© Pittsburgh Regional Health Initiative 2011 1 From Repair to Transformation: The Healthcare Quality Revolution Karen Wolk Feinstein,PhD President & Chief

© Pittsburgh Regional Health Initiative 2011 1

From Repair to Transformation: The Healthcare Quality Revolution

Karen Wolk Feinstein,PhDPres ident & Chief Executi ve Offi cer

I nve s ti n g i n H e a l t h C a re Q u a l i t y a n d Pa ti e n t S a fe t y

G ra n t m a ke rs I n H e a l t hJ u n e 1 3 , 2 0 1 1

Spreading Quality, Containing Costs.


“A Think, Do, Train and Give Tank”

A public charity with two supporting organizations• Pittsburgh Regional Health Initiative (PRHI)• Health Careers Futures (HCF)


Staff and Functions

Think Researchers Data analysts Communications,

media, writers Policy analysts Evaluators

Give Program officers Grant managers Fiscal agents for

HIV/AIDS funds Accounting

Do Program directors Event planners Trainers Grant writers Web designers Public relations

Train Curriculum developers Coaches and trainers

40+ Staff


Phase One:1997 to 2001 Pre-IOM Reports


What and Why: PRHI

Pittsburgh Regional Health Initiative (PRHI) A not-for-profit, regional, multi-stakeholder coalition

formed in 1997 An initiative of a business group, the Allegheny

Conference on Community Development

PRHI’s message Dramatic quality improvement (approaching zero

deficiencies) is the best cost-containment strategy for health care


The Persistence ofMedical Errors in U.S.

Adapted from Milliman: The Economic Measurement of Medical Errors, June 2010

Error Type% of

Injuries that are Errors

Count of Errors (2008)

Total Cost per

Error

Total Cost of Error

(millions)

Pressure Ulcer (Medicare Never Event) >90% 374,964 $10,288 $3,858

Postoperative Infection >90% 252,695 $14,548 $3,676

Infection due to Central Venous Catheter >90% 7,062 $83,365 $589

Catheter - Associated Urinary Tract Infection (Medicare Never Event)

>90% 12,839 $26,793 $344

Object Left in Body (Medicare Never Event) >90% 11,690 $8,031 $94

Blood-Type Incompatibility (Medicare Never Event) >90% 6,350 $11,738 $75

Total Cost of all errors = $19.5 Billion per year


Toyota/Lean Production Thinking: The Basics

Problems identified and solved Rapid root cause analysis Organized work areas Concise communication Active involvement of managers

“Go and see” On the floor

Intense respect for the employee: Every employee has what they need,

when they need it to succeed Career development

Team problem solving to meet customer need


What We Observe in Health Care

W. Edwards Deming, PhD: “Where Art Thou?”

Chaos Uncertainty Random Behaviors Work-Arounds Confusion Disorder Errors High Turnover Secrecy


PRHI’s Prescription for Transformation

Services That Add Value All Services Add Value

Preventable Complications

Unnecessary Treatments

Inefficiencies

Errors

100% Value

60% Value

40% Waste

NOW FUTURE


The Journey: From Vision to Innovation

PPC for Systems Transformation

PPC for Organizational Transformation

PPC for Repairs

An Early Vision for Perfecting Care

A Method for Perfecting Patient CareSM (PPC)

Incr

easin

g Valu

e with

Each

Step

PPC in New Technologies and New Models


Where Value Derives

THE PATIENT

• Outcomes of Care

• Efficiency of Care

• Zero Defects

Value begins at the front linewhere patients receive care


Our Method: Perfecting Patient CareSM PRHI’s Unique Brand of Quality Improvement

Adapted from Lean Patient-focused systems redesign Can be applied in the

course of everyday work The ultimate goal is perfection


Phase 2:2001 to 2008 QI in Acute Care


A Defining Initiative:Reducing Hospital-Acquired Infections

30+ hospitals participating in PRHI’s community-wide infection control project reported an average 68 percent reduction in CLABs over four years Results varied among institutions The Power of Perfecting Patient CareSM:

one hospital virtually eradicated CLABs from its main intensive care units


The Champion Role in Transformation

PPC empowers frontline staff…and more

Nurse Navigators

Nurse Managers

Team LeadersSalk Fellows

Patient Safety Fellows

Physician Champions

Clinical Pharmacists

Long-term Care Workers

Librarians

Hospital Trustees

Emergency Medical Technicians

Caregivers


Perfecting Patient CareSM (PPC) Training

Where We’ve Taught


68% Dropin CLABs in 34 regional hospitals

50% FewerReadmissionsw/ COPD focus

86% Reductionin medication errors

180 to Zero!Lost patient hours per month due to ambulance diversions

Efficiency Increased 100%

in pathology lab

17% Dropin pediatric clinic

wait times

100% Reductionin nurse turnover

50% Reductionin pap smear

sampling defects

>20% DeclineNosocomialC. difficileinfections

35 to Zero!defective charts

100% Compliancew/guidelines & aspirinuse in a diabetes clinic

PRHI Stories of Success in Acute Care


Our Methods and Successes Have Attracted Attention


Phase 3: 2009 and OnPost ACA: Managing

Complex Patients


The Second Systems Vision: Transforming the Care of Complex Patients

Acro

ss C

are

Setti

ngs

Essential Services System Requirements

Care Mgt

Clinical Pharmacy

Patient Engagement

Health IT

QI Training

Payment Incentives

Collaboration and

Integration

Medication Reconciliation

Informed Activated

Discerning Consumers

Data to Treat,

Measure, Evaluate

Perfect Patient

Care

Rewardsfor

Collaboration

Hospice/Palliative

Long Term Care

Rehab

Hospital

Emergency Services

Specialty Care

Primary Care

Screening and Tx

Behavioral Health

© Pittsburgh Regional Health Initiative 2011 21#21

What is essential to ourvision for reducing

readmissions?

