View from the Top: “It’s not about tools to achieve success in Lean Six Sigma. It’s about how to get leaders to believe in...
Who We Are             and How We Approach Transformation          © Pittsburgh Regional Health Initiative 2011   2
Who Are We?Pittsburgh Regional Health Initiative (PRHI)   A not‐for‐profit, regional, multi‐stakeholder coalition  formed ...
Regional Health Improvement Collaboratives:     The Infrastructure for Transformation  Unique           Multi   to U.S.   ...
Pittsburgh Regional Health InitiativeFounders:  Karen Wolk Feinstein, PhD     President and CEO since founding Paul O’Neil...
PRHI’s Prescription for Transformation                NOW                                                             FUTU...
The Problem Was Worse       Than We Thought      © Pittsburgh Regional Health Initiative 2011   7
How Does the U.S. Measure Up Globally?                                                                                    ...
The Bottom Line:  Transformation of         Organizations and Systems“Bringing state‐of‐the‐art care to all will require a...
Moving Beyond Repair to Transformation                              PPC in New Technologies and New Models                ...
The Original Vision   © Pittsburgh Regional Health Initiative 2011   11
Where Value Derives                             THE PATIENT                             • Outcomes of Care                ...
Toyota Lean Production Thinking: The Basics   Problems identified and solved   Rapid root cause analysis   Organized work ...
What We Observed in Health CareW. Edwards Deming, PhD:  “Where Art Thou?”ChaosUncertaintyRandom BehaviorsWork‐AroundsConfu...
Where We Beganon the Journey to Transformation          © Pittsburgh Regional Health Initiative 2011   15
Our Method:What We Value in Perfecting Patient CareSM (PPC) One universal improvement methodMeeting patient need is the fo...
What We Value About PPC (cont’d)Coaches and Core Champions are “embedded” professionalsKnowledge and learning are elicited...
Role of Leadership“The job of CEOs, COOs, CMOs, CNOs, Presidents, chairs, and chiefs must include dynamically discovering ...
The Executive Role in Transformation       Paul O’Neill ‐ Alcoa Chairman, 1987‐1999       Corporate commitment to reduce w...
The Champion Role in Transformation             PPC empowers frontline staff…and more                               Physic...
PPC University:  Preparing ChampionsFour‐day, in‐depth course dealing with actual, on‐the‐floor problems – at the point of...
Perfecting Patient CareSM (PPC) Training             © Pittsburgh Regional Health Initiative 2011   22
Demonstrating the Value of PPC         © Pittsburgh Regional Health Initiative 2011   23
STEP ONE:  Reducing Hospital‐Acquired Infections30+ hospitals participating in PRHI’s community‐wide infection control pro...
PPC Eliminates CLABs in One ICU After the standardization and additional training, the hospital essentially eliminated CLA...
PRHI Stories of Success in Acute Care                                            35 to Zero!                              ...
Our Methods and Successes Have Attracted Attention                  © Pittsburgh Regional Health Initiative 2011   27
But, success didn’t spread beyond individual units — and  sustainability was uncertain.         © Pittsburgh Regional Heal...
Transforming Healthcare Organizations: Hit all the notes on the xylophone or no music                                     ...
PPC for Organizational Transformation     What Does Organizational      Transformation Look Like?             © Pittsburgh...
System‐Wide Transformation:Veterans Affairs (VA) Hospital Attacks HAIsWhen Perfection is the Goal  Pittsburgh VA targets e...
Hand Hygiene© Pittsburgh Regional Health Initiative 2011   32
What Workers Need – Where They Need It             © Pittsburgh Regional Health Initiative 2011   33
Equipment Room DisorganizationKeeping the equipment room clean and organized eliminates time wasted searching for supplies...
(Orderly?) Supply Room                                                AFTER     © Pittsburgh Regional Health Initiative 20...
Unexpected Issue: Poor Transport at the VA   Problem:      Wheelchairs weren’t available      (or clean) when needed   Sol...
VA MRSA Intervention Results85% reduction in MRSA rate                         2                                          ...
Systemwide Improvement     © Pittsburgh Regional Health Initiative 2011   38
PPC:  The Transformed OrganizationLeadership engagement reaches to highest levelsOne universal improvement methodMeeting p...
PRHI is about VALUE                       Spreading Quality                                              andSpreading Qual...
Perfecting Care in Systems     © Pittsburgh Regional Health Initiative 2011   41
Treating Chronic Illness Accounts     for 75% of Expenditures      Percent of costs associated with medical needs         ...
Focus on Spending Leads to Complex Patients                       Concentration of Health Care Spending in the U.S. Popula...
