in life expectancy prior to age 60
• Last of 23 in infant mortality
• Enormous variability by region and state
• Low ranks for adults with health-related
  limitations in daily activities, children missing
  11 days of school due to illness or injury

Commonwealth Commission
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More Selected Highlights

• 49 of adults get recommended screening and
  prevention
• 50 of patients discharged from hospital with CHF
  get written instructions/materials
• Enormous disparities by race, ethnicity, SES, and
  insurance status for many outcomes and processes
  of care
• Even in managed care systems

Commonwealth Commission
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Resource Use at the End-of-Life

• US average during the last 6 months of life
• 13.9 hospital days
• 3.6 ICU days
• 33.5 physician visits
• 32.8 patients seeing 10 or more physicians
• Half of visits to specialists rather than primary
  care
• 20.1 of deaths during an ICU admission

Dartmouth Atlas
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Gaps and Performance Variation in Infection
ControlMethicillin-Resistant Staphylococcus
aureus (MRSA)
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Methicillin (oxacillin)-resistant Staphylococcus
aureus (MRSA) in U.S. Intensive Care Units,
1995-2004
Source National Nosocomial Infections
Surveillance (NNIS) System
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Equally Grave MRSA Problem in the United Kingdom
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Methicillin-resistant Staphylococcus aureus in
Europe, 19992002
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Is this remarkable variation due to

• Transmissibility and virulence of distinct
  strains (genotypes)?
• Size, design, or type of hospital?
• Sicker, more complex patients?
• Practice variation?
• Compliance with known, measurable evidence based
  practices?
• Less tangible features, such as culture and
  organization of an intensive care unit?
• Are nosocomial infections an expected
  consequences of caring for very sick, complex
  patients, or intolerable, potentially preventable
  adverse events

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A Modest Proposal

• Improve reliability of basic procedures
• Defect rates of 60-80 are not tolerable
• Isolation Procedures
• Hand hygiene
• Ventilator and central venous catheter care
• Screening cultures

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Reliability Science

• Health care is riddled with defects
• 40 compliance (60 defects) with hand
  hygiene!!??
• From the patients point of view, its all or
  nothing
• Reliability science offers effective approaches
  to reducing defects and harm in health care

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Reliability is failure free operation over time
from the viewpoint of the patient
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Defects in outpatient prevention and CHF care
Defects in hospital care
CHF requiring admission
Admission through discharge
Defects in outpatient CHF care management
Years/Months
Days
Years/Months
Defect free care overtime from the patients
viewpoint
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Levels of Reliability

• Chaotic process Failure in greater than 20 of
  opportunities
• 10-1 90 percent success 1 or 2 failures out
  of 10 opportunities (no consistent articulated
  process)
• education, exhortation, audit and feedback
• 10-2 1 failure or fewer out of 100
  opportunities (process is articulated by front
  line)
• Systems-oriented prevention, detection,
  mitigation
• 10-3 1 failure or fewer out of 1000
  opportunities
• 10-4 1 failure or fewer out of 10,000
  opportunities

Blood banking and anesthesiology alone
achieve the higher levels of reliability in
medicine
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Reliability in Healthcare

• Remember, its all or nothing not compliance
  with each individual component of best practice
• Most institutions do fairly well with individual
  components of evidence-based practice, but
  performance drops dramatically when the standard
  is all or nothing
• We are trying to decrease the defect rate and
  to achieve a reliability of performance to the
  10-2 level (95-99 compliance with the entire
  package of evidence-based practice)

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• Reliability requires knowledge about key
  evidence-based interventions
• AND
• Proactive risk assessment to identify critical
  control points (hazard points) where failures in
  key evidence-based practices may occur and not be
  detected/mitigated
• Hazard analysis critical control point (HACCP)
  and failure mode effects analysis (FMEA)

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Applying Reliability Science, Evidence, and
Quality Improvement to Dramatically Reduce
Central Venous Catheter Infections
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Guidelines v. Bundles (Intervention Packages)

• Guidelines tend to be long, all-inclusive, and
  confusing
• Many potential interventions are supported by
  some evidence
• Guidelines are difficult to translate into action
  and often are ignored by clinicians
• What if just a few key, actionable interventions,
  supported by strong evidence, were culled from
  the guidelines?

