Dale W' Bratzler, DO, MPH

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Patient Safety and QualityPowering Up
Performance
Dale W. Bratzler, DO, MPH President and
CEO Oklahoma Foundation for Medical Quality
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• The problems persist..

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Problems with Healthcare Financing

• 2.4 trillion in 2008 projected to reach 3.1
  trillion in 2012
• 4.3 times the amount spent on national defense
• 17 of GDP
• Annual premium that a health insurer charges an
  employer for a health plan covering a family of
  four averaged 12,700 in 2008
• Workers contributed 3,400 (an increase of 12
  from what they contributed in 2007
• Healthcare costs and debt a rising cause of
  bankruptcy and foreclosure

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Whats driving the costs?

• Contrary to popular belief..
• Rising costs not being driven by aging of the
  population, high cost of prescription drugs, or
  defense medicine and liability costs
• Higher costs for physicians and hospitals
• Much more use of specialty services, costly
  diagnostics, and costly procedures
• Payment system that rewards volume of care and
  use of technology
• Administrative overhead costs, marketing, and
  investor profits for third party payment

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Volume-based Payment

• Lack of accountability for the overall quality
  and costs of careand for local capacity
• Inadequate information on the risks and benefits
  of many common treatments and the related
  assumption (on the part of most patients and many
  physicians) that more medical care means better
  medical care
• A flawed payment system that rewards more care,
  regardless of the value (or quality) of that care.

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Problems with health status?
http//www.americashealthrankings.org/2008/glance.
html
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Problems with quality of healthcare?
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New Directions

• Health reform
• Comparative effectiveness
• Medical home Accountable Care Organizations??
• Health information technology
• Measurement
• Greater focus on outcomes and costs
• Transitions of care
• Community interventions

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http//www.ok.gov/oid/documents/SCIBlueprint309.pd
f
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Effective Health CareIs the evidence being used?
http//effectivehealthcare.ahrq.gov/index.cfm
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The Medical Home or Accountable Care
Organizations (ACOs)
Many of the deficiencies in U.S. health care are
reflections of the disjointed and poorly
coordinated care that patients receive as they
move across settings and among providers more
frequent and flawed care transitions, failures of
communication, and errors. Current organizational
forms, payment methods, and regulatory and
quality assessment systems reinforce this
fragmented system.
Fisher ES, et al. Health Affairs 26, no. 1
(2007) w44w57.
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Health Information Technology

• The promise..
• Improve health care quality
• Prevent medical errors
• Reduce health care costs
• Increase administrative efficiencies
• Decrease paperwork
• Expand access to affordable care

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Measurement

• Expanded focus on patient outcomes, costs, and
  efficiency
• Move away from processes of care
• Capture data on care management from electronic
  sources
• Claims and EHRs
• Focus on care across settings

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Community Interventions

• While current payment policy divides a patients
  care into silos (hospital, physician office, home
  health, nursing home, etc) all have some
  accountability for patient outcomes
• Does the patient really care about which
  Compare website there pressure ulcer, medical
  error, or adverse event is reported on if it
  affects them??

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Focus on Care TransitionsNew Target for CMS
Improvement Efforts

• The term care transitions refers to the
  movement patients make between health care
  practitioners and settings as their condition and
  care needs change during the course of a chronic
  or acute illness.

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• 19.6 (1 in 5) Medicare beneficiaries
  rehospitalized within 30 days
• Medicares cost of unplanned rehospitalizations
  in 2004 was 17.4 Billion
• Heart failure is the most common reason for 30
  day rehospitalizations (26.9) representing
  almost 8 of all rehospitalizations. 
• Heart failure is also the most frequent cause of
  rehospitalization among all surgical
  rehospitalizations
• 52 of discharged heart failure patients had no
  associated outpatient visit within 30 days
• Jencks SF, Williams MV, Coleman EA.
  Rehospitalizations among Patients in the Medicare
  Fee-for-Service Program. N Engl J Med
  20093601418-28

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How do we address the problems and impending
changes?

• Focus on leadership
• Improvement and real change must be supported at
  the highest level of management
• CEOs have to be visible leaders of the culture of
  quality and safety
• Boards of Directors must take responsibility
• Focus on Teamwork
• Collaborative sharing in networks of our peers

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Does leadership play a role in overall hospital
quality?Can you create metrics of
leadership?Can you measure the culture of an
organization?If you can measure leadership and
the culture of quality, can you use that
information to change organizational culture?
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The need for teamwork

• Replace autonomy with team-based care
• No single healthcare practitioner, regardless how
  smart or hardworking, can ensure correct and safe
  healthcare there is too much to know, too much
  complexity, and too little time
• Use of protocol-based care
• Standardization of processes
• Opt out policies for things that should be
  routine
• Lessons from other industries implement
  programs such as TeamSTEPPS in your institution.

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Summary

• Cost, access, quality, and variation in
  healthcare service use and delivery are driving
  national and local policy
• Health reform - in some format is likely if
  not inevitable
• There must be a greater emphasis of
  accountability in healthcare best quality at
  the lowest cost

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dbratzler_at_okqio.sdps.org