Currently: Where do the $$$ go? Hospital Care                      % of Healthcare Spending, U.S., 2008                   ...
Hospital Errors Lead to More Hospitalizations                   Infections Lead to Readmissions      • 1.2% of PA hospital...
Transforming Transformation into Two Targets        • Preventing hospitalizations     1     of complex patients        • P...
The Readmissions Cycle                    Incomplete                    Primary CareInfection   $                         ...
Data SourcePRHI’s researchers perform analyses on hospital discharge dataPRHI found that approximately 20% of discharges  ...
The Complex PatientWho is frequently hospitalized?      Do you know your customer?      Are you meeting their need?       ...
Let the Data Guide Our Work                         The Complex Patient                                                   ...
Why So Many Readmissions?“Nobody integrates care for the medical conditionas a whole and across the full cycle of care,inc...
The Second Systems Vision:                          Transforming the Care of Complex Patients                             ...
What is essential to our              vision for reducing                readmissions?                 Isn’t reimbursed   ...
Testing our Model:Reducing Preventable Hospitalizations — COPDOur data mining identified chronic obstructive pulmonary  di...
Kaizen Uncovers Current ConditionPatient discharged without training on inhaler useMD gives patient prescription for inhal...
Breaking the Cycle of COPD Readmissions       Patient is discharged without                                MD gives patien...
Kaizen Team Breaks CycleTeam determines two keys: Hospital – Patient education to address causes of  admission Community –...
The Solution Coordinates Transition        Between Hospital and CommunityHOSPITAL                  Patient is             ...
Teachable Moments                                                      With the goal of reducing                          ...
COPD Readmissions Reduction Results                                                                % of Patients Admitted ...
Reducing Preventable Hospitalizations:     Behavioral Health Comorbidities           Patients with co‐morbid depression   ...
A Solution:  Integrating Behavioral Health Into Primary Care                                 Informed, Activated Patient, ...
Results of Integrating Behavioral Health                into Primary Care  Of patients screened; 24% positive  49% achieve...
“High‐utilizer work is about building relationships with people who are in crisis.  The ones you build a relationship with...
New Models of Care: Leading with Behavioral HealthBehavioral Health Specialists  The Nuka Model           © Pittsburgh Reg...
Reducing Preventable Hospitalizations: PPC in Skilled Nursing Facilities (SNFs) 6% of seniors in SNFs = 17+% of healthcare...
PPC in Skilled Nursing Facility Reduces   Unplanned Hospital Admissions60% decrease in pressure ulcers25% improved pain ma...
Preventing Hospitalizations:                                New Rules for End of LifeDiscussing advance planning with     ...
Disruptive Innovations     © Pittsburgh Regional Health Initiative 2011   69
Disruptive Innovations:  System Transformations“The challenge we face is not unique to health care.  The transformational ...
Disruptive Innovations1. Simple, less expensive, “upstream” innovations2. Serve more with fewer features     Do not oversh...
The Technology Innovation“Training dosage had most important effect on measures of success.  A combination of PPC training...
The Web‐based Solution:  Tomorrow’s HealthCare™                 © Pittsburgh Regional Health Initiative 2011   73
Tomorrow’s HealthCareTM at a Glance                       Process & Quality                        Customized           Pr...
“Put everybody in the company to work to accomplish the transformation.”                                   ‐ W. Edwards De...
Tomorrow’s HealthCare™ Participants                                                              •   Manage               ...
Interactive Animated Learning        © Pittsburgh Regional Health Initiative 2011   77
You Can’t Reward What You Don’t Measure   Tomorrow’s HealthCareTM can be customized to measure                  what you w...
Lessons From the FieldThe combination of PPC and Tomorrow’s HealthCareTM is        being tested in many healthcare setting...
Lean Philosophy is a Way of Life        Not spot repairEnterprise thinkingMaximization of resourcesAdaption for survival a...
What We TeachSystems thinkingWork derives from customer pull/needCritical performance pathways extend to and from the orga...
Lean Organizations are AdaptiveChange is a constant, Now Accelerating Policy (payment, regulations, accountability) Demand...
New Models of Care: Hospital‐based Primary Care Resource Center Supports team‐based care                                  ...
New Models of Care:                                                                         Lin Medical Center            ...
Secondary Care Centers (cont’d)Asthma                                                                  Pelvic             ...
Moving Beyond Repair to Transformation                           PPC in New Technologies and New Models                   ...
