Crossing the-quality-chasm-briefing-1208

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Crossing the Quality Chasm: A New Health System for the 21st Century

Key Points Summary and 2008 Implications

December 18, 2008 Joanne Bohn, MBA


Summary Note on Briefing

Charts titled “Validation… ” are provided as trends and industry references to support preceding slides

and the future trends that unfolded after the IOM concepts were published in 2001


Outline

•  Book Overview

•  Key Points

•  Strategic Implications in 2008


Report Overview •  Crossing the Quality Chasm: A New Health System for the 21st

Century… was the 2nd report and study in the “Quality Chasm Series” issued by the Committee on Quality of Health Care in America (launched 1998) and followed their landmark report “To Err Is Human: Building a Safer Health System”.

•  Strategies are proposed for progressing toward the learning organization model for a national patient-centered care system. It denotes “…how the healthcare delivery system can be redesigned to innovate & improve care.”

•  The study was funded collectively by: –  Howard Hughes Medical Institute –  Kellogg Foundation –  Healthcare Financing Administration –  Commonwealth Fund –  Robert Wood Johnson Foundation –  California Healthcare Foundation –  AHRQ


Quality Chasm Series of Literature by the IOM

1999 2001 2003 2005

Identification of quality problems in

patient care

Identification of a framework for redesign of the US healthcare

system (6 aims for improvement)

Expansion of redesign process in the 2001 framework

Application of the framework in the mental health / substance abuse (M/

SU) sector of the industry

Discussion of underlying causes of ADEs and CPOE noted as top IT intervention

2006


Key Points


The Framework: Six Aims of High-Quality Health Care

1.  Safety1- Avoid injuries to patients 2.  Effective-

Provide services based on scientific

knowledge to all who can benefit

3.  Patient-Centered- Provide care that is

respectful & responsive to individual patient needs &

preferences 4.  Timely- Reduce waits & delays for those receiving &

Giving care

5.  Efficient- Eliminate waste including

ideas, equipment, supplies & energy

6.  Equitable- Providing consistent quality

of care regardless of gender, ethnicity, location or

socioeconomic status


Validation #1: December 11, 2008 Joint Commission Report- Sentinel Event Alert

Title: Safely Implementing Health Information and Converging Technologies

“United States Pharmacopeia MEDMARX database includes 176,409 medication error records for 2006, of which 1.25 percent resulted in harm. Of those medication error records, 43,372, or approximately 25 percent, involved some aspect of computer

technology as at least one cause of the error.”1

13 Suggested Actions by the Joint Commission for Mitigating Risk of Errors Related to HIT Implementations

Source; “Sentinel Event Alert- Safely Implementing Health Information and Converging Technologies”. Joint Commission Report. Issue 42, 12/11/08.


1. Examine workflow processes and procedures prior to HIT implementation

2.Actively involve clinicians and staff who will Use/be affected by the HIT (full life cycle)

3.Assess HIT needs; require IT staff to interact with users outside their facility; reduce interfaces

4.Continuously monitor HIT for problems; address resultant workarounds/incomplete error reporting early

5.Provide training program for all types of clinicians and staff with refresher courses; focus on benefits

7. Prior to taking a technology live, ensure all guidelines /standardized order sets are developed & tested

8. Develop a graduated system of safety alerts to aid Clinicians in determining urgency and relevancy

9.Mitigate harmful drug orders by requiring dept/pharm review & signoff on orders created outside parameters

10.Provide an environment that protects staff involved In data entry from undue distractions when using HIT

11.Post implementation, continue to reassess/enhance safety effectiveness and error-detection capability

Validation #1, ctd: Joint Commission Report 12/11/08 - Sentinel Event Alert- 13 Suggested Actions

6.Create and communicate policies specifying staff authorizations and responsibilities

12.Post-implementation, continually monitor/report errors, near misses or close calls caused by HIT

13.Re-evaluate applicability of security and confidentiality protocols as more medical devices interface with the IT network


