The document provides tips for leading quality and safety improvements, noting that leaders need to prioritize high-cost problems, lead improvement processes using systematic methods, and monitor outcomes to evaluate savings and spread successful changes. It emphasizes using data to motivate improvements and setting measurable targets to track progress and savings from reductions in waste and avoidable harm.

1. “Leading EIVI ”
Evidence Informed Value
Improvement
Details download from
http://homepage.mac.com/johnovr/FileSharing2.html
John Øvretveit,
Director of Research, Professor of Health Innovation and
Evaluation, Karolinska Institutet, Stockholm, Sweden
6/25/2010
1

2. Question to you…
 Do you know any quality
activities or projects which save
money?
 or bring-in more money than they
cost
 Please ask the person next to you
2

3. The “new normal”
 We must cut costs… and raise quality
 Quality activities cost…
which ones pay for themselves
or make savings/extra income?
 Accreditation?
 Chronic care model?
 Falls prevention?
 Anti-biotic prophylaxis before surgery?
Choose value improvements 3

4. What is a “Value Improvement”?
POSTERS IN HOSPITAL TOILET
“Safety cameras record pictures of personnel
not washing hands after using toilet” Problem cost-

5. Examples:
 “Read back” now used consistently to confirm message
received and understood
 Patient Pathway redesign, using less clinician time & fewer
delays
“A change which saves money and
suffering…caused by poor organisation or
under-supported providers”
Evidence-based = proven and likely to improve
5
our service value

6. Evidence – the search
 problems and potential savings
 solutions and their “spend costs”
 Evidence of savings or losses
 for implementers, or others, now or later
6

7. Evidence and experience I will share
 Quality economics research & projects in Sweden and
Norway 1999-2009
 2009: 5 systematic reviews of research and book
7

8. What did I find, from the search?
Guess one – hands up:
 All quality and safety improvements save
money?
 No improvements save money?
 Some quality and safety improvements save
money?
 Which ones, for whom, and when? 8

9. Cost of poor
quality
6/25/2010
9

10. Patient: 84 year old, obstructive airways
disease and heart failure
- Stable at home, fiercely independent
- Supported with regular visits to primary care by son,
and home cleaner,
and cat “Matty” 6/25/2010 10

11. Health care experience
10am Friday fall at home - breaks hip
 14.00 admitted ER
 17.00 internal medicine unit
 Change of medications
Weekend - no operations
Monday – orthopaedic surgeon informed
late
Tuesday am operation
6/25/2010 11

12. Health care experience
Friday - isolated due to MRSA developing
in wound on arm from fall
Discharged 1 week later with no
information to PHC
Readmitted 2 weeks later with weight loss,
pneumonia and infected wound
6/25/2010 12

13. 6 weeks – what the numbers do not show
6/25/2010 13

14. Estimates
 $17.4b costavoidable re-hospitalizations for older
patients,(50% preventable by better coordination (Jenks et al 2009)
 25% of hospital days and clinical procedures inappropriate
 25% of radiological tests not necessary (UK Royal College of Radiologists)
 €415bn/yr “wasted on outmoded and inefficient medical
procedures in the US” Juran study
the cost of poor quality care will likely exceed $1 trillion by 2011
 40% medications unnecessary (Rand USA studies)
 €330m medicines returned to pharmacies for disposal each
year UK (BMJ 2002)

15. Estimates
..by our current very
conservative estimates,
only 44 % of all
resources consumed in
health care delivery
add value.
Thus 56 % – represents
potentially recoverable
waste

16. Poor quality and safety - types
 Under-coordination
 500 GPs - 70% reported late discharge summaries “often” or “very often”, 90%
reporting it “compromised clinical care” and 68% “compromised patient safety ”. One
summary arrived 11 years late
 The slips “in-beween” – music is the space between the notes
Chassin et al 1986:
 Over-use (no medical benefit) Tests and antibiotics.
 Under-use of effective treatments
 anticoagulant to prevent thrombi (also 79% of eligible heart attack
survivors fail to receive beta blockers)
 Miss-use (esp miss diagnosis 10%-15%) (anticoagulant to
1
prevent thrombi)
6

17. Adverse events – avoidable injury & costs
Typical Loss, to the average provider (medicare payment)
(longer length of stay and extra treatments):
 pressure ulcer $2,400;
 postoperative sepsis $16,000;
 postoperative embolism and deep vein thrombosis
$8,500;
 postoperative hemorrhage $6,000;
 Iatrogenic pneumothorax $10,200
NB - Even after reimbursement for the extra treatment
(see also HFMA 2006).
17