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Lean Six Sigma And Process Improvement In Healthcare Summit

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Lean Six Sigma And Process Improvement In Healthcare Summit

  1. 1. View from the Top: “It’s not about tools to achieve success in Lean Six Sigma. It’s about how to get leaders to believe in and EMBRASE quality!” Karen Wolk Feinstein,PhD P re s i d e nt  &   C h i ef  E xe c u t i ve   O f f i c e r   Lean Six Sigma and Process Improvement  Spreading Quality, in Healthcare Summit, New Orleans, LA  Containing Costs. May 11, 2011 © Pittsburgh Regional Health Initiative 2011 1
  2. 2. Who We Are  and How We Approach Transformation © Pittsburgh Regional Health Initiative 2011 2
  3. 3. Who Are We?Pittsburgh Regional Health Initiative (PRHI)   A not‐for‐profit, regional, multi‐stakeholder coalition  formed in 1997  An initiative of a business group, the Allegheny  Conference on Community DevelopmentPRHI’s message Dramatic quality improvement (approaching zero  deficiencies) is the best cost‐containment strategy for  health care © Pittsburgh Regional Health Initiative 2011 3
  4. 4. Regional Health Improvement Collaboratives:  The Infrastructure for Transformation Unique  Multi  to U.S.  Stakeholder Focus PRHI = one Neutral Measurement/ of the first Regional Transparency 40+ Payers Quality Improvement ProvidersA Decade of  Purchasers Disease Management Growth Employers1995‐2005 PatientsTHE GOAL:       Quality Improvement Cost Containment © Pittsburgh Regional Health Initiative 2011 4
  5. 5. Pittsburgh Regional Health InitiativeFounders: Karen Wolk Feinstein, PhD President and CEO since founding Paul O’Neill Alcoa Chairman 1987‐1999 U.S. Secretary of Treasury 2001‐2002 © Pittsburgh Regional Health Initiative 2011 5
  6. 6. PRHI’s Prescription for Transformation NOW FUTURE Preventable Complications40%  Unnecessary TreatmentsWaste Inefficiencies Errors 100%  Value All Services Add Value Services That Add Value60% Value © Pittsburgh Regional Health Initiative 2011 6
  7. 7. The Problem Was Worse     Than We Thought © Pittsburgh Regional Health Initiative 2011 7
  8. 8. How Does the U.S. Measure Up Globally? New  United  United  Australia Canada    Germany Netherlands Zealand Kingdom StatesOVERALL RANKING (2010)Quality Care Effective Care Safe Care Coordinated Care Patient‐Centered CareAccess Cost‐Related Problem Timeliness of CareEfficiencyEquityLong, Healthy, Productive LivesHealth Expenditures/ Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290 Country Rankings Excellent Fair Poor Source: Commonwealth Fund Commission on a High Performance Health © Pittsburgh Regional Health Initiative 2011
  9. 9. The Bottom Line:  Transformation of  Organizations and Systems“Bringing state‐of‐the‐art care to all will require a fundamental, sweeping redesign of the entire health system … merely making incremental improvements in current systems of care will not suffice.” ‐ The Institute of Medicine March 2001 © Pittsburgh Regional Health Initiative 2011 9
  10. 10. Moving Beyond Repair to Transformation PPC in New Technologies and New Models PPC for Systems Transformation PPC for Organizational Transformation PPC for Repairs A Method for Perfecting Patient CareSM (PPC) An Early Vision for Perfecting Care © Pittsburgh Regional Health Initiative 2011 10
  11. 11. The Original Vision © Pittsburgh Regional Health Initiative 2011 11
  12. 12. Where Value Derives THE PATIENT • Outcomes of Care • Efficiency of Care • Zero DefectsValue begins at the frontline © Pittsburgh Regional Health Initiative 2011 12
  13. 13. Toyota Lean Production Thinking: The Basics Problems identified and solved Rapid root cause analysis Organized work areas Concise communication Active involvement of managers “Go and see” On the floor Intense respect for the employee: Every employee has what they need,  when they need it to succeed Career development Team problem solving to meet customer need © Pittsburgh Regional Health Initiative 2011 13
  14. 14. What We Observed in Health CareW. Edwards Deming, PhD:  “Where Art Thou?”ChaosUncertaintyRandom BehaviorsWork‐AroundsConfusionDisorderErrorsHigh TurnoverSecrecy © Pittsburgh Regional Health Initiative 2011 14
  15. 15. Where We Beganon the Journey to Transformation © Pittsburgh Regional Health Initiative 2011 15
  16. 16. Our Method:What We Value in Perfecting Patient CareSM (PPC) One universal improvement methodMeeting patient need is the focus of all workFrontline clinical teams apply daily problem‐solving methods and work process improvement techniquesResearch occurs and is performed at the frontlineFocus is clinical care improvement © Pittsburgh Regional Health Initiative 2011 16
