*Jc conf23jun2010 copy

“Leading EIVI ”

Evidence Informed Value ImprovementDetails download from

http://homepage.mac.com/johnovr/FileSharing2.html

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John Øvretveit,Director of Research, Professor of Health Innovation

and Evaluation, Karolinska Institutet, Stockholm, Sweden

04/13/2023

Question to you…

Do you know any quality activities or projects which save money?

or bring-in more money than they cost

Please ask the person next to you2

The “new normal” We must cut costs… and raise quality

Quality activities cost…

which ones pay for themselves

or make savings/extra income?

Accreditation?

Chronic care model?

Falls prevention?

Anti-biotic prophylaxis before surgery?

Choose value improvements 3

What is a “Value Improvement”?

POSTERS IN HOSPITAL TOILET“Safety cameras record pictures of personnel not

washing hands after using toilet” Problem cost-effective

Examples: “Read back” now used consistently to confirm message received

and understood

Patient Pathway redesign, using less clinician time & fewer delays

“A change which saves money and suffering…caused by poor organisation or under-supported providers”

Evidence-based = proven and likely to improve our service value 5

Evidence – the search

problems and potential savings

solutions and their “spend costs”

Evidence of savings or losses

for implementers, or others, now or later

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Evidence and experience I will share Quality economics research & projects in Sweden and Norway

1999-2009

2009: 5 systematic reviews of research and book

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What did I find, from the search?

Guess one – hands up: All quality and safety improvements save

money? No improvements save money? Some quality and safety improvements save

money?

Which ones, for whom, and when? 8

Cost of poor quality

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Patient: 84 year old, obstructive airways disease and heart failure

- Stable at home, fiercely independent- Supported with regular visits to primary care by son,

and home cleaner,

and cat “Matty”

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Health care experience

10am Friday fall at home - breaks hip 14.00 admitted ER 17.00 internal medicine unit Change of medications

Weekend - no operationsMonday – orthopaedic surgeon informed

lateTuesday am operation

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Health care experience

Friday - isolated due to MRSA developing in wound on arm from fall

Discharged 1 week later with no information to PHC

Readmitted 2 weeks later with weight loss, pneumonia and infected wound

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6 weeks – what the numbers do not show

Estimates $17.4b cost avoidable re-hospitalizations for older patients,

(50% preventable by better coordination (Jenks et al 2009)

25% of hospital days and clinical procedures inappropriate

25% of radiological tests not necessary (UK Royal College of Radiologists)

€415bn/yr “wasted on outmoded and inefficient medical procedures in the US” Juran study

the cost of poor quality care will likely exceed $1 trillion by 2011

40% medications unnecessary (Rand USA studies)

€330m medicines returned to pharmacies for disposal each year UK (BMJ 2002)

Estimates ..by our current very

conservative estimates, only 44 % of all resources consumed in health care delivery add value.

Thus 56 % – represents potentially recoverable waste

Poor quality and safety - types Under-coordination

500 GPs - 70% reported late discharge summaries “often” or “very often”, 90% reporting it “compromised clinical care” and 68% “compromised patient safety ”. One summary arrived 11 years late

The slips “in-beween” – music is the space between the notes

Chassin et al 1986: Over-use (no medical benefit) Tests and antibiotics.

Under-use of effective treatments anticoagulant to prevent thrombi (also 79% of eligible heart attack

survivors fail to receive beta blockers)

Miss-use (esp miss diagnosis 10%-15%) (anticoagulant to prevent thrombi)

Some cause Injury (AE), some, no harm but poor quality16

Adverse events – avoidable injury & costs

Typical Loss, to the average provider (medicare payment)

(longer length of stay and extra treatments):

pressure ulcer $2,400; postoperative sepsis $16,000; postoperative embolism and deep vein thrombosis

$8,500; postoperative hemorrhage $6,000; Iatrogenic pneumothorax $10,200

NB - Even after reimbursement for the extra treatment

(see also HFMA 2006). 17

Three targets for QI and cost reduction

1 High Cost Adverse Events:

avoidable patient suffering

and waste

2 Process improvement

3 Waste

as revealed by Lean quality methods and reports (eg UK NIII productive ward, 10 high impact)

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Where to look for avoidable poor quality/high cost

Hospitals

Primary health care

Nursing homes

Health/welfare system

ICU, ER, OR, Radiology, Outpatients, Discharge planning

& all “in betweens”

Diagnosis, avoidable referrals and admissions, prescribing, chronic care and multiple morbidity

Pressure ulcers, falls, prescribing, avoidable admissions, MRSA, shift handovers

Transfers and patient information handovers, chronic care & multiple morbidity

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Can you fill in the numbers / year for your service?