18. Three targets for QI and cost reduction
1 High Cost Adverse Events:
avoidable patient suffering
and waste
2 Process improvement
3 Waste
as revealed by Lean quality methods and
reports (eg UK NIII productive ward, 10 high
impact) 1
8

19. Where to look for avoidable poor quality/high
ICU, ER, OR, Radiology,
cost
Hospitals Outpatients, Discharge planning
& all “in betweens”
Primary health Diagnosis, avoidable referrals and
care admissions, prescribing, chronic
care and multiple morbidity
Nursing homes Pressure ulcers, falls, prescribing,
avoidable admissions, MRSA, shift
Health/welfare handovers
Transfers and patient information
system handovers, chronic care &19 multiple

20. Can you fill in the numbers / year for your
Type of event service? 2
1 3 Cost
Number Cost of /yr
/yr event
(average, to the
service)
Hospital acquired
infection (HAI)?
Adverse drug event
Patient falls?
Pressure ulcers? 2
Wrong site surgery? 0
6/25/2010

21. Johns suggestion
Get more informed about high cost problems, from:
1) Research on problems, costs, possible waste,
elsewhere but likely in your service
2) Your data from: discharge and admissions data,
reports, review of medical charts (JC tracer method, IHI
trigger tool).
Special focus on ICU, ER, OR, Radiology, Outpatients
3)Estimate 10 highest cost from a) cost/problem, b)
frequency
2
6/25/2010
1

22. Reminder
But will cost of solution be more?
Savings depend on the solution
“spend cost”
4) Estimate cost to reduce problem by
25% and 50% - next
2
6/25/2010
2

23. Solutions
& Potential
Savings
2
6/25/2010
3

24. Are you engaging this motivated resource? -
patients
2
4

25. Solutions – do they work, and do they cost more than the
problem?
– do they work, and do they cost more than the
problem?
1)Effectiveness evidence
Clinical practices: AHRQ 2001 11 “Nike list”
 Timely antibiotics before surgery
 Barrier precautions before
central line catheters, etc)
2
2) Less evidence about organisational 5

26. Solutions
3) Less evidence of effectiveness of
implementation strategies
Eg training, reminders, etc?
4) Little evidence of costs of solutions
In one service
In a variety
2
6

27. Others reported experience
Falls resulting in fractures av cost $30,000
 30% over 65 with a fall-related fracture die
“An investment of $25,000 in a fall prevention program yielded
$115,000 in savings in fracture care”
Nosocomial infections cost a minimum of $5,000 per episode.
“An investment of $1,000 in hand hygiene yielded $60,000 in
avoided care costs”
Calculation details not given
(Source: Bagian reports from VHA (in AHRQ 2008)

28. Our Swedish research – Service accountants using
routine data - Savings in first year
 100,000€ Better coordinated care planning before
discharge in hospital geriatric unit (1.035.410 SEK)
 14,000€ Review of medications in one home for older
people (146 334 SEK) (73€ per patient/year (732 SEK).
 71,000 – 630,000€ Emergency unit patient vita signs
assessment improvement between (713 298 SEK and 6 317 270 SEK in the
first year)(depending on assumptions)
 24,000€ yr1, 65,000€ yr2 Reducing sphincter injury in
delivery from 5,3%-3,9% (239 122 SEK (2006 first year) and 652 836SEK
(2007).

29. Return on Investment – Managed care QIROI
Selected 10 Medicaid managed care organizations QI for high-
risk high-cost patient populations
12/ 1 - A complex case management program to treat adults
with multiple comorbidities
6/ 1 - case management for children with asthma with high ER
use or inpatient admissions
1.2/ 1 intervention for high-risk pregnant mothers
1.1/ 1 program for adult patients with diabetes
3 broke even,
3 cost between 18 and 26 times more than they saved (Greene 2008)

30. Savings or extra income depends on
 How effectively and completely you make the
change
 motivation, project management and expertise
 Step 2: “change into cash”
 can you use the saved bed days, time or
materials to increase income through treating
more patients?
 Or redeploy staff/beds, or charge higher price?
3
 Does your payer measure quality,
6/25/2010
0

31. Financing system disincentives
 Mary case : discharge early - no information, readmission
with acute pneumonia - No quality measures
 Triple incentive for poor quality
 Save on early discharge (lower LOS, DRG based fixed income)
 Paid for readmission
 Save on costs of time to give info to PHC and cost of system for
this
(No finance to invest in improvement)
Paid to treat illness caused by healthcare
3
or poor coordination
1
 Eg readmissions due to poor treatment or early discharge