  17. 17. What We Value About PPC (cont’d)Coaches and Core Champions are “embedded” professionalsKnowledge and learning are elicited and shared across organizationUltimate goal is perfection — 100% error reduction and best clinical practicesLeadership engagement reaches to highest levels © Pittsburgh Regional Health Initiative 2011 17
  18. 18. Role of Leadership“The job of CEOs, COOs, CMOs, CNOs, Presidents, chairs, and chiefs must include dynamically discovering ever better approaches for performances.What they don’t do is get into the nitty gritty of mastering the skills necessary for discovering greatness–starting with small, safe, skill‐incubating pilots and then expanding to more comprehensive, complex, and sophisticated applications.” ‐ Steven J. Spear Author of “Decoding the DNA of  the Toyota Production System” and  “Fixing Healthcare from the Inside,  Today” © Pittsburgh Regional Health Initiative 2011 18
  19. 19. The Executive Role in Transformation Paul O’Neill ‐ Alcoa Chairman, 1987‐1999 Corporate commitment to reduce workplace  injury rate to zero Imported Toyota Production System, manager  accountability, real‐time data reporting to Alcoa;  reduced workplace injuries by 90% over 12 years Alcoa became the safest company in the world © Pittsburgh Regional Health Initiative 2011 19
  20. 20. The Champion Role in Transformation PPC empowers frontline staff…and more Physician Champions Long‐term Care Workers Nurse NavigatorsPatient Safety Fellows Nurse Managers Salk Fellows Team Leaders Librarians Clinical Pharmacists Hospital Trustees Caregivers Emergency Medical Technicians © Pittsburgh Regional Health Initiative 2011 20
  21. 21. PPC University:  Preparing ChampionsFour‐day, in‐depth course dealing with actual, on‐the‐floor problems – at the point of patient careExamine PPC principles, using hands‐on exercises Learn the Rules of Work Redesignand toolsObserve actual clinical problems and solve them! © Pittsburgh Regional Health Initiative 2011 21
  22. 22. Perfecting Patient CareSM (PPC) Training © Pittsburgh Regional Health Initiative 2011 22
  23. 23. Demonstrating the Value of PPC © Pittsburgh Regional Health Initiative 2011 23
  24. 24. STEP ONE:  Reducing Hospital‐Acquired Infections30+ hospitals participating in PRHI’s community‐wide infection control project reported an average 68 percent reduction in CLABs over      four years Results varied among institutions The Power of Perfecting Patient CareSM: one hospital  virtually eradicated CLABs from its main intensive        care units  © Pittsburgh Regional Health Initiative 2011 24
  25. 25. PPC Eliminates CLABs in One ICU After the standardization and additional training, the hospital essentially eliminated CLABs in its CCU 4% 3% 2% Pre Improvement Post Improvement 1% 0% Coronary Care Unit © Pittsburgh Regional Health Initiative 2011 25
  26. 26. PRHI Stories of Success in Acute Care 35 to Zero! defective charts 68% Drop in CLABs in 34 regional hospitals 86% Reduction in medication errors 50% Reduction 50% Fewer in pap smear Readmissions sampling defects w/ COPD focus 17% Drop in pediatric clinic wait times Efficiency Increased  180 to Zero! 100%Lost patient hours per month  in pathology labdue to ambulance diversions >20% Decline Nosocomial 100% Compliance 100% Reduction w/guidelines & aspirin C. difficile in nurse turnover use in a diabetes clinic infections © Pittsburgh Regional Health Initiative 2011 26
  27. 27. Our Methods and Successes Have Attracted Attention © Pittsburgh Regional Health Initiative 2011 27
  28. 28. But, success didn’t spread beyond individual units — and  sustainability was uncertain. © Pittsburgh Regional Health Initiative 2011 28
  29. 29. Transforming Healthcare Organizations: Hit all the notes on the xylophone or no music Global Vision Culture of Quality and Safety Quality Improvement Strategy Targets and Measurement Designated Champions and Teams Training, Education and Coaching Interdisciplinary/Transitional Collaborations Research/Experimentation/Registries Consumer and Purchaser Engagement Information Technology Public Reporting Incentives for High Performance © Pittsburgh Regional Health Initiative 2011 29
  30. 30. PPC for Organizational Transformation What Does Organizational  Transformation Look Like? © Pittsburgh Regional Health Initiative 2011 30
