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Crossing the-quality-chasm-briefing-1208

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  • 1. Crossing the Quality Chasm: A New Health System for the 21st Century Key Points Summary and 2008 Implications December 18, 2008 Joanne Bohn, MBA © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 2. 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 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 3. Outline •  Book Overview •  Key Points •  Strategic Implications in 2008 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 4. 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 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 5. Quality Chasm Series of Literature by the IOM Identification of Discussion of underlying quality problems in Expansion of redesign process causes of ADEs and CPOE patient care in the 2001 framework noted as top IT intervention 1999 2001 2003 2005 2006 Identification of a framework for Application of the framework in the redesign of the US healthcare mental health / substance abuse (M/ system (6 aims for improvement) SU) sector of the industry © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 6. Key Points © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 7. The Framework: Six Aims of High-Quality Health Care 1.  Safety1- Avoid injuries to patients 2.  Effective- 6.  Equitable- Providing consistent quality Provide services of care regardless of gender, based on scientific ethnicity, location or knowledge to all socioeconomic status who can benefit 3.  Patient-Centered- 5.  Efficient- Provide care that is Eliminate waste including respectful & responsive to ideas, equipment, individual patient needs & supplies & energy 4.  Timely- preferences Reduce waits & delays for those receiving & Giving care © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 8. 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. © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 9. Validation #1, ctd: Joint Commission Report 12/11/08 - Sentinel Event Alert- 13 Suggested Actions 1. Examine workflow processes and procedures 7. Prior to taking a technology live, ensure all guidelines prior to HIT implementation /standardized order sets are developed & tested 2.Actively involve clinicians and staff who will 8. Develop a graduated system of safety alerts to aid Use/be affected by the HIT (full life cycle) Clinicians in determining urgency and relevancy 3.Assess HIT needs; require IT staff to interact with 9.Mitigate harmful drug orders by requiring dept/pharm users outside their facility; reduce interfaces review & signoff on orders created outside parameters 4.Continuously monitor HIT for problems; address 10.Provide an environment that protects staff involved resultant workarounds/incomplete error reporting early In data entry from undue distractions when using HIT 5.Provide training program for all types of clinicians 11.Post implementation, continue to reassess/enhance and staff with refresher courses; focus on benefits safety effectiveness and error-detection capability 6.Create and communicate policies specifying staff 12.Post-implementation, continually monitor/report authorizations and responsibilities 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 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 10. Validation #2: Obama-Biden Health Plan Provide Quality, Affordable & Portable Health Coverage For All Establish New Public New National Health New Tax Credits for Families Health Plan Insurance Exchange and Small Businesses Expand eligibility Employer’s Have Option Guarantee Eligibility For Medicare & SCHIP Of “Play or Pay” Model To All Americans Modernizing The U.S. Health Care System To Lower Costs & Improve Quality $10B/Yr Require Health Plans to Utilize Hospitals & Health Plans Investment In HIT Proven Disease Mgmt Programs Increase Transparency Allow Safe Drug Imports; Establish Independent Inst. Strengthen Anti-trust Incr. Payer Competition on Comparative Effectiveness Laws/Reduce Malpractice Promoting Prevention & Strengthening Public Health Increase Focus on Strengthen School-based Expand Funding for Public Worksite Interventions Health Screening Programs Health Workforce Training Increase Funding to Expand Community Realign Public Policy; Invest in Workforce -based Preventive Interventions Recruitment; Develop National Public Health Strategy © 2010. Clinical Horizons, Inc. All Rights Reserved Source: http://www.barackobama.com/pdf/issues/HealthCareFullPlan.pdf
  • 11. 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 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 12. Validation #3: NIH Increase in Total Research Funding 1992-2007 Funding trend tracks with “growing increase in science and technology” © 2010. Clinical Horizons, Inc. All Rights Reserved Source: http://www.nih.gov/about/almanac/appropriations/part2.htm
  • 13. Validation #3, ctd: Increase in Chronic Conditions (i.e. Diabetes) Source: "Diabetes is surging worldwide."By Marc Santora of The New York Source: http://www.cdc.gov/diabetes/statistics/prev/national/tablepersons.htm , Times. 6/11/06 (figures from International Diabetes Federation) http://www.diabetes.org/uedocuments/NationaldiabetesFactSheetRev.pdf © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 14. Validation #4: Increase in Uninsured (Care Gap Expanding) Increasing care gap tracks with “poorly organized delivery system” 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 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 15. Ten Rules to Guide Redesign of the Health Care System 1. Care Based on Continuous Healing 6. Safety as a System Property- Patients Relationships- Patients should have should be safe from injury by the care system; access to care 24/7 and in many forms which should strive to prevent & mitigate errors 2. Customization Based on Patient Needs 7. The Need for Transparency- & Values- System meets most common needs Patients should have access to care & capable of fulfilling unique preferences 24/7 and in many forms 3. Patient As the Source of Control2- 8. Anticipation of Needs- The health system Patients receive adequate information to make should anticipate patient needs rather than Informed choices about healthcare decisions reacting to them 4. Shared Knowledge & Free Flow of Info- 9. Continuous Decrease in Waste- Patients have open access to their medical The health system will not waste resources info and communication with their clinician or patient time 5. Evidence-based decision making- Patients 10. Cooperation Among Clinicians- receive care based on best available scientific Clinicians & institutions should collaborate & knowledge with no variation Coordinate to ensure coordination of care © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 16. Five Elements for Improving the Delivery System to Ameliorate Outcomes 2.  