32. The summary
 up to 50% of your costs - potential savings
But
1) Spend cost of solution? - for your service
(25% effective?)(how effective in your service?)
2) Turn this into cash savings or extra income?
- change 2
= you have to make estimates, and then track
for sure 3
6/25/2010
2

33. Next - “Leading EIVI”
“We realized that if we just cut out cost, more often than
not we’re reducing quality.
What we’ve learned is that if we reduce cost by reducing
waste, we actually improve quality” Dr Gary Kaplan. CEO VMMC
What do leaders need to do?
Which leaders?
 Level?
 Role?
 service manager accountable for resources;
 clinical leader professionally accountable;
3
 quality/safety officer
6/25/2010
3

34. Reviews of research - From web site
 .
2005
2009 3
2010 4

35. Findings : Your actions depend on
1) Role
 Position/role: level, general manager or clinical leader
2) The QS task
 Type of quality and safety work QA/QI simple, radical -
many departments/professions
3) Context
 Internal , External
= Leader development/support to enable different actions
and tasks, for different QS objectives, in different
contexts. 3
5

36. .
Agreement about steps for different types of improvement,
Less about how many of the tasks the leader does, with or
without consultation.
- evidence that more successful improvement is where the
leader creates a social process
- tasks are shared and exchanged at different times,
- leaders role is to start and sustain this process.
- how they do this depends on the situation
BUT clinical professionals do not see this “organisational
work” as their best use of time, and have no skills for it3
6/25/2010
6

37. What a leader needs – 7 things
1 Get knowledge
 AEs or sub-optimal quality in our service?
 Classification of range of problems, for data collection
 Data: frequency, volume of patients affecting, potential cost
2 Get motivation
 Benefits for me? Convince with credible data by credible
source
3 Prioritise and set targets
 Understand which improvements could reduce avoidable harm
save money or increase income, in your service
3
7

38. What is needed – 7 things
4 Lead process for improvement
 enlist project team, with senior sponsor and clinical champion,
expert facilitation, using systematic methods appropriately
5 Monitor and progress
 team reports, managers remove blocks (or lay down team)
6 Evaluate savings and outcomes
 track costs, spend costs, potential savings, real savings/increase
in income
7 Sustain and spread
 Procedures, training and supervision, document and
roll-out
3
8

39. Success depends on more than the leader’s efforts and
skill
Seed Gardener/planting & nurture Climate / soil
Your change?
Change idea Implementation actions
+ + Context
Evidence + Implementation + Environment 39
6/25/2010

40. Motivation Incentives and Culture
 Are employees motivated to give extra effort
to QI?
 Incentives (reinvest savings?)
 Attitudes
and culture?
4
0

41. Engagement – does the rational work?
 PPT presentation – potential partnership opportunity
 Our individual challenges – ageing, economy, partner to
reproduce
 What others have done
 The benefits
 Lower costs
 Taxation advantages
 Evidence says its good for our health and for the kids
 What you need to do
 Take questions and answers now 4
 Or…Or appeal to the heart – how good they are, their importance,
1

42. 10 top tips for leading improvement
1 No measure = no use
 Ask “when will a measurable change in outcome, costs or intermediate
indicator be seen?
 How much this will cost and save?
2 Stop any activity which cannot say this.
3 Improvement and innovation efforts take time
 to change what people do
 and to make a measurable difference to patient care
4 Check, stop, or speed it
 Know how to tell if its not working – intermediate measures
5 Finish off

4 and
Look for what people have started which is likely to produce results
finish it off 2

43. Top tips 6-10 for leading improvement
6 Doctor and manager must lead it
 Interest and motivate them
 Make sure they use the methods appropriately
7 Be a Viking
 Steal and apply – use changes and implementation approaches proven in
services like yours
8 Don’t loose in translation
 Adapt to adopt but don’t loose the active ingredient
9 Free the talent and side step the negatives
 Find the “can doers” and support them to show the doubters that it works
10 Work on the head and the heart 4
 Rational steps and methods, driven by people upset by poor quality
3

44. Conclusions
 High cost of poor quality
 Some effective targeted solutions, little
evidence of “spend cost”
 Some certain savings, but depends on
implementation skill
 Financing system rewards poor quality
4
4

45. Leading EIVI – the challenges
.
4
5

46. Questions
 This surprised me….
 This might not be true in my service…
 This I can use in my work and service….
4
6/25/2010
6

47. .
TOOLS and
Resources
4
7

48. Click Links to web Site Quality Safety &
Tools
 Johns web site with papers and tools
http://homepage.mac.com/johno
vr/FileSharing2.html
4
6/25/2010
8