  31. 31. System‐Wide Transformation:Veterans Affairs (VA) Hospital Attacks HAIsWhen Perfection is the Goal Pittsburgh VA targets elimination  of methicillin‐resistant  Staphylococcus aureus (MRSA) Identified lack of standardization  for hand hygiene and use of  personal protective equipment Used red tape as visual cue for  when to gown and glove © Pittsburgh Regional Health Initiative 2011 31
  32. 32. Hand Hygiene© Pittsburgh Regional Health Initiative 2011 32
  33. 33. What Workers Need – Where They Need It © Pittsburgh Regional Health Initiative 2011 33
  34. 34. Equipment Room DisorganizationKeeping the equipment room clean and organized eliminates time wasted searching for supplies and reduces opportunities for contamination BEFORE AFTER © Pittsburgh Regional Health Initiative 2011 34
  35. 35. (Orderly?) Supply Room AFTER © Pittsburgh Regional Health Initiative 2011 35
  36. 36. Unexpected Issue: Poor Transport at the VA Problem:  Wheelchairs weren’t available  (or clean) when needed Solution: Colored labels to identify which unit a wheelchair belonged Locations identified for convenient wheelchair courtesy points Wheelchairs regularly cleaned and maintained Outcome: Patients were on time more often for appointments  (from ~40% to 90% on‐time rate) Wheelchairs returned to the VA after patient transfers  (otherwise would have been lost) © Pittsburgh Regional Health Initiative 2011 36
  37. 37. VA MRSA Intervention Results85% reduction in MRSA rate 2 Start of Intervention MRSA Infections 1.5 per 1000 BDOC 1 0.5 0 2000 2001 2002 2003 2004Sustained compliance with hand hygiene, gowning, and glovingTeam continues to identify opportunities to reduce MRSA ratesFor more information, go to www.prhi.org to watch a Teachable Moment about this project © Pittsburgh Regional Health Initiative 2011 37
  38. 38. Systemwide Improvement © Pittsburgh Regional Health Initiative 2011 38
  39. 39. PPC:  The Transformed OrganizationLeadership engagement reaches to highest levelsOne universal improvement methodMeeting patient need is the focus of all workFrontline clinical teams apply daily problem‐solving methods and work process improvement techniquesResearch occurs and is performed at the frontlineFocus is clinical care improvementCoaches and Core Champions are “embedded” professionalsKnowledge and learning are elicited and shared across organizationUltimate goal is perfection — 100% error reduction and best clinical practices © Pittsburgh Regional Health Initiative 2011 39
  40. 40. PRHI is about VALUE  Spreading Quality andSpreading Quality,Containing Costs. Containing Cost © Pittsburgh Regional Health Initiative 2011 40
  41. 41. Perfecting Care in Systems © Pittsburgh Regional Health Initiative 2011 41
  42. 42. Treating Chronic Illness Accounts  for 75% of Expenditures Percent of costs associated with medical needs Preventive use  only Minor acute <1% 8% Major chronic  Major acute/  interventional interventional 23% 34% Chronic illness  management 35%Source: Luft, Harold. Total Cure. Cambridge, 2008: Harvard University Press. pg. 66 © Pittsburgh Regional Health Initiative 2011 42
  43. 43. Focus on Spending Leads to Complex Patients Concentration of Health Care Spending in the U.S. Population, 2007 The 5% of the U.S. population  with highest health care  100% expenses was responsible for  97.0% nearly half of total health care Health Care Spending spending 81.2% 80% 74.6% Percent of Total 65.2% 60% 49.5% 40% 22.9% 20% 3.0% 0% Top 1% Top 5% Top 10% Top 15% Top 20% Top 50% Bottom 50% Percent of Population, Ranked by Health Care Spending © Pittsburgh Regional Health Initiative 2011 43
  44. 44. Currently: Where do the $$$ go? Hospital Care % of Healthcare Spending, U.S., 2008 Retail sales of durable  Home health care medical equipment Government public  3% 1% health activities 3% Dental services 4% Other professional  serives and personal care 6% Hospital Care Nursing home care 31% 6% Investment in  research, structures  and equipment 7% Program administration  and net cost of private  insurance Physician and clinical  7% Retail sales of  services prescription durges 21% 10% Source: Modern Healthcare January 11, 2010, pg. 7 © Pittsburgh Regional Health Initiative 2011 44
  45. 45. Hospital Errors Lead to More Hospitalizations Infections Lead to Readmissions • 1.2% of PA hospital patients contract a     hospital‐acquire infection • 30% of all infected patients are re‐admitted  within 30 days of initial discharge due                  to infection • 60% of patients who contract surgical site  infections are readmitted within 30 days Source:  Pennsylvania Health Care Cost Containment Council, “The Impact of Healthcare‐Associated Infections in  Pennsylvania,” 2009 © Pittsburgh Regional Health Initiative 2011 45
