INSIGHTS FROM SYSTEM IMPLEMENTATION STRATEGIES

Transcription

1 TRANSFORMATIONAL CHANGE INSIGHTS FROM SYSTEM IMPLEMENTATION STRATEGIES BELFAST FEBRUARY RAFAEL BENGOA DBS HEALTH. UNIVERSITY OF DEUSTO. BILBAO. SPAIN

2 The Challenges DEMOGRAPHY EPIDEMIOLOGY. CHRONIC CLINICAL COMPLEXITY Más pacientes crónicos. Más pluripatología C omplejidad diagnósticos procedimientos quirúrgicos medicamentos de actos clínicos profesionales/ paciente FRAGMENTATION. SILOS EXPECTATIONS ECONOMIC «No se puede hacer medicina del siglo XXI con el chasis de 1.970». Bengoa

3 (*) 2012 (**) Scenarios Realistic case Best case Worst case

4 POLICY RESPONSE COST CONTAINMENT 1. REGULATION COVERAGE MODELO DE ASEGURAMIENTO (RDL 16, RD 1192) CARTERA DE PRESTACIONES SANITARIAS (RDL 16) 2. REGULATION FINANCING COPAYMENT FARMA (RDL 16 y su desarrollo normativo) COPAYMENT SERVICES: (Transporte sanitario, prestación ortoprotésica ( RDL 16 y su desarrollo normativo)

5 BROADER POLICY RESPONSE TO THAT CONTEXT. Ongoing System- Wide Transformations USA Coverage Expansion & Health System Reform EUROPE Coverage Expansion Done Health System Reform 5

6 SOME MAINTAINING STATUS QUO (TOO RICH! ) Others Responding 1. THE MARKET IS THE SOLUTION. - NETHERLANDS; USA? 2. FORCES OF TRANSFORMACION - MOST EUROPE

7 1. THE MARKET AS A RESPONSE? DEMOGRÁFICOS EPIDEMIOLÓGICOS CLÍNICOS Y COMPLEJIDAD FRAGMENTACIÓN ASISTENCIAL EXPECTATIVAS CIUDADANAS SEGURIDAD CLÍNICA Y CALIDAD THE MARKET AS A RESPONSE? WHICH OF THESE CHALLENGES IS RESOLVED BY THE MARKET? ECONÓMICOS

8 2. SYSTEM TRANSFORMATION AS A RESPONSE? STRUCTURES SYSTEMS Vs. PATIENT Estructuras y servicios sanitarios Fragmentado Reactivo, episódico Paternalista Acceso presencial Liderazgo vertical Financiación de estructuras PATIENT CENTERED. Continuity of care Proactive system Patient empowerment Decentralized leadership Paying for value Health & social care coordination

9 Taking Shape in many settings INTEGRATED LOCAL SYSTEMS Holanda: U.S.A: Scotland: England: Northern Ireland : New Zealand: Basque Country: Care Groups Accountable Care Organizations (ACO) Managed clinical networks Integrated care pioneers Integrated care partnerships «Locality clinical partnerships» (LCP) Microsystems OSIs

10 Precision Medicine

11 Precision Medicine Precision Management

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14 Precision Medicine Precision Management YES?

15 PRECISION MANAGEMENT Telemedicine, telecare, telemonitorization...

16 Precision Management : Decrease in Nursing Homes Hospitalization Rates in More-Engaged and Less-Engaged Facilities After Introduction of Telemedicine Percent decrease in hospitalizations per 1,000 resident days 0 Treatment group (n=6) Control group (n=5) Total treatment group (n=6) More-engaged facilities (n=4) Less-engaged facilities (n=2) Source: Adapted from D. C. Grabowski and A. J. O Malley, Use of Telemedicine Can Reduce Hospitalization of Nursing Home Residents and Generate Savings for Medicare, Health Affairs, Feb (2):

17 Precision Management RISK STRATIFICATION & POPULATION MANAGEMENT La foto del País Vasco en función de la Estratificación de Riesgo

18 ACTIVE PATIENT = BETTER FOR THE PATIENT ACTIVE PATIENT = 8-21 % MORE EFFICIENT SOURCE: HEALTH AFFAIRS. January

19 sion Management we know how to measure level of activation. Medication Adherence by Level of Activation for Different Conditions National Study University of Oregon

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21 recision Management Staff Engagement NHS Staff Management and Health Service Quality West and Dawson 21

22 Precision management ELECTRONIC MEDICAL RECORD. EMR OSABIDE GLOBAL:

23 Precision management Coordinated & integrated care

24 Precision management Electronic Prescription. Impact : Reduction of adverse effects, duplication.

25 Precision management REWARDING COORDINATED HIGH VALUE CARE New payment approaches ; Bundled payment, global payment ensuring one party is accountable for spending and outcomes for an overall episode. Pago por acto Pago capitativo Bundle Payment Global Payment

26 26 TOOLS SEEM TO BE THERE FOR PRECISION MANAGEMENT! WHY ISN T TRANSFORMATION GOING FASTER & TO SCALE? WHAT ARE WE LEARNING?