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What Is a Bundle?

• A grouping of best practices with respect to a
  disease process that individually improve care,
  but when applied together result in substantially
  greater improvement
• The science behind the bundle is so well
  established that it should be considered standard
  of care
• Bundle elements are dichotomous and compliance
  can be measured yes/no answers
• All components of the bundle must be performed
  its all or nothing

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Central Venous Catheter Bundle

• Hand hygiene before inserting a catheter
• Subclavian vein as the preferred insertion site
• Maximal barrier precautions for line insertion
• Hand hygiene
• Non-sterile cap and mask
• Sterile gown and gloves
• Large sterile drape
• Antiseptic prep used for catheter insertion as
  per hospital protocol
• 2 chlorhexidine supported by evidence

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Quality Improvement for Catheter Insertion

• Train all who will insert catheters and check
  competency
• Put all needed supplies in a standard, readily
  available pack on a cart
• Use a checklist to insure all components are
  completed correctly
• Empower nurse to stop procedure if mistakes are
  made (matrons charter)
• Feed back data (e.g., days between CVL-associated
  infections) in graphic format

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Central line-associated bloodstream infection
rate in 66 ICUs, Southwestern Pennsylvania, April
2001-March 2005
CDC
Pronovost et al.,N Engl J Med 20063552725 Decre
ase from 7.7 to 1.4 per 1000 catheter days in 103
ICUs
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A Hand Hygiene Bundle

• Staff knowledge
• Staff competency
• Alcohol and gloves available at the point of care
• Operational, full dispensers providing correct
  volume of rub
• At least 2 sizes of gloves
• Correct performance of hand hygiene gloves worn
  for standard precautions

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MRSA Bundle

• High reliability hand hygiene for all
• High reliability MRSA screening (elective
  high-risk surgical patients, high risk
  microsystems)
• ? preemptive barrier precautions pending
  screening culture results
• Isolation/Cohorting for infected and colonized
  patients
• Environment/fomite disinfection
• Compliance with central venous catheter and
  ventilator bundles

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Six Changes That Save Lives

• Rapid response teams
• Evidence-based care for acute myocardial
  infarction
• Prevention of adverse drug events (medication
  reconciliation)
• Prevention of central line infections (Central
  Line Bundle)
• Prevention of surgical site infections (correct
  perioperative antibiotics at the proper time and
  other elements of the Surgical Infection Bundle)
• Prevention of ventilator-associated pneumonia
  (Ventilator Bundle)

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5 Million Lives Campaign

• The Platform
• Reduce Surgical Complications Adopt SCIP
• Prevent Harm from High Alert Medications
• Prevent MRSA Infections
• Reduce Readmissions in patients with Congestive
  Heart Failure
• Prevent Pressure Ulcers
• Get Boards on Board

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Reduce Re-admissions from Congestive Heart
Failure (CHF)

• The Goal
• Reduce the 30-day re-admission rate of patients
  discharged with the diagnosis of CHF by 50 by
  December 2008

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Why is this a Campaign Plank?

• One of the nations leading causes of
  hospitalization and re-hospitalization,
  especially among the elderly
• 12-15 millions office visits, 6.5 million
  hospitalizations
• One of the leading causes of re-hospitalization
  (27 within 1 month of discharge, 47 within 3
  months)
• 27-56 billion in direct costs annually
• Campaign is focusing on in-hospital care of CHF
• Additional interventions to improve the
  hospitals hand-off of patients to the community
  will follow in the Spring