  46. 46. Transforming Transformation into Two Targets • Preventing hospitalizations  1 of complex patients • Preventing infection 2 Ø Target Burnout © Pittsburgh Regional Health Initiative 2011 46
  47. 47. The Readmissions Cycle Incomplete  Primary CareInfection $ $ Emergency Room Hospitalizations © Pittsburgh Regional Health Initiative 2011 47
  48. 48. Data SourcePRHI’s researchers perform analyses on hospital discharge dataPRHI found that approximately 20% of discharges      are readmitted within 30 days © Pittsburgh Regional Health Initiative 2011 48
  49. 49. The Complex PatientWho is frequently hospitalized? Do you know your customer? Are you meeting their need? © Pittsburgh Regional Health Initiative 2011 49
  50. 50. Let the Data Guide Our Work The Complex Patient Skilled  Nursing Chronic  DiseaseBehavioral Health and Substance Abuse HIV/AIDS End of Life © Pittsburgh Regional Health Initiative 2011 50
  51. 51. Why So Many Readmissions?“Nobody integrates care for the medical conditionas a whole and across the full cycle of care,including early detection, treatment, rehabilitation,and long-term management.” ‐ Michael E. Porter &    Elizabeth Olmstead Teisberg, PhD © Pittsburgh Regional Health Initiative 2011 51
  52. 52. The Second Systems Vision:   Transforming the Care of Complex Patients Informed  Data to  Collaboration  Medication  Activated  Treat, Perfect  and  Screening  Patient Rewards Reconciliation Discerning  and Tx Measure, For Quality Integration Consumers Evaluate CareAcross Care Settings Hospice/Palliative Long Term Care  Rehab Hospital Emergency Services Specialty Care Primary Care Care  Clinical  Patient  Behavioral  Health  QI  Financial  Mgt Pharmacy Engagement Health IT Training Incentives Essential Services                                                 System Requirements © Pittsburgh Regional Health Initiative 2011 52
  53. 53. What is essential to our vision for reducing readmissions? Isn’t reimbursed Care  Clinical Patient   Behavioral  HIT QI Management Pharmacy Engagement Health Training © Pittsburgh Regional Health Initiative 2011 53
  54. 54. Testing our Model:Reducing Preventable Hospitalizations — COPDOur data mining identified chronic obstructive pulmonary  disease (COPD) as prominent cause of hospital admissions           (4th highest) and readmissions (3rd highest) 4,000 Readmissions in Western PA, 2005-06 35.0% 3,500 30.0% # Readmits Readmit Rate 3,000 25.0% % Readmitted # Readmitted 2,500 20.0% 2,000 15.0% 1,500 10.0% 1,000 500 5.0% 0 0.0% CHF Pneumonia Depression COPD Kidney Abnormal Diabetes Asthma Failure Heartbeat Diagnosis at Initial Admission © Pittsburgh Regional Health Initiative 2011 54
  55. 55. Kaizen Uncovers Current ConditionPatient discharged without training on inhaler useMD gives patient prescription for inhaler, but no trainingPatient gets inhaler from pharmacy, but trainingPatient fails to use inhaler properly, leading to hospitalizationPatient is treated with nebulizer during hospital stayDANGEROUS CYCLE © Pittsburgh Regional Health Initiative 2011 55
  56. 56. Breaking the Cycle of COPD Readmissions Patient is discharged without  MD gives patient prescription  training in use of inhaler for inhaler, but no training Patient is treated with  Patient gets inhaler from nebulizer during hospital stay pharmacy, but no training Patient fails to use  inhaler properly, leading  to hospitalization © Pittsburgh Regional Health Initiative 2011 56
  57. 57. Kaizen Team Breaks CycleTeam determines two keys: Hospital – Patient education to address causes of  admission Community – Improved patient education and  support in the community © Pittsburgh Regional Health Initiative 2011 57
  58. 58. The Solution Coordinates Transition  Between Hospital and CommunityHOSPITAL Patient is  COMMUNITY MD gives patient  discharged  prescription for  without  inhaler, but no  training in use  training of inhalerPatient Patient is discharged WITH  Improved training in use of inhaler patienteducationto address educationcauses of  Patient is  Patient gets  and treated with  Patient uses inhaler  inhaler from admission nebulizer  properly, leading to  pharmacy, but  support* during hospital  no training stay improved functioning in the Patient fails to  community use inhaler  properly,  leading to  hospitalization *Care Clinical Patient Behavioral Mgt + Pharmacy + Engagement + Health © Pittsburgh Regional Health Initiative 2011 58