Care Management

Clinical Pharmacy

Patient Engagement

Behavioral Health

HIT QI Training

Isn’t reimbursed


The Complex Patient

Who is frequently hospitalized?

Do you know your customer?

Are you meeting their need?


Let the Data Guide Work

The Complex Patient

HIV/AIDS End of Life

Skilled Nursing

Chronic Disease(COPD)

Behavioral Health and Substance Abuse

Multiple ConditionsPRHI

CurrentProject


The Solution Coordinates Transition Between Hospital and Community

Improvedpatient

education and

support*in the

community

Patienteducationto addresscauses of admission

COMMUNITYHOSPITAL

Patient uses inhaler properly, leading to

improved functioning

Patient is discharged WITH training in use of inhaler

MD gives patient prescription for inhaler, but no

training

Patient gets inhaler from

pharmacy, but no training

Patient fails to use inhaler properly, leading to

hospitalization

Patient is treated with

nebulizer during hospital

stay

Patient is discharged

without training in use

of inhaler

+ + +*Care Mgt

ClinicalPharmacy

PatientEngagement

BehavioralHealth


COPD Readmissions Reduction Results

By focusing on the transitions between care settings: 30 readmissions prevented $160,000+ saved Net savings of $80,000+ after

cost of Care Manager

Jan-Dec 2008 Jan-Dec 20090%1%2%3%4%5%6%7%8%9%

10%11%12%13%14%15%

% of Patients Admitted for COPD Exacerbation and Readmitted within

30 Days for COPD or Pneumonia

44% Reduction

PRHICurrentProject


AHRQ Grant: Partners in Integrating Care

$3.5 million from AHRQ to disseminate and implement behavioral health services in primary care settings

© Jewish Healthcare Foundation, et.al. 26

PRHICurrentProject

http://www.icsi.org/index.aspx?catID=2

http://www.wchq.org/index.php


PRHI’s Accountable Care Network in Pittsburgh

PARTNERS

• Pittsburgh Regional Health Initiative

• Highmark

• Jefferson Regional Medical Center

• Monongahela Valley Hospital

CLINICAL SITES

• 2 Community Hospitals

• 24 Physician Practices

• 68 Physicians

FUNDERS

• Jewish Healthcare Foundation

• Governor’s Office of Healthcare Reform

• Highmark Foundation

• Richard K. Mellon Foundation

PRHICurrentProject


“Closure” is a 5-year initiative approved by the JHF Board in 2008 to change expectations for end-of-life. Our goal is to empower consumers and healthcare professionals with easy-to-access, simple-to-understand information and resources to make educated decisions about end-of-life care

Closure / End of Life

PRHICurrentProject


Reducing Preventable Hospitalizations:PPC in Skilled Nursing Facilities (SNFs)

6% of seniors in SNFs = 17+% of healthcare costs

20% of hospital patients discharged to a SNF were readmitted

51% of residents have one or more ER visits

38% have a hospitalizations: 41% are readmitted

Kaiser Family Foundation data

Long Term Care

Champions PRHICurrentProject


Disruptive Innovations

1. Simple, less expensive, “upstream” innovations

2. Serve more with fewer features

Do not overshoot customer need

Show better understanding of customer need

© Pittsburgh Regional Health Initiative 2011 31#31

“Training dosage had most important effect on measures of success. A combination of PPC training, additional training, and coaching were associated with improved outcomes. Social networking or on-line technology can foster a virtual PPC community.”

- Donna O. Farley, PhD RAND: Results from the

Retrospective Evaluation Effects of PPC University Training

The Technology Innovation


Tomorrow’s HealthCare™ Spreading & Sustaining Change

PRHICurrentProject


Summary of Good Investments

Education, training, coaching

• Building an army of champions

Research on complex patients

Consumer engagement and

empowerment

Pilots• New Models of Care

• End of Life• Behavioral Health

Workforce — new roles for new workers

Disruptive Innovations:

• New Models, New Tools


The Current Agenda

For the Patient, it is care that is kind, competent, customized, comprehensive, safe and efficient; addressing the needs of vulnerable populations, including:

Seniors (Caregiver Champions) and Long Term Care Champions

The poor (Safety Net Medical Home Initiative) The chronically ill (Accountable Care Network) Those who are approaching End-of-Life (Closure) Persons living with behavioral health problems (AHRQ grant),

and persons living with HIV/AIDS (Readmissions Reduction project)


The Current Agenda (cont’d)

For the Healthcare Worker, it means that care is:

Informed and supported (Regional Extension & Assistance Center for HIT)

Incentivized (Robert Wood Johnson Foundation payment reform grant and the Fine Awards)

Prepared by training and coaching (Perfecting Patient CareSM, Tomorrow’s HealthCareTM, PPC University, Fellowships and Champions Programs)


For Organizations and Systems, this focus includes:

Training, coaching and leadership development (Perfecting Patient CareSM)

Comprehensive improvement and education tools (Tomorrow’s HealthCareTM)

Transformations and new models of care (Patient Centered Medical Homes, Accountable Care Networks, Primary Care Resource Centers)

Payment Reform (Robert Wood Johnson Foundation payment reform grant and the website The Center for Healthcare Quality and Payment Reform— www.chqpr.org)

The Current Agenda (cont’d)

Documents

© Pittsburgh Regional Health Initiative 2011 1 From Repair to Transformation: The Healthcare Quality Revolution Karen Wolk Feinstein,PhD President & Chief