Patient Safety and Quality: The Unfinished Agenda

1
Patient Safety and QualityThe Unfinished Agenda

• Harvey V. Fineberg, M.D., Ph.D.
• Syracuse Healthcare Quality Forum
• 22 April 2009

2
IOM Study of Medical Errors
2000
3
Response To IOM Errors Report

• 51 of the American public closely followed the
  media coverage (Kaiser Family Foundation, 2000)
• Congress appropriated 50 million for AHRQ
  patient safety center
• President Clintons call to action (DHHS Quality
  Interagency Coordinating Committee)
• Leapfrog Group reinforced and energized
• National Academy for State Health Policy
• Many national associations taking action

4
IOM Study of Health Care Quality
2001
5
Dimensions of Quality of Care

• Health care should be
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

6
Dimensions of Quality of Care

• Health care should be
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

7
Quality, Efficiency, and Value

• Meaning and measurement of efficiency
• Relationship between efficiency and quality
• Examples and reasons for inefficiency in health
  care
• Strategies and examples to improve efficiency,
  quality and value

8
Meanings of Efficiency

• Technical
• Production
• Allocative
• Market
• Health

9
Technical Efficiency

• When no greater output can be achieved for a
  given level of resource input. Production occurs
  on the technical production possibility
  frontier.

10
Technical Efficiency

• When no greater output can be achieved for a
  given level of resource input. Production occurs
  on the technical production possibility
  frontier.

Input A
Input B
11
Technical Efficiency

• When no greater output can be achieved for a
  given level of resource input. Production occurs
  on the technical production possibility
  frontier.

Input A
Input B
12
Technical Efficiency

• When no greater output can be achieved for a
  given level of resource input. Production occurs
  on the technical production possibility
  frontier.

13
Production Efficiency

• Optimal combination of resource inputs (labor,
  equipment, supplies, etc.) to achieve a given
  output. Production is efficient if a given level
  of output is achieved at the lowest resource
  cost.

14
Production Efficiency

• Optimal combination of resource inputs (labor,
  equipment, supplies, etc.) to achieve a given
  output. Production is efficient if a given level
  of output is achieved at the lowest resource
  cost.

Input A
Input B
15
Production Efficiency

• Optimal combination of resource inputs (labor,
  equipment, supplies, etc.) to achieve a given
  output. Production is efficient if a given level
  of output is achieved at the lowest resource
  cost.

Ratio of Input Costs
Input A
Input B
16
Allocative Efficiency

• Resources are allocated so as to optimize
  benefit to a population
• Market Efficiency
• Distribution of goods according to individual
  preferences
• Competitive market marginal cost marginal
  price
• Health Efficiency
• Distribution of health resources to maximize the
  level of health in the population

17
Allocative Efficiency

• When would market efficiency equal health
  efficiency? Among the assumptions
• Complete and accurate information
• No barriers to market access and exchange
• Personal preferences (utilities) for health
  expenditures coincide with health improvements
• Equivalent purchasing power across purchasers

18
Measuring Efficiency

• Identifying all inputs
• Pricing (resource cost) of each input
• Identifying relevant outputs
• Valuing the outputs (outcomes)

19
Outputs of Interest in Health

• Element of service
• Episode of illness or health condition
• Management of disease over a period of time
• Overall health of an individual
• Health of a community or society

20
Efficiency is not about

• Just cutting costs
• Enhancing revenues
• Making the doctors life easier (rather than the
  patients life better)
• Achieving justice

21
Quality and Efficiency

• Efficiency, in terms of eliminating waste, is one
  dimension of quality in health care.
• Quality, in terms of net benefits to health, is
  half of the equation for health efficiency.

22
Efficiency in Health

• Efficiency is a relationship of value how much
  output of value (health benefit) per input of
  value (resource cost)
• Focus on efficiency forces consideration of both
  sides of the value proposition benefits and
  costs
• EFFICIENCY

23
An estimated thirty to forty cents of every
dollar spent on health care a half trillion
dollars a year is spent on costs associated
with overuse, underuse, misuse, duplication,
system failures and inefficiency.
2005
24
Expected Quality and CostsEfficient Producer
Quality
Cost
25
Expected Quality and CostsEfficient Producer
Quality
Cost
26
Expected Quality and CostsEfficient Producer
Increasing Production Efficiency
Quality
Cost
27
Expected Quality and CostsSmart Consumer
Quality
Cost
28
Expected Quality and CostsSmart Consumer
Quality
Cost
29
Health Consumption Observed Quality and Costs
30
Episode Treatment GroupTM Analysis
Presented by E. McGlynn, RAND
31
Episode Treatment GroupTM Analysis
Presented by E. McGlynn, RAND
32
Why is Health Care Inefficient?