Validation #2: Obama-Biden Health Plan

Provide Quality, Affordable & Portable Health Coverage For All

Modernizing The U.S. Health Care System To Lower Costs & Improve Quality

Promoting Prevention & Strengthening Public Health

Establish New Public Health Plan

New National Health Insurance Exchange

New Tax Credits for Families and Small Businesses

Expand eligibility For Medicare & SCHIP

Employer’s Have Option Of “Play or Pay” Model

Guarantee Eligibility To All Americans

$10B/Yr Investment In HIT

Require Health Plans to Utilize Proven Disease Mgmt Programs

Hospitals & Health Plans Increase Transparency

Allow Safe Drug Imports; Incr. Payer Competition

Establish Independent Inst. on Comparative Effectiveness

Strengthen Anti-trust Laws/Reduce Malpractice

Increase Focus on Worksite Interventions

Strengthen School-based Health Screening Programs

Expand Funding for Public Health Workforce Training

Increase Funding to Expand Community -based Preventive Interventions

Realign Public Policy; Invest in Workforce Recruitment; Develop National Public Health Strategy

Source: http://www.barackobama.com/pdf/issues/HealthCareFullPlan.pdf


Underlying Factors for Inadequate Care Across Entire US Healthcare System

Growing complexity of science and technology

Increase in chronic conditions

Poorly organized delivery system

Constraints on exploiting the revolution in information technology


Validation #3: NIH Increase in Total Research Funding 1992-2007

Source: http://www.nih.gov/about/almanac/appropriations/part2.htm

Funding trend tracks with “growing increase in science and technology”


Validation #3, ctd: Increase in Chronic Conditions (i.e. Diabetes)

Source: "Diabetes is surging worldwide."By Marc Santora of The New York Times. 6/11/06 (figures from International Diabetes Federation)

Source: http://www.cdc.gov/diabetes/statistics/prev/national/tablepersons.htm , http://www.diabetes.org/uedocuments/NationaldiabetesFactSheetRev.pdf


Validation #4: Increase in Uninsured (Care Gap Expanding)

Source: US Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States: 2006. Data released August 2007. Table 6. People With or Without Health Insurance Coverage by Selected Characteristics: 2005 and 2006. Link: http://www.census.gov/hhes/www/hlthins/hlthin06/p60no233_table6.pdf

Increasing care gap tracks with “poorly organized delivery system”


Ten Rules to Guide Redesign of the Health Care System

1. Care Based on Continuous Healing Relationships- Patients should have access to care 24/7 and in many forms

2. Customization Based on Patient Needs & Values- System meets most common needs & capable of fulfilling unique preferences

3. Patient As the Source of Control2- Patients receive adequate information to make Informed choices about healthcare decisions

4. Shared Knowledge & Free Flow of Info- Patients have open access to their medical info and communication with their clinician

5. Evidence-based decision making- Patients receive care based on best available scientific knowledge with no variation

6. Safety as a System Property- Patients should be safe from injury by the care system; which should strive to prevent & mitigate errors

7. The Need for Transparency- Patients should have access to care 24/7 and in many forms

8. Anticipation of Needs- The health system should anticipate patient needs rather than reacting to them

9. Continuous Decrease in Waste- The health system will not waste resources or patient time

10. Cooperation Among Clinicians- Clinicians & institutions should collaborate & Coordinate to ensure coordination of care


Five Elements for Improving the Delivery System to Ameliorate Outcomes

1.  Evidence-based, Planned Care

2.  Reorganization of Practices to Provide Improved Delivery

of Care

3.  Systematic Attention To Patients Need For

Information & Behavioral Change

5.  Ready Access to Necessary Clinical

Expertise

4.  Supportive Information Systems

National Patient Outcomes


Three Focus Areas for Accomplishing the Six Aims

6 Aims for Improving Quality of Care

1. Need for improved organization of the delivery system3

2. Improving accessibility & usefulness of clinical evidence

3. Need for changes to the environment of payment4


Validation #5: Transition from Inpatient to Outpatient Services (1981-2005)

Change in surgical service mix supporting the need for evaluation and reform in the US care delivery model

Source: http://www.aha.org/aha/research-and-trends/chartbook/2007chartbook.html

Avalere Health analysis of American Hospital Association Annual Survey data, 2005, for community hospitals.