49. Resources
Assess if a change will work in our organisation.
From AHRQ http://www.innovations.ahrq.gov
a)Based on good evidence and experience b) Clear advantage
compared to current, c) Compatible with current system and
values d) Simple to implement e) Easy to test before full
commitment, f) Impact of change observable.
Also download: Brach et al 2008 AHRQ “Will it
work here”, downloadable from Johns web site
ACHS folder 4
6/25/2010
9

50. AHRQ 2008 workshop for good overview
 Creating a Business Case for Quality Improvement
Research: Expert Views, Workshop Summary, NATIONAL
ACADEMIES PRESS, Washington, D.C.
 http://www.nap.edu/catalog/12137.html

51. Calculate
 Waste costs
 LOS, staff time, materials, loss of income
 Spend costs (50% solution)
 Cost of time for project team & other costs
 Savings - after 1 year starting the project
 How much will you have spent?
 How much will you have saved?
 How long after starting do you start saving?
 What are the steps to turn potential into real savings or
extra income?

52. USA literature "The business case for quality"
Reiter KL et al. 2006. “How to develop a business case for quality.”
International Journal for Quality in Health Care; 19(1): 50-55.
Gosfield, A Reinertsen, J (2003) Doing Well By Doing Good: Improving
the Business Case for Quality, The Reinertsen Group Alta, Wyoming
Gross, P et al 2007 The Business Case for Quality at a University Teaching
Hospital The Joint Commission Journal on Quality and Patient Safety
March 2007 Volume 33 Number 3, 163-169.
Leatherman, S et al 2003 The Business Case For Quality: Case Studies
And An Analysis HEALTH A F FA I R S ~ Vo lume 2 2 , Nu mber 2 17-
25

53. DETAILS
5
6/25/2010
3

54. Practical recommendation 1 - providers
1 Select quality projects for support
 Decide criteria for Q-support
 This organisation does not support quality projects or
activities which do not meet these criteria…
 …because it takes time and money from activities which are
effective for QI and from clinical care.
 Criterion: an estimate of current cost of the problem, likely
spend and potential savings at 1,2,3 yrs.
2 Do estimates.
5
 The Steps: cost, spend, save or loss
4

55. Step 1: COST? How much does problem
cost us?
 Do you a) waste time or resources, b) loose
income (or patients) with this problem?
 eg MRSA case = Yes to a) and to b) if measured and
publically known
 eg VAP in ICU = Yes (if paid by item/drg)
5
6/25/2010
5

56. Step 2: EFFECTIVE?
If high cost, is it preventable/reducable?
 Someone somewhere has an effective solution
 We can implement it effectively
Step 3: SPEND?
Quantify the time and cost of implementation in money
 If we can reduce the problem, how much do we need to
spend to reduce it?
 Eg 100,000 € to reduce by 10% - and show confidence
range (eg 95% certain 80,000-120,000 €)
5
 Personnel time needed, and using other peoples estimates
6/25/2010
6

57. Step 4: SAVE OR LOSS?
Cost - spend = save or loss at 1yr,2yr 3 yr
“Theoretical savings”: less time or materials used
Cash savings: change 2 is using saved time to increase
income or reduce spending
Estimate Time To Pay-Off - 18 months? Or never?
If you will loose money but health system/purchaser
saves
Then take your estimates to them and agree a deal 5
They may fund the project
6/25/2010
7

58. Practical recommendation - Funders/heath
system
1. Change financing system
Measure and fund quality, as well as volume and cost
 Better outcomes and prevention saves you money
 Require quality data from providers or third parties
 Change item of service funding to include quality measures
 Don’t pay providers to treat the injuries they cause
 Experiment with “bundle payments” for chronic care and long-
episode funding
5
8

59. Practical recommendation - Funders/heath
system
2 Invest in proven value improvements (make your
list)
Give money to implement
 Some safety interventions (eg coordination)
 Some improvements (eg day surgery, process
imp)
 Some chronic illness programmes
(egcollaboratives, or directly to provider project)
5
9

60. Advice
1 Criteria for choosing: Costly problem, effective solution,
implementable (investment, time, support), savings more
than costs
2 In betweens : improve clinical communication and
collaboration between
shifts, professions, services, facilities
3 Leading Value Improvement is more successful
Unites clinicians, managers, purchasers, patients,
politicians
6
0

61. Conclusions
Each person write down and then share in the group:
1. These were the main points…
2. This was new or surprising, for me…
3. The most useful idea for my work was…
4. What I would like to find out more about…
6/25/2010
61