• Payment for wrong outputs (units of service
  rather than care of illness, quality of care, or
  health outcome)
• Financial incentives reward inefficiency
  (complications or re-admission)
• Lack of price incentives to patients
• Providers indifferent to induced costs

33
Why is Health Care Inefficient?

• Insufficient attention to prevention and
  long-term results
• Fragmented and uncoordinated delivery system
• Lack of information on performance and quality
• Dysfunctional competition rather than value-based
  competition

34
Making Anesthesia Better

• Deaths from anesthesia decline
• Early 1980s 1 per 10,000
• Today 1 per 200,000
• Malpractice claims, judgments, and fees decline
• Proportion of malpractice claims targeting
  anesthesiologists 19727.9 20013.8
• Proportion of malpractice claims closed with
  payment 1970s64 1990s45

35
Making Anesthesia Better

• 1985 Anesthesia Patient Safety Foundation
• Forum for health professionals, device
  manufacturers, regulatory bodies, and others
• Patient safety newsletter
• Seed grants in safety research
• New technology
• Pulse oximeter and capnometer
• Redesigned machines, standardized practice
  guidelines, improved training programs, hospital
  safety committees

36
St. Johns Hospital

• 866-bed, not-for-profit hospital and trauma
  center in Springfield, Missouri
• 32 operating rooms and 45-room trauma center
• 29,000 surgical procedures in 2005
• 74,000 emergency department visits in 2005, 22
  of whom are admitted and comprise 20 of the
  surgical load

37
St. Johns Hospital

• Problems (2002 analysis by E. Litvak)
• Lack of flexibility in scheduling elective
  surgeries that produced unpredictable and
  excessive use of overtime
• Mid-week peaks in surgery and resulting backup in
  admissions that often made it impossible for
  patients to have a bed on the appropriate floor
  and receive optimal post-surgical care

38
St. Johns Hospital

• Solution (peak-flow management techniques
  operations research)
• Set aside a single OR for overflowboth elective
  and unplannedsurgeries
• Smooth the scheduling of elective surgeries
  across the five weekdays

39
St. Johns Hospital

• Results
• After smoothing elective surgery, the capacity
  for ED admissions rose from 647 (October 2004) to
  1100 (October 2005)
• Excluding ICU, a 59 increase in inpatient
  capacity was realized without adding additional
  inpatient nursing beds
• The number of OR rooms needed after 3 p.m.
  dropped by 45, and OR overtime declined to a
  record low level of 2.9

40
St. Johns Hospital

• Results (continued)
• Since 2003, surgical volume has increased by 33,
  and trauma surgeons experienced a 4.6 increase
  in revenue
• Waiting time for emergent and urgent surgical
  cases after 3 p.m. was reduced by 45
• Prior to smoothing, the rate of patient placement
  into the appropriate bed for orthopedic patients
  was 83 after smoothing, the rate of appropriate
  placement rose to 96

41
Strategies to Increase Efficiency

• Improve outcomes (health benefits) without
  raising costs (i.e., without consuming more
  resources) or while saving resources

42
Strategies to Increase Efficiency

• Improve outcomes (health benefits) without
  raising costs (i.e., without consuming more
  resources) or while saving resources
• OR
• Reduce costs without reducing benefits (health
  outcomes) or while improving health outcomes

43
Strategies to Increase Efficiency

• Improve outcomes (health benefits) without
  raising costs (i.e., without consuming more
  resources) or while saving resources
• OR
• Reduce costs without reducing benefits (health
  outcomes) or while improving health outcomes
• Get more value from every health care dollar