27 DIFFERENT SYSTEMS BUT SAME ACKNOWLEDGEMENTS Present health care systems are not systems Business as usual will not create the required organisation of the future It is not a medical science issue ; it is policy issue Moving to more proactive & integrated systems requires policy intervention System Change is very complex ; need to have an implementation plan

28 Implementation Strategies Senior leadership decide to manage two agendas. Resist and transform Senior leadership packaged and communicated extensively the Reasons for Change. Senior leadership was disruptive. Senior leadership followed a planned approach to change. Senior leadership sought a better balance of push & pull strategies. Senior leadership reasoned in terms of System leadership. Senior leadership used many levers. Senior leadership avoided isolated change Silos. Senior leadership developed a high involvement culture with health care professionals. Senior leadership sought early wins in order to sustain progress. Senior leadership and the Tyranny of the urgent.

29 SENIOR LEADERSHIP MANAGED 2 AGENDAS SIMULTANEOUSLY RESIST CULTURE TOUGH BUT DOES NOT CHANGE STATUS QUO TRANSFORMATIVE CULTURE TOUGH BUT DOES CHANGE STATUS QUO

30 SENIOR LEADERSHIP WAS DISRUPTIVE. POSITIVE DISRUPTION. Christensen, Grossman & Hwang The delivery of care has been frozen in two business models the general hospital and the physician s practice -..which were designed a century ago The situation screams for business model innovation 30

31 SENIOR LEADERSHIP WAS DISRUPTIVE. POSITIVE DISRUPTION. The home is the hub New payment mechanisms for value The patient needs to self manage DON T USE YOUR CAPITAL FOR NEGATIVE DISRUPTION ONLY DISRUPTIVE INNOVATIONS HAVE THE POTENTIAL TO MAKE HEALTH CARE MORE AFFORDABLE AND ACCESSIBLE C. CHRISTENSEN 31

32 Senior leadership packaged and communicated extensively the Reasons for Change. Much broader consultation processes Support of Unions

33 SENIOR LEADERSHIP PROVIDED A VISION AT THE POLICY LEVEL. IN MANY ORGANIZATIONS THE LIMBS ARE MOVING BUT THERE IS NO HEAD; NO VISION. NO COHESIVE STRATEGY COORDINATED/INTEGRATED CARE PROVIDES THAT VISION PROVIDES A NARRATIVE THAT GOES BEYOND COST CONTAINMENT NEED TO ELEVATE THE ISSUE TO THE POLICY LEVEL 33 R. Bengoa

34 Senior leadership sought a better balance of push & pull strategies.. - Some level of orquestration from above but seeking to identify commitment rather than compliance - Key element of the orquestration is from the payment reforms ( value) rather than from micromanagement of providers. - Distributed leadership is more frequent

35 Senior leadership used many levers. TOP- DOW N STANDARIZABLE INTERVENTIONS STRATIFICATIÓN CALL CENTER ELECTRONIC MEDICAL RECORD FINANCING AND JOINT COMMISSIONING ELECTRONIC PRESCRIPTION SCALABILITY BOTTOM UP LOCAL INNOVATION CASE NURSING PACIENT EMPOWERMENT HEALTH AND SOCIAL CARE COORDINATION SUBACUTE CENTRES INTEGRATED CARE 35 R.BENGOA/J. MORA

36 Senior leadership developed a high involvement culture with health care professionals. More bottom-up participatory process helps to enforce continuity of projects and get beyond political cycles These high involvement cultures require an environment where local providers can innovate organisationally.

37 Senior leadership sought early wins in order to sustain progress. EARLY WINS YES BUT NOT YOUR EARLY WINS. RATHER ENCOURAGE EARLY WINS TO BE LOCAL. ALLOW MODELS WHICH PERMIT LOCAL ORGANIZATIONS TO RETAIN SOME OF THE EFFICIENCIES FOUND. THIS WILL GIVE THOSE WINS SUSTAINIBILTY OVER TIME

38 SCOTLAND

39 BASQUE COUNTRY TOP- DOWN STANDARIZABLE INTERVENTIONS STRATIFICATIÓN CALL CENTER ELECTRONIC MEDICAL RECORD FINANCING AND JOINT COMMISSIONING ELECTRONIC PRESCRIPTION MEDICINE POPULATION HEALTH TRIPLE AIM BOTTOM UP CASE NURSING PACIENT EMPOWERMENT EFFICIENCY HEALTH AND SOCIAL CARE COORDINATION SUBACUTE CENTRES INTEGRATED CARE LOCAL INNOVATION 39 R. BENGOA/J. MOR

40 Institute of Health Improvement Framework for Implementation

41 41 Go for the high hanging fruit but remember Love without a budget is not true love