My Agenda. The Healthcare World of The Quality, Safety and Value Revolutions: Why Transforming Healthcare is No Longer Elective

Transcription

1 The Quality, Safety and Value Revolutions: Why Transforming Healthcare is No Longer Elective Robert M. Wachter, MD Professor and Associate Chairman, Department of Medicine Chief, Division of Hospital Medicine University of California, San Francisco I am not in the office at the moment. Please send any work to be translated. My Agenda Quality, patient safety, and value: a decade-long historical perspective Some unanticipated consequences and major challenges around transparency and value-promotion policies The need for alignment (and why is this so hard for physicians) Final thoughts The Healthcare World of Quality/safety assumed to be excellent Mental model for improvement largely wrong No business case to improve safety/quality No local expertise, research or best practices All of above led to predictable results

2 Trend Line Simplified Growing business case for safety/quality Steady progression from relatively weak pressures (social pressure, accreditation w/ low chance to fail, transparency), eventually settling on all of the above plus payment changes While ACA promotes these changes, nearly all are independent of ObamaCare Recognition of need to remake delivery system to survive/succeed in new healthcare world Value-based Purchasing and Healthcare Exceptionalism Value = Quality/Cost Calculation of the VBP Penalty How Does VBP Work? 2% of baseline DRG payment withheld Hospitals earn back the withhold based on their VBP score For example, a hospital with a VBP score of 60 points earns back ~60% of its 2% withhold Your VBP Score Clinical: 65 Satisfaction: Estimated Financial Impact HOLDBACK EARN BACK NET TO YOU $1,897,139 $1,177,807 -$719,331 Press Ganey Associates, Inc.

3 The New World Order: Transparency plus Payment Changes The Two Pauls Value-based Purchasing (VBP) (1% 2%) Hospital-acquired Conditions (HACs) (no pay) Readmission penalties (1% 3%) Meaningful use for IT implementation (bonus for MU 1% cut 3% cut) Plus new payment models such as bundling and ACOs (who knows?) $s at stake by 2017: ~10% of Medicare paymts The Need to Get a Handle on Healthcare Costs Mark Smith UCSF s Model Organizational Chart for a Value Improvement Program Numerator of the Value Equation Denominator of the Value Equation

4 The CEO s (Old) Job The doctors brought in the patients, so the hospital s customer was the doctors You don t call your best customer onto the carpet for problematic behavior, whether it is: Disruptive Too expensive Poor quality The 99-1 vote But this is not a viable strategy in today s world This organizational framework could survive only if the hospital and the physicians were under absolutely no pressure to provide the highest quality, safest care at the lowest possible cost. But over the past decade this bit of healthcare exceptionalism (since it is unlike virtually every other part of the market-based economy) has eroded like a polar ice cap, aided by a variety of strategies that have created immense pressure to perform. This New Reality has exposed the fatal flaws in the typical hospital/medical staff relationship: how can a hospital ever achieve excellence when it is governed by two parties that are at best wary but collegial; at worst, overtly venomous. A Few Challenges in a World of Integration and Systems Thinking The Glass Cockpit The ipatient How do we handle deviations from best practices : an exercise in calibration and diplomacy

5 The Glass Cockpit Syndrome : The Tragedy of Air France 447 The patient is still at the center, but more as an icon for another entity clothed in binary garments: the ipatient. Often, emergency room personnel have already scanned, tested, and diagnosed, so that interns meet a fully formed ipatient long before seeing the real patient. The ipatient s blood counts and emanations are tracked and trended like a Dow Jones Index, and pop-up flags remind caregivers to feed or bleed. ipatients are handily discussed (or cardflipped ) in the bunker [the team s conference room], while the real patients keep the beds warm and ensure that the folders bearing their names stay alive on the computer. A 7-year-old Girl s Depiction of her MD Visit Toll E. The cost of technology. JAMA 2012

6 The Fastest Growing Job in Medicine How Will Practice Deviations be Handled? Are Please What Recent you call some is your guidelines the kind CMO reason of for for suggest moron? deviation? approval So, What Will It Take? New organizational arrangements that create aligned incentives & population perspective Comparative data: individual & group level Clinically meaningful, well presented Can look outside for lessons, but use mostly local comparators Begin w/ groups, emphasize positive (at least at first); later move to individuals, low performers Structured care protocols, forcing functions Often best to take docs out of the loop So, What Will It Take? (cont.) A new skill set QI/safety, Lean, teamwork, leadership Work to understand how IT is helping, and how it s not Must have an improvement and innovation methodology Get MD buy-in, up front & ongoing Useful MD participation is seen as path for success Can try incentives, but be careful not to step on professionalism or teamwork

7 Final Words With change comes opportunity Leadership is critical to getting the job done Good news: you re not alone lots of other forces promoting the quality/safety/value agenda In the end, patients are likely to benefit from all of this Keep our eyes on the ball Choluteca Bridge, Honduras Hurricaine Mitch, 1998