44
Strategies to Enhance Value
InnovationEvaluationDiffusionPerformance
45
Strategies to Enhance Value

• Discover, design and invent technologies that
  provide more efficient solutions (direct savings
  and induced savings improved results)
• Incentives for research and development of
  efficient technology and program design
• Institutional innovation to bridge academic
  centers and technology creators and speed
  transition from research through prototype
  development and product availability
• Payment for efficient solutions

46
Strategies to Enhance Value

• Evaluate health outcomes and costs of
  technologies, care strategies, and providers
• Assess resource costs and health outcomes as a
  routine part of care
• Design information systems that serve patient
  records and can be used to evaluate patient
  outcomes and performance
• Devise, test, and deploy evaluation alternatives
  to RCTs that are cheaper, faster and more
  directly relevant to different patient
  populations
• Comparative Effectiveness research

47
Strategies to Enhance Value

• Use evidence more effectively in decisions by
  care givers and patients ( appropriate use
  misuse and overuse)
• Make information technology and decision-support
  systems more widely available
• Develop uniform standards for health IT, provide
  financial resources to introduce and support IT
  systems, and mandate their use
• Measure and make available to the public
  information on results and cost by physicians,
  hospitals, nursing homes, and health plans

48
Strategies to Enhance Value

• Redesign care processes to reduce avoidable
  errors in care
• Follow recommendations in series of IOM reports,
  from To Err is Human (1999) and Crossing the
  Quality Chasm (2001) to Preventing Medication
  Errors (2006)
• Systems approach, with many interacting parts
• Safer design, bar coding and labeling
• Improve coordination of care

49
Strategies to Enhance Value

• Train health professionals to improve quality and
  practice efficiently
• Educate jointly across the several health
  professions to provide comprehensive care to
  patients
• Regard as core professional competencies the
  ability to evaluate evidence and develop and use
  practice guidelines
• Increase use of simulation training
• Improve coordination of care

50
Strategies to Enhance Value

• Enhance value-based competition for health care
  dollars
• Reduce barriers to inter-state health insurance
  competition among health insurers
• Pay for episodes of illness or periods of
  managing patients rather than for procedures
• Provide feedback on performance to providers and
  to patients

51
Strategies to Enhance Value

• Give providers financial incentives to increase
  value
• Pay for performance and reward high-value
  providers
• Pay for prevention
• Pay for management of chronic conditions and
  coordination across hospital, nursing home, and
  community-based care
• Couple payment to evaluation
• Stop paying for hospital-acquired infection

52
Strategies to Enhance Value

• Give patients financial incentives to increase
  value
• Income-related co-payment and deductible
• Reduce insurance premiums for healthy lifestyle
  choices
• No deductible for preventive services
• Lower co-payment and deductible for use of
  high-value providers

53
Strategies to Enhance Value

• Use systems engineering methods to improve
  performance
• Reduce variability
• Optimize workflow
• Enhance use of resources

54
Strategies to Enhance Value

• Streamline administrative systems
• Uniform insurance forms and procedures
• Bulk purchasing cooperatives and competitive
  bidding
• Reliance on information technology

55
Strategies to Enhance Value

• Emphasize prevention of disease
• Individual education and incentives
• Community-based programs
• Policies and payments that promote primary
  prevention of disease

56
Strategies to Enhance Value

• Use information technology in a networked system
• Personal medical records
• Patient-centered communication (Patient-Patient
  Provider-Pt Pr-Pr)
• Administration (billing, scheduling, inventory)
• Enhance safety (pharmacy fulfillment)
• Clinical decision support

57
Strategies to Enhance Value

• Use information technology in a networked system
  (continued)
• Quality assurance and improvement
• Individual monitoring and population surveillance
• Exploratory to comprehensive observational
  studies
• Registries and clinical trials
• Real-time clinical CME

58
(No Transcript)
59
(No Transcript)
60
Reframe the Culture of Medicine

• Professionalism that embraces quality,
  efficiency, and value
• Professionalism insulated from commercial
  conflict-of-interest
• From autonomy to responsibility
• From institution-centered to patient-centered
  care
• From my patient to all patients

61
Toward Improved Health Care
Efficiency Outcome per Cost Value
Quality and Safety Performance
Use and Non-Use Practice
Standards Guidelines
Evidence Clinical Research
Opinion Personal experience