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Seven Key Interventions

• Left ventricular systolic (LVS) heart function
  assessment (CMS,JCAHO,ACC,AHA)
• ACE inhibitor or ARB at discharge for CHF
  patients with systolic dysfunction (LVEF(CMS,JCAHO,ACC,AHA)
• Anticoagulant at discharge for CHF patients with
  chronic/recurrent atrial fibrillation (ACC,AHA)

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Seven Key Interventions

• Influenza immunization (ACIP)
• Pneumococcal immunization (ACIP)
• Smoking cessation counseling (CMS,JCAHO,ACC,AHA)
• Discharge instructions that address all of the
  following activity level, diet, discharge
  medications, follow-up appointments, weight
  monitoring, and what to do if symptoms worsen
  (CMS,JCAHO,ACC,AHA)

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Other Interventions to Consider

• Beta blocker therapy for patients who have
  minimal or no evidence of fluid overload or
  volume depletion (AHA,ACC)
• Well supported by randomized controlled trials
• If started at discharge (as recommended by AHA
  Get With The Guidelines-HF)
• Insures patient is started on therapy and hastens
  attainment of therapeutic levels
• Requires close monitoring and follow-up
  post-discharge
• Discharge contract

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Tips for Getting Started

• Form a multi-disciplinary improvement team
• Include hospitalist, nurse, nurse educator, case
  manager, QI representative, patient, cardiology
  and emergency department opinion leaders, and
  others involved in the system of care
• Segment pick a segment to work on first
• Patients being discharged directly to home
• Patients not needing ICU care
• Standardize
• Use nurse-driven protocols (ordering LVS function
  testing, smoking cessation instruction,
  immunizations)
• Link ACE inhibitor/ARB orders directly to
  interpretation of
• LVS function testing
• Give patients a standard discharge instruction
  booklet (in appropriate language) at admission or
  when diagnosis is made, and reinforce throughout
  stay

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Tips for Getting Started on Transition Planning

• Involve case managers focus on CHF at admission
• Use a discharge checklist with nurse-patient/famil
  y/caregiver face time
• Respect health literacy use teach back to insure
  comprehension use Ask-Me-3
• Reconcile medications insure understanding of
  purpose, regimen, and side effects
• Provide real-time information transfer for next
  provider(s)
• Speak with emergency contact for high risk
  patients
• Schedule follow-up phone calls to patient/family
  to occur within 48 hours and physician visit
  within 1 week for average risk patients
• Schedule, before patient leaves, follow-up visit
  (home or office) for high risk patients to occur
  within 48 hours after discharge
• Discharge high risk patients to
  multi-disciplinary
• case management

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Toyota Specifications

• Toyota Specifications
• Measures were selected primarily from IHIs Whole
  System Measures, which are aligned with the IOM
  Six Dimensions.
• The on each scale indicates the Toyota
  performance specification.
• The specifications were based on the best results
  seen by IHI, top-decile performance, or
  best-practice results in other industries.

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Patient Experience
They give me exactly the help I want (and need)
exactly when I want (and need) it Population
includes adults in the Hows Your Health?
database, aged 19-69
Best Practice Results
Current Average
Primary Care Practices
CCHMC Inpatient Outpatient
25-30
71
100
0
20
40
60
80
Percent of Patients Who Responded Strongly
Agree to the Phrase Above
Additional comments from John Wasson Currently,
about 25-30 of adults aged 19-69 will strongly
agree. We find that in primary care practices the
rate is about 40 and we are finding a group of
practices with a average rate of about 60. There
is wide variance around these averages. Note
The phrasing above has been modified by John
Wasson to read, I receive exactly the care I
want and need exactly when and how I want and
need it.
Source John Wasson, Hows Your Health?
http//www.howsyourhealth.org
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Health Status Would you say that in general your
health is excellent, very good, good, fair, or
poor?
Results are stratified by annual household income
(2001)
Source Centers for Disease Control and
Prevention (CDC) National Center for Chronic
Disease Prevention and Health Promotion, Division
of Adult and Community Health, Health-Related
Quality of Life Surveillance --- United States,
1993-2002
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Hospital Standardized Mortality Ratio (HSMR)
2004 Top Decile
2004 US Average
2000 US Average
McLeod
HealthPartners
CCHMC PICU
86
69
0
20
40
80
100
60
120
HSMR
Source Sir Brian Jarman, MedPar database CCHMC
data is Standardized PICU Mortality Ratio (
actual patient deaths / expected deaths)
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The Triple Aim