Reorganization of Practices to Provide Improved Delivery of Care 3.  Systematic Attention 1.  Evidence-based, To Patients Need For National Patient Information Planned Care Outcomes & Behavioral Change 5.  Ready Access to 4.  Supportive Necessary Clinical Information Systems Expertise © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 17. Three Focus Areas for Accomplishing the Six Aims 1. Need for improved organization of the delivery system3 6 Aims for Improving Quality of Care 2. Improving accessibility & 3. Need for changes to the usefulness of clinical evidence environment of payment4 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 18. Validation #5: Transition from Inpatient to Outpatient Services (1981-2005) 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. Change in surgical service mix supporting the need for evaluation and reform in the US care delivery model © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 19. Validation #6: Change in Community Hospital 3 ED Services Capacity and Use Source: http://www.aha.org/aha/research-and-trends/chartbook/2007chartbook.html Increasing reliance for treatment by various demographic segments through ED services coupled with closings of ED departments 91-01 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 20. Validation #7: Change in Family Health Insurance Premiums and Federal Poverty Level Acceleration of family premiums over federal poverty level. Evidence of need for change in the delivery system and payment reform © 2010. Clinical Horizons, Inc. All Rights Reserved SOURCE: Kaiser Family Foundation. http://facts.kff.org/chart.aspx?ch=157
  • 21. Validation #8: 2008 Payment Reform Options Summary on a Project of the Bipartisan Policy Center Funded Through the RWJF 1: Continue Current Financing Structure 2: Rollback High-Income Tax Cuts Redirect revenue funds to better use Use revenue generated from expiring tax cuts Economic Implications: No clear way to improve Economic Implications: Greatest impact on high-income funds utilization and recoup increased spending tax payers; may reduce national productivity Health System Implications: Increase in health programs Health System Implications: Effect a “one-time” coupled with further erosion of employer-based coverage adjustment in tax revenue and no real impact and potential for continued increase in uninsured workforce on healthcare spending or cost containment 3: Reform the Health Benefit Tax Exclusion 4: Institute a Play-or-Pay Model Limit/eliminate employer premiums from employees’ TI Employers pay for employee insurance or a tax equal to Economic Implications: High-income employees cost of alternative source coverage for workers absorb tax increase; employers reduce non-wage costs Economic Implications: Expands pool of employers contributing to health financing Health System Implications: Altering nature of coverage limiting health benefit tax exclusion may change Health System Implications: Dependent on design; it price sensitivity and/or population cost awareness 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 SOURCE: “Financing the U.S. Health System: Issues and Options for Change.” Bipartisan Policy Center Report. 6/08. © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 22. Six Dimensions of Patient-centered Care Respect for patient’s Information, values, preferences, Coordination and communication, and and expressed needs integration of care education Emotional support- Involvement of family Physical comfort Relieving fear and and friends anxiety © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 23. Model Progression: Stages of Development Stage 4 Highly adaptive system thriving on collaborative relations that continuously Learning increases system efficiency through Organization innovation and quality improvement Stage 3 Gravitation toward a patient-centered system. Team practices increase and adoption of HIT accelerates Stage 2 Loosely structured multidisciplinary teams focused around physician specialization Stage 1 Organized Highly fragmented delivery system Chaos © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 24. Validation #9: NCQA PCMH Model as an Organizational Transformation Project Focus on physician directed practice, strengthening care coordination across the care continuum and for all stages of a patient’s care needs © 2010. Clinical Horizons, Inc. All Rights Reserved Source: NCQA Jan. 2008 Presentation (Phyllis Torda) http://www.nrhi.org/downloads/PPC-PCMHJan2008.pdf
  • 25. Six Domains of Health Information Technology Consumer Clinical Care Health Administrative and Professional Financial Public Health Research Education Transactions 4 Domains can be viewed as stand alone but also strategically supporting consumer health and clinical care5 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 26. 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 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 27. Strategic Implications in 2008 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 28. 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 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 29. 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 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 30. 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 © 2010. Clinical Horizons, Inc. All Rights Reserved
  • 31. Thank You for Your Time Author Contact Information: Email: joanne.bohn@clinicalhorizons.com Website: http://www.clinicalhorizons.com Phone: 502-645-5776 © 2010. Clinical Horizons, Inc. All Rights Reserved