2004/13/2023

Type of event 1 Number /yr

2 Cost of event (average, to the service)

3 Cost /yr

Hospital acquired infection (HAI)?Adverse drug event

Patient falls?Pressure ulcers?Wrong site surgery?

Other common adverse event

Johns suggestionGet more informed about high cost problems, from:

1) Research on problems, costs, possible waste, elsewhere but likely in your service

2) Your data from: discharge and admissions data, reports, review of medical charts (JC tracer method, IHI trigger tool).

Special focus on ICU, ER, OR, Radiology, Outpatients

3)Estimate 10 highest cost from a) cost/problem, b) frequency

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Reminder

But will cost of solution be more?

Savings depend on the solution “spend cost”

4) Estimate cost to reduce problem by 25% and 50% - next

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Solutions & Potential

Savings2304/13/2023

Are you engaging this motivated resource? - patients

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Solutions – do they work, and do they cost more than the problem?

– do they work, and do they cost more than the problem?

1)Effectiveness evidence

Clinical practices: AHRQ 2001 11 “Nike list”

Timely antibiotics before surgery

Barrier precautions before

central line catheters, etc)

2) Less evidence about organisational

changes – team based care models 25

Solutions

3) Less evidence of effectiveness of implementation strategies

Eg training, reminders, etc?

4) Little evidence of costs of solutions

In one service

In a variety

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Others reported experienceFalls resulting in fractures av cost $30,000 30% over 65 with a fall-related fracture die

“An investment of $25,000 in a fall prevention program yielded $115,000 in savings in fracture care”

Nosocomial infections cost a minimum of $5,000 per episode.

“An investment of $1,000 in hand hygiene yielded $60,000 in avoided care costs”

Calculation details not given(Source: Bagian reports from VHA (in AHRQ 2008)

Our Swedish research – Service accountants using routine data - Savings in first year

100,000€ Better coordinated care planning before discharge in hospital geriatric unit (1.035.410 SEK)

14,000€ Review of medications in one home for older people (146 334 SEK) (73€ per patient/year (732 SEK).

71,000 – 630,000€ Emergency unit patient vita signs assessment improvement between (713 298 SEK and 6 317 270 SEK in the

first year) (depending on assumptions)

24,000€ yr1, 65,000€ yr2 Reducing sphincter injury in delivery from 5,3%-3,9% (239 122 SEK (2006 first year) and 652 836SEK

(2007).

Return on Investment – Managed care QIROI

Selected 10 Medicaid managed care organizations QI for high-risk high-cost patient populations

12/ 1 - A complex case management program to treat adults with multiple comorbidities

6/ 1 - case management for children with asthma with high ER use or inpatient admissions

1.2/ 1 intervention for high-risk pregnant mothers

1.1/ 1 program for adult patients with diabetes

3 broke even,

3 cost between 18 and 26 times more than they saved (Greene 2008)

Savings or extra income depends on

How effectively and completely you make the change motivation, project management and expertise

Step 2: “change into cash” can you use the saved bed days, time or materials to

increase income through treating more patients?

Or redeploy staff/beds, or charge higher price?

Does your payer measure quality,

and financially reward or punish poor quality?

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Financing system disincentives Mary case : discharge early - no information, readmission with

acute pneumonia - No quality measures

Triple incentive for poor quality Save on early discharge (lower LOS, DRG based fixed income)

Paid for readmission

Save on costs of time to give info to PHC and cost of system for this

(No finance to invest in improvement)

Paid to treat illness caused by healthcare

or poor coordination Eg readmissions due to poor treatment or early discharge 3

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The summary

up to 50% of your costs - potential savingsBut 1) Spend cost of solution? - for your service

(25% effective?)(how effective in your service?)