  59. 59. Teachable Moments With the goal of reducing  readmissions of patients with  COPD, learn how a team from  UPMC St. Margaret  redesigned the way they  delivered care.www.prhi.org/ppc_teachablemoments.php © Pittsburgh Regional Health Initiative 2011 59
  60. 60. COPD Readmissions Reduction Results % of Patients Admitted for COPDBy focusing on the transitions  Exacerbation and Readmitted within 30 Days for COPD or Pneumoniabetween care settings: 15% 14% 30 readmissions prevented 13% 12% $160,000+ saved 11% 10% 44% Net savings of $80,000+ after  9% 8% Reduction cost of Care Manager 7% 6% 5% 4% 3% 2% 1% 0% Jan-Dec 2008 Jan-Dec 2009 © Pittsburgh Regional Health Initiative 2011 60
  61. 61. Reducing Preventable Hospitalizations:   Behavioral Health Comorbidities Patients with co‐morbid depression  are more likely to be readmitted % Readmitted with % Readmitted with No Secondary Secondary Depression Depression Asthma 29% 42% COPD 43% 51% Pneumonia 34% 42% All Other 29% 37%Patients with depression and co‐morbid substance use disorders are more likely to be hospitalized for four days or longer Source:  PRHI Analysis of PHC4 Data  2005‐2006, SW PA © Pittsburgh Regional Health Initiative 2011 61
  62. 62. A Solution:  Integrating Behavioral Health Into Primary Care Informed, Activated Patient,  All patients are screened for behavioral  Primary Care Physician, and Office Staff health and/or substance abuse issues SBIRT IMPACT Clinical  Specialist         (or BHCM) Consulting  Consulting  Brief interventions  Psychiatrist and self‐ Pharmacist Consults weekly  management  Performs med.  with the  support rev. and consults  CS/BHCM on all  with PCP, PRN cases © Pittsburgh Regional Health Initiative 2011 62
  63. 63. Results of Integrating Behavioral Health     into Primary Care Of patients screened; 24% positive 49% achieved at least 50% reduction in depression  symptoms at six months 24% reported ER visit at baseline versus 14% through     six months in ITPC Led to $3.5 Million partnership among Minnesota,  Wisconsin and Pennsylvania © Pittsburgh Regional Health Initiative 2011 63
  64. 64. “High‐utilizer work is about building relationships with people who are in crisis.  The ones you build a relationship with, you can change behavior…” ‐ Jeffrey Brenner, M.D. Camden Coalition of Healthcare Providers © Pittsburgh Regional Health Initiative 2011 64
  65. 65. New Models of Care: Leading with Behavioral HealthBehavioral Health Specialists  The Nuka Model © Pittsburgh Regional Health Initiative 2011 65
  66. 66. Reducing Preventable Hospitalizations: PPC in Skilled Nursing Facilities (SNFs) 6% of seniors in SNFs = 17+% of healthcare costs 20% of hospital patients discharged to a SNF  were readmitted 51% of residents have one or more ER visits 38% have a hospitalizations:  41% are readmitted © Pittsburgh Regional Health Initiative 2011 66
  67. 67. PPC in Skilled Nursing Facility Reduces  Unplanned Hospital Admissions60% decrease in pressure ulcers25% improved pain management40% improvement in risk assessment complianceUnplanned hospital admissions among residents with chronic conditions reduced to zero over a 12‐month period © Pittsburgh Regional Health Initiative 2011 67
  68. 68. Preventing Hospitalizations: New Rules for End of LifeDiscussing advance planning with  Estimates show that  about 27% of Medicares patients before a health crisis annual budget goes to  care for patients in their Respecting the patient’s end of life plans final year of lifeCommunicating a realistic prognosis to the patientReferring patient for palliative care and/or hospice in a timely mannerSource: http://www.usatoday.com/money/industries/health/2006‐10‐18‐end‐of‐life‐costs_x.htm © Pittsburgh Regional Health Initiative 2011 68
  69. 69. Disruptive Innovations © Pittsburgh Regional Health Initiative 2011 69
  70. 70. Disruptive Innovations:  System Transformations“The challenge we face is not unique to health care.  The transformational force that has brought value to other industries is disruptive innovation.  The healthcare industry screams for disruption.” ‐ Clayton M. Christensen The Innovator’s Prescription: A  Disruptive Solution for Health Care © Pittsburgh Regional Health Initiative 2011 70
  71. 71. Disruptive Innovations1. Simple, less expensive, “upstream” innovations2. Serve more with fewer features Do not overshoot customer need Show better understanding of customer need © Pittsburgh Regional Health Initiative 2011 71
