The Future in Quality and Safety

Don Goldmann, MD

Chief Medical and Scientific Officer

Institute for Healthcare Improvement

Clinical Professor of Pediatrics

Harvard Medical School

Professor of Immunology and Infectious Diseases, and

Epidemiology, Harvard TH Chan School of Public Health

@DAGoldmann

dgoldmann@ihi.org

March, 2016

Acibadem

Future in Health

IHI’s Mission:

To improve health and health care worldwide

IHI in Brief • Small not-for-profit in Cambridge with the goal of improving

healthcare and health in the US and globally for all people (embarrassing disparities in the US)

• Collaborate with Strategic Partners (13) and an extensive faculty (>100) and a fellow network (>70), without which we cannot attain our goals ‒ Strategic Partner examples: Jonkoping Sweden, Kaiser Permanente,

Hamad Medical Center Qatar, Hospital Israelita Albert Einstein Brazil, US Military Health System, NHS Scotland)

• Determined to “change the conversation” about what is possible – historically, what we do best (100,000 Lives Campaign, Triple Aim)

• Focus on innovation, implementation, results, and spread and scale up of what works

• Relentlessly optimistic (young, motivated staff)

• Transparent

• Grounded in scientific improvement ‒ Driving sustainable, credible results that can withstand critical scrutiny

Please visit IHI.org for lots more information

IHI Open School – Disruptive Innovation

Designed by Students to Democratize Knowledge

As of 2/1/2016 Measure

396,853 Students and residents registered

788 Chapters (3 in Turkey)

361,911 Learners completing courses

74,343 Learners earned certificate

2,486,618 Courses completed

HarvardX/IHI MOOC (Massive Open On-Line

Course): Practical Improvement Science

11,012 learners 148 countries

Top 10 Countries

Learners by Education Level

> High School

High School

College

Advanced

Learners by Age (Median 41)

25 and under

26-40

over 41 63% 37%

Learners by Region

Africa

Asia Pacific

Europe

Latin America

Middle East

North America

Not Specified

5,360 United States 143 Denmark

1,001 United Kingdom 122 Brazil

567 Australia 111 Mexico

506 Canada 109 Saudi Arabia

263 India 103 South Africa

Where are Health and Healthcare

Headed?

• The deceptively simple “Triple Aim”

‒ System designs that simultaneously improve three

dimensions of health and healthcare:

• Patient experience of care (including quality and

satisfaction outcomes)

• Per capita cost of health care.

• Health of the population

Value

U.S. Institute of Medicine Healthcare Delivery Framework

Crosscutting

Dimensions

E

Q

U

I

T

Y

V

A

L

U

E

Components of

Quality Care

Type of Care

Chronic condition

management

Acute

Treatment

Preventive

Care

Effectiveness

Safety

Timeliness

Patient/family-centeredness

Care Coordination

Health Systems Infrastructure Capabilities

Access

Efficiency

Crosscutting

Dimensions

E

Q

U

I

T

Y

V

A

L

U

E

Components of

Quality Care

Type of Care

Chronic condition

management

Acute

Treatment

Preventive

Care

Effectiveness

Safety

Timeliness

Patient/family-centeredness

Care Coordination

Health Systems Infrastructure Capabilities

Access

Efficiency

Moving beyond the hospital to the entire healthcare delivery system

Mega Trends

• “Bundled” condition-specific and population-based global

payment models

– Value-based purchasing will be the rule in almost all health

economies

• ACOs (Accountable Care Organizations) in the U.S.

– Accountability measures for payment, benchmarking, and public

reporting (such as mortality, harm, readmissions, prevention and

treatment of chronic diseases) will be the norm

• Focus on prevention and “upstream” social determinants

of health, including health of individuals and communities

• Disparities reduction, equity

• Data transparency

Mega Trends

• Patient safety in all settings (hospital, nursing home,

clinic, home)

• Team-based, inter-professional care

• Transformation of training of doctors and other health

professionals to practice in a Triple Aim environment

• Burned out, overwhelmed work force

‒ Urgently need to make room for intrinsic motivation

• Real patient-centered care: “What matters to you?,” not

“What’s the matter?”

‒ “Lean” from the point of view of the patient, not just the delivery

system

10

Case Study of an Accountability Measure –

HSMR (Hospital Standardized Mortality Ratio)

• Developed by Sir Brian Jarman following Bristol Inquiry

• Use for improvement – So high-level that it may not reflect organizational quality

• Drill down measurement by department, condition critical

– Some studies suggest that the great majority of deaths in-hospital are not “preventable” so unaffected by improvement efforts

• Use for judgment (payment, benchmarking, detection of outliers) – Benchmarking

• Gaming (Florence Nightingale and William Farr)

• Up-coding

• Incomplete risk-adjustment

• Rankings vary considerably by measurement method

– But, useful for screening for statistically significant outliers for more thorough investigation (Francis Report in England following Mid-Staff Trust mortality inquiry)

• Use for patient choice – Unlikely to be relevant for most decisions

Adjusted 30-day mortality rates following fractured hip in over-65s

Benchmarking Comparisons versus Outlier Detection

Funnel Plot of Cardiac Surgery Mortality

30-day mortality rate for cardiac bypass grafts, New York State

Data Transparency is Increasing…

• Public data sources (in the US) ‒ HEDIS (Healthcare Effectiveness Data and Information Set)

‒ Hospital Compare (Center for Medicare and Medicaid Services (CMS)

‒ Why Not the Best (Commonwealth Fund)

‒ Leapfrog Group (patient safety)

‒ Consumer Reports

‒ Social Media and HealthGrades “Consumer Grading”

• International comparative data ‒ OECD (Organization for Economic Co-operation and Development)

‒ WHO Millennium Development Goals and Sustainable Goals

‒ Commonwealth Fund International Scorecard

Publicly post strategic data on organization website

Make progress towards reaching aims visible