2) Turn this into cash savings or extra income? - change 2

= you have to make estimates, and then track for sure

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Next - “Leading EIVI”“We realized that if we just cut out cost, more often than

not we’re reducing quality. What we’ve learned is that if we reduce cost by reducing

waste, we actually improve quality” Dr Gary Kaplan. CEO VMMC

What do leaders need to do?

Which leaders? Level? Role?

service manager accountable for resources; clinical leader professionally accountable; quality/safety officer 3

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Reviews of research - From web site

.

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2005

20092010

Findings : Your actions depend on1) Role

Position/role: level, general manager or clinical leader

2) The QS task Type of quality and safety work QA/QI simple, radical -

many departments/professions

3) Context Internal , External

= Leader development/support to enable different actions and tasks, for different QS objectives, in different contexts.

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.Agreement about steps for different types of improvement,

Less about how many of the tasks the leader does, with or

without consultation.

- evidence that more successful improvement is where the

leader creates a social process

- tasks are shared and exchanged at different times,

- leaders role is to start and sustain this process.

- how they do this depends on the situation

BUT clinical professionals do not see this “organisational

work” as their best use of time, and have no skills for it

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What a leader needs – 7 things

1 Get knowledge AEs or sub-optimal quality in our service? Classification of range of problems, for data collection Data: frequency, volume of patients affecting, potential cost

2 Get motivation Benefits for me? Convince with credible data by credible

source

3 Prioritise and set targets Understand which improvements could reduce avoidable harm

save money or increase income, in your service

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What is needed – 7 things

4 Lead process for improvement enlist project team, with senior sponsor and clinical champion,

expert facilitation, using systematic methods appropriately 5 Monitor and progress  team reports, managers remove blocks (or lay down team)

6 Evaluate savings and outcomes track costs, spend costs, potential savings, real savings/increase

in income

7 Sustain and spread Procedures, training and supervision, document and roll-out

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Success depends on more than the leader’s efforts and skill

Seed Gardener/planting & nurture Climate / soil

Change idea + Context + Implementation actions

Your change?

Evidence + Implementation + Environment

Motivation Incentives and Culture Are employees motivated to give extra effort to

QI?

Incentives (reinvest savings?)

Attitudes

and culture?

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Engagement – does the rational work? PPT presentation – potential partnership opportunity

Our individual challenges – ageing, economy, partner to reproduce

What others have done

The benefits Lower costs

Taxation advantages

Evidence says its good for our health and for the kids

What you need to do

Take questions and answers now

Or…Or appeal to the heart – how good they are, their importance, recognition, need trust, truly desire, honest

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10 top tips for leading improvement1 No measure = no use

Ask “when will a measurable change in outcome, costs or intermediate indicator be seen?

How much this will cost and save?

2 Stop any activity which cannot say this.

3 Improvement and innovation efforts take time to change what people do and to make a measurable difference to patient care

4 Check, stop, or speed it Know how to tell if its not working – intermediate measures 

5 Finish off Look for what people have started which is likely to produce results and

finish it off 42

Top tips 6-10 for leading improvement6 Doctor and manager must lead it

Interest and motivate them Make sure they use the methods appropriately

7 Be a Viking Steal and apply – use changes and implementation approaches proven in

services like yours

8 Don’t loose in translation Adapt to adopt but don’t loose the active ingredient

9 Free the talent and side step the negatives Find the “can doers” and support them to show the doubters that it works

10 Work on the head and the heart Rational steps and methods, driven by people upset by poor quality

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Conclusions High cost of poor quality Some effective targeted solutions, little

evidence of “spend cost” Some certain savings, but depends on

implementation skill Financing system rewards poor quality

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Leading EIVI – the challenges.

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Questions

This surprised me….

This might not be true in my service…

This I can use in my work and service….

