Quality Improvement. Goals & Objectives. u What is Quality Health Care. u Where are the gaps in care JOHN W. RAGSDALE, III, MD JULY 2017

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1 Quality Improvement JOHN W. RAGSDALE, III, MD JULY 2017 DEPARTMENT OF COMMUNITY AND FAMILY MEDICINE PRIMARY CARE SEMINAR SEA PINES, SC Goals & Objectives u What is Quality Health Care u Where are the gaps in care u Current strategies to improve care u Outline Quality Improvement framework and implementation 1

2 Definition of Quality Quality Health Care: providing patients with the right medicine, treatment or test at the right time and in the right location Quality Health Care: should be safe, effective, patient-centered, timely, efficient and equitable IOM Crossing the Quality Chasm 2001 Components of Health Care Quality u Equity - reducing gaps in health status among populations u Adding life to years full physical, mental and social potential u Adding health to life reduce disease and disability u Adding years to life increase life expectancy 2

3 Changing Paradigm in Healthcare u Accelerating national epidemic of chronic disease u Increasingly effective treatment of chronic illnesses u Co-morbidity problem u Shift towards population management u Movement from individual responsibility to systems-based care Mostly Failed Promises u IOM report in 2001 Crossing the Quality Chasm u System requires transformation u Six Aims for improvement u CMS.gov 2015 u Preventive services percent of U.S. population uhepatitis A vaccination 12.% ucolon cancer screening: 23.6%, ucholesterol 70% ubreast cancer screening 61.6% u Under use a greater problem than over use u Variability by chronic condition u Obamacare: u Uninsured 2014 : 17.9% u Uninsured 2016: 12.9% 3

4 American Health Care Act 2017 u Likely decreased numbers of totaled population insured by million u Likely will impact those with lower socio-economic status more than the wealthier population u Likely will have big savings u Estimates over $330 billion over 10 years Lots of Uncertainty. 4

5 Basis of the Chronic Disease Epidemic: Percentage of US Population 65 Years and Older Simple Rules for the 21 st Century Health Care System Current Approach u Care based on visits u Professional autonomy drives variability u Professionals control care u Information is a record u Decision making based on training and experience u Do no harm is an individual responsibility New Rule u Based on continuous healing relationships u Care customized according to patient needs and values u Patient is source of care u Knowledge is shared and information flows freely u Decision making is evidence-based u Safety is a system property Source: Crossing the Quality Chasm: A New Health System for the 21 st Century 5

6 Simple Rules for the 21 st Century Health Care System Current Approach u Secrecy is necessary u System reacts to needs u Cost reduction is sought u Preference is given to professional roles rather than system New Rules u Transparency is necessary u Needs are anticipated u Waste is continuously decreased u Cooperation among clinicians is a priority Source: Crossing the Quality Chasm: A New Health System for the 21 st Century Quality Problems Crossing the Quality Chasm uunderuse of beneficial services uoveruse of procedures that are not medically necessary umistakes leading to patient injury IOM,

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9 Strategies for Improvement u IHI The Triple Aim u National Committee for Quality Assurance (NCQA) u PCMH u Diabetes, Heart Stroke, Low Back Pain u Medicare u PQRS, Meaningful Use u Hospital Core Measure u MACRA 9

10 The Triple Aim u Improving the individual experience of care u Improving the health of populations u Reducing the per-capita cost of care for a population Berwick, et al, Health Affairs, vol. 27,

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12 MACRA: The Medicare Access and CHIP Reauthorization Act u Will continue to promote EMRs u Will be evaluating claims data to see how well you and your practice are doing u Must report at least six measures including one outcome measure u Measures under PQRS will continue to be available Improvement Journey Varying degrees of engagement from practice Slow to spread Slow to create buy-in Training challenges Prior to 2010 Used Model for Improvement, PDSA and collaborative models to identify spread change 2010: Adopted Kaizen event approach for system level improvem ent efforts. Applied to Rooming Process Challenging to sustain 2011: Trained to and spread standard work concept. Developed Standard Work. Limited resources 2012: Used Value stream mapping to do pilot project work on Care Manageme nt Role Redesign Challenged to Continuously Improve 2012: Initiated Redesign Oversight Committee and used Kaizen rapid improvement approach to stabilize post maestroimplementatio n. Developed more standard work. 12

13 What is Lean? The endless transformation of waste into value from the customer s perspective. Womack and Jones, Lean Thinking Every worker applying the scientific method to every part of daily work. an organization s cultural commitment to applying the scientific method to designing, performing, and continuously improving the work delivered by teams of people, leading to measurably better value for patients and other stakeholders. - John Toussaint, MD Where Did it Come From? 1930s Taichi Ohno and others at Toyota wanted the continuity in process flow that Henry Ford had pioneered with the Model T AND be able to provide a wide variety of products. Their innovations developed the Toyota Production System. 13