Validation #6: Change in Community Hospital ED Services Capacity and Use 3

Increasing reliance for treatment by various demographic segments through ED services coupled with closings of ED departments 91-01

Source: http://www.aha.org/aha/research-and-trends/chartbook/2007chartbook.html


Validation #7: Change in Family Health Insurance Premiums and Federal Poverty Level

SOURCE: Kaiser Family Foundation. http://facts.kff.org/chart.aspx?ch=157

Acceleration of family premiums over federal poverty level. Evidence of need for change in the delivery system and payment reform


Validation #8: 2008 Payment Reform Options Summary on a Project of the Bipartisan Policy Center Funded Through the RWJF

SOURCE: “Financing the U.S. Health System: Issues and Options for Change.” Bipartisan Policy Center Report. 6/08.

1: Continue Current Financing Structure Redirect revenue funds to better use

Economic Implications: No clear way to improve funds utilization and recoup increased spending

Health System Implications: Increase in health programs coupled with further erosion of employer-based coverage

and potential for continued increase in uninsured workforce

2: Rollback High-Income Tax Cuts Use revenue generated from expiring tax cuts

Economic Implications: Greatest impact on high-income tax payers; may reduce national productivity

Health System Implications: Effect a “one-time” adjustment in tax revenue and no real impact on healthcare spending or cost containment

3: Reform the Health Benefit Tax Exclusion Limit/eliminate employer premiums from employees’ TI

Economic Implications: High-income employees absorb tax increase; employers reduce non-wage costs

Health System Implications: Altering nature of coverage limiting health benefit tax exclusion may change

price sensitivity and/or population cost awareness

4: Institute a Play-or-Pay Model Employers pay for employee insurance or a tax equal to

cost of alternative source coverage for workers Economic Implications: Expands pool of employers

contributing to health financing

Health System Implications: Dependent on design; it may increase employer-sponsored coverage

5: Implement a Value-Added Tax Replace Medicare payroll tax with a value-added tax on manufacturers/sellers of goods and services

Economic Implications: Flat tax on consumption, encourage more savings than other options, and spreads burden of healthcare across entire population

Health System Implications: No direct connection to reform, but could increase public awareness of system cost


Six Dimensions of Patient-centered Care

Respect for patient’s values, preferences, and expressed needs

Coordination and integration of care

Information, communication, and

education

Physical comfort Emotional support- Relieving fear and

anxiety

Involvement of family and friends


Model Progression: Stages of Development

Stage 2 Loosely structured multidisciplinary teams focused around physician

specialization

Stage 3 Gravitation toward a patient-centered system. Team practices increase and

adoption of HIT accelerates

Highly adaptive system thriving on collaborative relations that continuously

increases system efficiency through innovation and quality improvement

Learning Organization

Stage 4

Stage 1 Highly fragmented

delivery system

Organized Chaos


Validation #9: NCQA PCMH Model as an Organizational Transformation Project

Source: NCQA Jan. 2008 Presentation (Phyllis Torda) http://www.nrhi.org/downloads/PPC-PCMHJan2008.pdf

Focus on physician directed practice, strengthening care coordination across the care continuum and for all stages of a patient’s care needs


Six Domains of Health Information Technology

Clinical Care

Administrative and Financial

Transactions Public Health Professional

Education Research

Consumer Health

4 Domains can be viewed as stand alone but also strategically supporting consumer health and clinical care5


Other Topics Discussed

•  Applying Evidence to Health Care Delivery

•  Aligning Payment Policies with Quality Improvement

•  Preparing the Workforce

  Clinical Education and Training

  Regulation of the Professions

  Legal Liability Issues

  Research Agenda for the Future Care Workforce


Strategic Implications in 2008


Implications for Healthcare Providers in 2008

Clinical Transformation:  Bridging the Quality Gap- the adoption of HIT6 has and will continue to

serve as an enabler for quality improvements in our healthcare system

 The Patient-centered Care Model- increased industry focus on consumer knowledge and consumerism7, need for reduction of errors, changes in medical staff education are all contributors to the transition toward this model