  72. 72. The Technology Innovation“Training dosage had most important effect on measures of success.  A combination of PPC training, additional training, and coaching were associated with improved outcomes.  Social networking or on‐line technology can foster a virtual PPC community.” ‐ Donna O. Farley, PhD RAND:  Results from the  Retrospective Evaluation Effects  of  PPC University Training © Pittsburgh Regional Health Initiative 2011 72
  73. 73. The Web‐based Solution:  Tomorrow’s HealthCare™ © Pittsburgh Regional Health Initiative 2011 73
  74. 74. Tomorrow’s HealthCareTM at a Glance Process & Quality Customized Professional Learning Improvement ePortfolio NetworkingPerfecting Patient  Lean tools & techniques Individual, team &  Communities of CareSM  Online Assessment templates institute projects interestDemonstrations &  Registries  Educational credit &  Best practice sharingtools Sample interventions project tracking Open source content Certification &  Implementation &  Project progress  developmentaccredited education planning guides assessment tools Discussion boardsCase studies & examples © Pittsburgh Regional Health Initiative 2011 74
  75. 75. “Put everybody in the company to work to accomplish the transformation.” ‐ W. Edwards Deming, PhD © Pittsburgh Regional Health Initiative 2011 75
  76. 76. Tomorrow’s HealthCare™ Participants • Manage • Communicate • Measure • Reward • Spread Champions Healthcare Executives Physicians • Test • Prove • Team up • Collaborate • Improve • Capture Team  Tomorrow’sLeaders & Managers HealthCare™ Frontline  • Educate Staff • Motivate • Learn • Incentivize • Experiment • Reward • Document © Pittsburgh Regional Health Initiative 2011 76
  77. 77. Interactive Animated Learning © Pittsburgh Regional Health Initiative 2011 77
  78. 78. You Can’t Reward What You Don’t Measure Tomorrow’s HealthCareTM can be customized to measure  what you want to reward Pay for  Hospital  Performance Admissions Data Patient  Electronic  Registries Health Records © Pittsburgh Regional Health Initiative 2011 78
  79. 79. Lessons From the FieldThe combination of PPC and Tomorrow’s HealthCareTM is  being tested in many healthcare settings Community  Health  Hospitals Centers Behavioral  Skilled  Health Nursing © Pittsburgh Regional Health Initiative 2011 79
  80. 80. Lean Philosophy is a Way of Life Not spot repairEnterprise thinkingMaximization of resourcesAdaption for survival and competitive positioning Vitruvian Man © Pittsburgh Regional Health Initiative 2011 80
  81. 81. What We TeachSystems thinkingWork derives from customer pull/needCritical performance pathways extend to and from the organizationTeamworkAutomation and PrecisionEfficiency and “work leveling”Rapid Frequent Problem SolvingWork Redesign begins at the Frontline  Circuit Board Exercise © Pittsburgh Regional Health Initiative 2011 81
  82. 82. Lean Organizations are AdaptiveChange is a constant, Now Accelerating Policy (payment, regulations, accountability) Demand Workforce Patients  Quality Expectations Technology © Pittsburgh Regional Health Initiative 2011 82
  83. 83. New Models of Care: Hospital‐based Primary Care Resource Center Supports team‐based care  PCP Refers Patient for PCRC coordination of chronic  Nurse Care Management medical conditions Managers Provides added‐value  Chronic Disease primary care support  Care Spirometry Coordination services beyond the means  of small practices Pharmacist PRIMARY CARE Anticoagulation Consults RESOURCE Clinic Can utilize excess hospital  CENTER space Behavioral Health Self- Screening Management Smoking Cessation Support Reaching “Meaningful Use” EHR Targets © Pittsburgh Regional Health Initiative 2011 83
  84. 84. New Models of Care:  Lin Medical Center United States Secondary Care Centers Zvulun hospitals have  40% more  acute beds per  1000  population  United States Care Model than Israel HOSPITALS IN THE UNITED STATESUrgi‐Care Specialists  Ambulatory  Same Day  Outpatient  23 Hour  Hospitals Centers Offices Surgi‐ Surgery Imaging OBS Units Centers SECONDARY CARE CENTERS IN ISRAEL Cost‐effective, ambulatory care: Israeli Care Model operates between primary and hospital care  with multi‐disciplinary post‐discharge follow up,  team‐based specialty clinics. © Pittsburgh Regional Health Initiative 2011 84
  85. 85. Secondary Care Centers (cont’d)Asthma Pelvic Floor Breast Cancer COPD Parkinson’s Disease © Pittsburgh Regional Health Initiative 2011 85
  86. 86. Moving Beyond Repair to Transformation PPC in New Technologies and New Models PPC for Systems Transformation PPC for Organizational Transformation PPC for Repairs A Method for Perfecting Patient CareSM (PPC) An Early Vision for Perfecting Care

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