14 Toyota Production System Revolutionizing Care Delivery Patient-Centered Care Maestro Care Implementation Right patient, right place, right time Innovating in Clinical Growth Primary/Specialty Network Development Access Improvement Duke Medicine Pavilion Cancer Center Reinventing care design & payer strategies Population health management Clinically Integrated Network Care bundles Performance Excellence Quality & Patient Safety Patient Experience Finance & Growth Work Culture Kaizen 3P 6Sigma Leveling Reliability Value Stream Mapping FMEA 8 Wastes Standard Work Gemba A3/PDSA 5S & Visual Management Hoshin Kanri 5Whys Quality -Error Proofing Physicians, Providers & Direct Care Staff Deliver great, compassionate patient care efficiently and effectively; constantly seek innovations in safety and quality Support Care Staff Improve the patient experience; support optimal care delivery; excellence in operational execution Lean Systems & Principles All Providers, Staff, Volunteers Demonstrate values-based behaviors and decision-making DUHS Values Caring for Our Patients, Their Loved Ones, & Each Other Excellence Safety Integrity Diversity Teamwork 14

15 What is it about? Define Value for the customer- putting the patient/ customer first patient-centered healthcare Respect for People respectful of our community, providers and staff Caring for our patients, their loved ones and EACH OTHER Identify & Eliminate Waste: remove process steps that are waste respectful of our community, providers and staff Create continuous flow by eliminating the root cause of the waste Continuously Improve Lean Is Value-Creating and Waste Reduction u Value added: any activity the patient is willing to pay for or deems necessary u Non-value added: activities the patient deems unnecessary or are unwilling to pay for u Non-value added but necessary: activities that support the patient as necessary today but are not considered of value by the patient Duke Primary Care provides comprehensive, patient-centered healthcare in an environment that is respectful of our community, providers and staff. Caring for Our Patients, Their Loved Ones, and Each Other Excellence Safety Integrity Diversity Teamwork Check IN Wait Intake Wait Provider Visit Wait Lab Wait Check Out 15

16 Lean is an Attitude of Continuous Improvement Take nonstandard work processes and transform them into standard processes that improve performance and then continue to improve the standard work design through PDSA How do we Solve Problems? Our Natural Human Tendency? Why do we do this??? Perception of a Problem BLACK HOLE The SOLUTION Impressions & Assumptions FACTS Theory Courtesy of LEI 16

17 How should we Solve Ask Questions to Help Ourselves SEE: Problems? What is actually happening? What do I actually know? Lean is a Unity of Purpose Balanced Scorecard Quality & Patient Safety Patient Experience Finance & Growth Work Culture The Real or Main Problem Impressions & Assumptions FACTS FACTS FACTS FACTS A SOLUTION Theory Courtesy of LEI 17

18 Lean is Respect for People Who do the Work Lean is Visual Toyota has average people, brilliant processes, and produce superb results. You have brilliant people, broken processes and produce mediocre results. Fujio Cho to Jim Womack We squander workers brilliance passing patients across the gaps in our processes. It s not the people it s the process! 18

19 Success Relies on Leader Standard Work at All Leve Lean Enterprise Institute 19

20 How do we make improvements and reduce waste? Evaluating Health Care Selecting Evaluation Measures u Relevance u Meaningfulness or interpretability u Scientific or clinical evidence u Reliability or reproducibility u Feasibility u Validity u Health Importance 20

21 Quality and Patient Safety February 2016 February

22 Division Family Medicine: Patient Experience February 2016 February 2017 How did we do this? u Found a system to look at how we were doing as a practice u Rinse, wash repeat u Demanded quality data from EMR u Embraced the practice from front staff to MD s u Celebrated small victories u Transparency 22

23 u Summary Measurement leads to Quality Improvement In Closing u u u Quality health care gap is LARGE u Avoidable deaths u Avoidable sick days u Avoidable hospital cost u Lost productivity Public reporting leads to higher performance - TRANSPARANCY Employers/purchaser wants/demand Quality & at provider/practice level u P4P will link quality & $$$ u ONLY JUST BEGINNING People build the systems. People innovate. People work collaboratively. People create. People use the tools. People apply the methods. People solve problems. People lead. But people need help. They need methods. They need tools. They need systems. They need to be empowered to solve problems. They need coaches. They need leaders. This is where it all comes together it s the heart of Lean and the opportunity for realizing the full potential of this amazingly adaptive system. Source: Erika Fox, An Adaptive System 23

24 References Crossing the Quality Chasm, Institute of Medicine, National Academy Press, Washington, DC ( To Err is Human, Institute of Medicine, National Academy Press, Washington, DC ( The Quality Assurance Project, 7200 Wisconsin Avenue, Bethesda, MD (USAID) QA Brief Vol 9, number 1, Spring, Quality Improvement Series, Family Practice Management, March, April, May Medscape