 Following the “Ten Rules”- sharing of knowledge (consumers and clinicians), elimination of waste through quality improvement initiatives, and increasing collaborative networks of physicians and healthcare systems will continue to accelerate improvements in the following8:  Access to care,  Quality and costs of care,  Management of chronic conditions for an ever changing population


Implications for Healthcare Providers in 2008

Organizational Transformation:   Bridging the Quality Gap- since 2001 the surge in adopting HIT has

supported increased collaboration among health systems, physicians, payers, and regulatory agencies

  Demographic Changes and Increases in Chronic Conditions- These issues are driving healthcare workforce strategies for sustainment, education, and the dealing with the forecasted future shortage in clinician talent

  Innovation in Our Payment System- at the national level this is needed to improve access to care and alleviate the burden of paying for uncompensated care9

  Transition from Stage 1 to Stage 4 in Relation to HIT Adoption- Infusion of HIT systems that impact workflow and communications can initially increase and stress workforces; however as we advance through the learning curve processes are standardized, people adapt to changes, and we transition toward Stage 4, the learning organization plateau


Reference Listing

1.  Source; “Sentinel Event Alert- Safely Implementing Health Information and Converging Technologies”. Joint Commission Report. Issue 42, 12/11/08. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm

2.  “Hospital Quality Improvement: Strategies and Lessons Learned from U.S. Hospitals” Commonwealth Fund Study. 4/07. http://www.commonwealthfund.org/usr_doc/Silow-Carroll_hosp_quality_improve_strategies_lessons_1009.pdf?section=4039

3.  “Managed Consumerism In Health Care”. Health Affairs. November/December 2005. Volume 24, No. 6. http://content.healthaffairs.org/cgi/reprint/24/6/1478

4.  “Financing the U.S. Health System: Issues and Options for Change.” Bipartisan Policy Center report. June 2008 Authors: Meena Seshamani, MD, PhD (John Hopkins School of Medicine), Jeanne M. Lambrew, PhD (Center for American Progress), Joseph R. Antos, PhD (American Enterprise Institute). http://www.rwjf.org/files/research/financingjune2008.pdf

5.  “Pay-for-Performance: Will the Latest Payment Trend Improve Care?” JAMA, February 21, 2007—Vol 297, No. 7. Meredith B. Rosenthal, PhD, R. Adams Dudley, MD, MBA http://www.bridgestoexcellence.org/Documents/JAMACommentary.pdf

6.  “Health Information Technology in the United States: Where We Stand, 2008”. Robert Wood Johnson Foundation Study. 2008. http://www.rwjf.org/files/research/3297.31831.hitreport.pdf

7.  “The ONC-Coordinated Federal Health IT Strategic Plan: 2008-2012”. 6/3/08 http://www.hhs.gov/healthit/resources/HITStrategicPlan.pdf

8.  “CPOE Lessons Learned in Community Hospitals.” Massachusetts Technology Collaborative. 12/06 http://www.masstech.org/ehealth/CPOE_lessonslearned.pdf

9.  “Can Incentives for Healthy Behavior Improve Health and Hold Down Medicaid Costs?” Center on Budget and Policy Priorities. By Pat Redmond, Judith Solomon, and Mark Lin. 6/1/07 http://www.cbpp.org/6-1-07health.pdf

10.  US Dept of Health and Human Services (HHS) Strategic Plan 2007-2012: Chapter 2- Healthcare http://aspe.hhs.gov/hhsplan/2007/hhsplanpdf/hhsplanc2.pdf


Thank You for Your Time

Author Contact Information: Email: [email protected] Website: http://www.clinicalhorizons.com

Phone: 502-645-5776

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Crossing the-quality-chasm-briefing-1208