• Optimize and balance
• Patient experience over time
• I get exactly the help I need and want exactly
  when I want it and need it (safe, effective,
  efficient, patient-centered, timely, equitable)
• Population health
• Self-perceived health status, quality of
  life/functional status, productive life years
• Per capita cost (societal)

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Problems

• The healthcare system is fragmented and
  financially mal-aligned
• Hospitals profit from increasing admissions and
  performing expensive, high-tech procedures. They
  have little incentive to decrease societal costs
• Physicians and medical groups do not reap the
  financial benefit of improving health and
  reducing hospital visits/admissions
• Payers seek to reduce per capita costs for the
  people they cover, but may not have their eye on
  the patient experience and population health
• Little systems thinking or foreign competition
• Tech explosion and increase in availability
  paradoxically increases demand

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Promising Developments

• Increased alignment of payment, evidence-based
  practice, measurement, and certification/re-certif
  ication requirements for physicians
• Growing consensus among regulators, payers, and
  providers regarding a common set of metrics to
  evaluate quality of care and the impact of
  improvement efforts
• Demonstration projects with suspended rules for
  payment (CMS)
• Collaborative improvement initiatives (federal,
  regional, state, professional organizations)
• Increasing promotion and use of information
  technology and inter-operable systems.

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Integrator

• Entity that is responsible for patient
  experience, population health, and cost
• Companies (Hershey, QuadGraphics)
• Visionary payers
• Integrated health systems (Kaiser-Permanente)
• Large health systems that own practices and
  hospitals and have a stable patient base
• National/regional health systems (Jonkoping
  County, Sweden)
• Visionary states/cities (Massachusetts, Oregon,
  ?Louisiana)
• Government health systems (VA, Indian Health
  Service, CMS demonstration projects)

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Segmentation

• Age
• Chronic illness
• Region

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Driver Diagram for Triple Aim
Primary Drivers
Secondary Drivers
Evidence based care Improved dissemination and
uptake of medical knowledge Collaboration on
standardization of definitions Trusted body to
assemble evidence

• .

Measurement that is transparent Public health
interventions Design and coordination of care
at the patient level Universal access to
care Financial management system
Education Community outreach Government
regulation City planning design and redesign

• Individuals Healthcare Experience
• Population Health
• Per Capita Cost

Identification of provider responsible for
coordination Handoff management Planning and
execution of a shared treatment plan (all
providers and patient and family) Information
technology support
Primary care access At least a minimally defined
set of benefits for the population including
secondary and tertiary care Incentives supporting
design
Operational Cost Capitol Expense Waste Reduction
and coordination resources Appropriate use of
technology and procedures Supply side management
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What are the Triple Aim Toyota Specs for
Louisiana?
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Adjusted Nosocomial Bloodstream Infection Rates
(Including Only Patient-related Variables as
Covariates)
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Variation in parenteral nutrition utilization
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Adjusted Bloodstream Infection Rates (Including
Patient- and Treatment-related Variables as
Covariates)
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10-1 PerformanceIntent, Vigilance and Hard Work

• Exhortation to work harder
• Awareness, education and training
• Audit and feedback of compliance data
• Personal check lists

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10-2 PerformanceEmphasis on Systems

• Sophisticated failure prevention, identification,
  and mitigation systems
• Decision aids and reminders built into the system
• Desired action the default (based on evidence)
• Redundant processes
• Taking advantage of habits and patterns
• Standardization of process with clear
  specification and articulation

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CVC Infections are not a right of
passageDramatic improvement is possibleSome
ICUs have gone months without a CVC infection
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• Institute for Healthcare Improvement