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TOOLS and Resources

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Click Links to web Site Quality Safety & Tools

Johns web site with papers and tools

http://homepage.mac.com/johnovr/FileSharing2.html

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ResourcesAssess if a change will work in our organisation.From AHRQ http://www.innovations.ahrq.gov a)Based on good evidence and experience b) Clear advantage

compared to current, c) Compatible with current system and values d) Simple to implement e) Easy to test before full commitment, f) Impact of change observable.

Also download: Brach et al 2008 AHRQ “Will it work here”, downloadable from Johns web site ACHS folder

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AHRQ 2008 workshop for good overview Creating a Business Case for Quality Improvement

Research: Expert Views, Workshop Summary, NATIONAL ACADEMIES PRESS, Washington, D.C.

http://www.nap.edu/catalog/12137.html

Calculate Waste costs

LOS, staff time, materials, loss of income

Spend costs (50% solution)Cost of time for project team & other costs

Savings - after 1 year starting the project How much will you have spent? How much will you have saved? How long after starting do you start saving?

What are the steps to turn potential into real savings or extra income?

USA literature "The business case for quality"

Reiter KL et al. 2006. “How to develop a business case for quality.” International Journal for Quality in Health Care; 19(1): 50-55.

Gosfield, A Reinertsen, J (2003) Doing Well By Doing Good: Improving the Business Case for Quality, The Reinertsen Group Alta, Wyoming

Gross, P et al 2007 The Business Case for Quality at a University Teaching Hospital The Joint Commission Journal on Quality and Patient Safety March 2007 Volume 33 Number 3, 163-169.

Leatherman, S et al 2003 The Business Case For Quality: Case Studies And An Analysis HEALTH A F FA I R S ~ Vo l u m e 2 2 , Nu m b e r 2 17-25

DETAILS

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Practical recommendation 1 - providers

1 Select quality projects for support

Decide criteria for Q-support This organisation does not support quality projects or activities

which do not meet these criteria…

…because it takes time and money from activities which are effective for QI and from clinical care.

Criterion: an estimate of current cost of the problem, likely spend and potential savings at 1,2,3 yrs.

2 Do estimates.

The Steps: cost, spend, save or loss54

Step 1: COST? How much does problem cost us?

Do you a) waste time or resources, b) loose income (or patients) with this problem? eg MRSA case = Yes to a) and to b) if measured and

publically known eg VAP in ICU = Yes (if paid by item/drg)

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Step 2: EFFECTIVE? If high cost, is it preventable/reducable?

Someone somewhere has an effective solution We can implement it effectively

Step 3: SPEND?

Quantify the time and cost of implementation in money If we can reduce the problem, how much do we need to

spend to reduce it? Eg 100,000 € to reduce by 10% - and show confidence

range (eg 95% certain 80,000-120,000 €) Personnel time needed, and using other peoples estimates5

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Step 4: SAVE OR LOSS?

Cost - spend = save or loss at 1yr,2yr 3 yr

“Theoretical savings”: less time or materials used

Cash savings: change 2 is using saved time to increase income or reduce spending

Estimate Time To Pay-Off - 18 months? Or never?

If you will loose money but health system/purchaser saves

Then take your estimates to them and agree a deal

They may fund the project 5704/13/2023

Practical recommendation - Funders/heath system

1. Change financing system

Measure and fund quality, as well as volume and cost Better outcomes and prevention saves you money

Require quality data from providers or third parties Change item of service funding to include quality measures Don’t pay providers to treat the injuries they cause Experiment with “bundle payments” for chronic care and long-

episode funding

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Practical recommendation - Funders/heath system

2 Invest in proven value improvements (make your list)

Give money to implement

Some safety interventions (eg coordination)

Some improvements (eg day surgery, process imp)

Some chronic illness programmes

(eg collaboratives, or directly to provider project)

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Advice

1 Criteria for choosing: Costly problem, effective solution, implementable (investment, time, support), savings more than costs

2 In betweens : improve clinical communication and collaboration between

shifts, professions, services, facilities

3 Leading Value Improvement is more successful

Unites clinicians, managers, purchasers, patients, politicians

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Conclusions

Each person write down and then share in the group:

1. These were the main points…

2. This was new or surprising, for me…

3. The most useful idea for my work was…

4. What I would like to find out more about…