Presentation at the American Psychiatric Association Institute on Psychiatric Services, San Francisco, CA, October 31, 2014

1. Institute of Psychiatric Services
San Francisco, CA
October 31, 2014
Sonia Tyutyulkova, MD, PHD

2. The Quality Gap

3. Value
patient health outcomes/cost of care

4. “individual physicians, nurses, technicians, pharmacists, and others
involved in patient care work diligently to provide high-quality,
compassionate care to their patients.
The problem is… that the system does not adequately support them in
their work. The system lags in adjusting to new discoveries, disseminating
data in real time, organizing and coordinating the enormous volume of
research and recommendations, and providing incentives for choosing
the smartest route to health, not just the newest, shiniest - and often
most expensive tool.”
Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. IOM report 2012
The Issues are Structural

5. What would the ideal care delivery system look like
for our organization?

6. Methods
Two step process
 A workgroup developed recommendations for the
care delivery model.
 Agency-wide engagement and feedback on the
recommendations.

7. Methods - Timeline, Process
Project Kick-off March 2013
Workgroup develops draft recommendations June 2013
Draft presented agency-wide July 2013
Agency-wide feedback from staff August 2013
Final recommendations to CEO
September
2013

8. Methods - Workgroup Composition
Representation
 By discipline
 Across programs
 By position in the organization
 Geographic (by county)

9. Methods - Workgroup Composition
 Disciplines
 Psychiatry
 Nursing
 LCSW-C
 Case manager
 Employment specialist
 Residential coordinator
 Psychiatric rehabilitation staff
 Patient

10. Methods - Workgroup Composition
 Services/programs
 Assertive Community Treatment
 Residential Services
 Psychiatric Rehabilitation Program
 Vocational Rehabilitation Program
 Forensic Services
 Targeted Case Management
 Development
 Human Resources

11. Methods - Workgroup Composition
 Position in the organization
 Direct care staff
 Team lead
 Supervisor
 Program manager
 Program or division director
 Executive

12. Value
“… It is value for the patient that is the central goal (in
healthcare), not value for other actors per se.”
Porter ME. What is value in health care? N Engl J Med. 2010;363:2477-81

13. Vincent van Gogh. Old Man in Sorrow (On the Threshold of Eternity)
Value from the patient perspective

14. Vincent van Gogh. Old Man in Sorrow (On the Threshold of Eternity)
Value from the patient perspective
 Ability to connect at basic “human
experience” level, being listened
to.
 Continuity in the relationship.
 Seamlessness of services and
environment.

15. Framework – Discussion Reference Points
 Care organized around patient's needs.
 Continuity over time, across settings, providers, conditions,
and episodes of care.

16. M.C. Escher (1898-1972 ), Sky and Water (1938), woodcut
Perspectives

17. Patient-Centered Care
Alliance U
“Care that is respectful of and responsive to individual person
preferences, needs, and values and ensuring that person values
guide all clinical decisions.”
Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in
America, Institute of Medicine. Washington, DC, USA: National Academies Press. 2001

18. Alliance U
 Effective care. Grounding care in evidence and providing services based on
scientific knowledge to all who could benefit and refraining from providing services
to those not likely to benefit.
 Equitable Care. Care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and socioeconomic
status.
 Population-based care. A system designed to meet the most common types of
needs but has the capacity to respond to individual persons’ choices and
preferences; anticipates person’s needs rather than simply reacts to events.
Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in
America, Institute of Medicine. Washington, DC, USA: National Academies Press. 2001

19. Alliance U
 Core curriculum. This curriculum will be refined based on age and cognitive
abilities. (IMR, motivational interviewing)
 Population-specific curriculum. This curriculum will meet the specific needs
of sub-populations. (family psycho-education, RAISE, Trauma focused
CBT, cognitive remediation)
 “Extra-curricular” activities based on individual interests.
 Individualized behavioral plans to address symptoms that prevent recovery,
e.g. negative symptoms, acting out behaviors.

20. Barriers to Patient-Centered Care

21. Barriers to Patient-Centered Care
 Fragmentation
 Department/division silos
 Geographic silos
 Information silos – lack of
information, information blockages
 Separate policies and procedures for
each program
 Separate quality standards for each
program
 Separate division budgets
 Payment based on services/visits
 Communication gaps

22. Team-Based Care
 Rather than “focused factories” concentrating on
narrow groups of interventions, we need integrated
practice units that are accountable for the total care
for a medical condition and its complications.
 Accountability for value should be shared among the
providers involved.
Porter ME. What is value in health care? N Engl J Med 2010;363:2477-81

23. Team-Based Care
Multidisciplinary collaborative care team of providers is:
 the “unit” essential to providing quality care along a
continuum;
 the unit that will assume responsibility and accountability
for all aspects of providing care to the individual and;
 the collective decision-maker regarding all aspects
concerning the care of the individual.

24. Team Structure and Responsibilities
 Fluid and flexible structure to allow for changing individual
needs to be met along the continuum;
 Free flow of information between providers;
 The team assumes shared responsibility for continuity and
coordination of care across:
 all of the person’s conditions
 internal and external providers and services
 settings
 transition points

25. Barriers to Team-Based Care
 Inefficiency
 Inefficient use of limited human resources;
 Inefficient use of limited fiscal resources;
 Lack of streamlined workflow;
 Inefficient or missing care processes
 Culture
 Provider’s culture – task and service oriented;
 Organizational culture;
 Client culture

26. Efficient Care
“Care that avoids waste, including waste of equipment, supplies,
ideas, and energy.”
Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in
America, Institute of Medicine. Washington, DC, USA: National Academies Press. 2001

27. Organizational Support for
Team-Based, Patient-Centered Care
In order for the collaborative care teams to function efficiently
and effectively, an organizational structure and efficient care
processes that facilitate and support their work have to be in
place.

28. Organizational Infrastructure
Supporting Team-Based, Patient-Centered Care
 Decentralize the organizational care infrastructure, shift to local
team-based care.
 Centralize:
 all administrative and support functions (e.g. referral and
admissions screening, transportation, billing, grant management,
purchasing, administrative support for benefits);
 tracking and data management;
 programming.

29. Organizational Structure
Addressing the Ideal Healthcare Delivery System
“… organizational chart that is inverted to place patients and their care
providers on top, flat with few degrees of separation between patients and
executive leadership, and webbed to reflect connections…”
“Organizational Structure for Addressing the Attributes of the Ideal Healthcare Delivery System”. Cowen, ME et al.
Journal of Healthcare Management; Nov/Dec 2008; 53, 6

30. Current State

31. The Ideal Model

32. Culture Transformation
“Going Lean in Health Care.” Institute for Healthcare Improvement. 2005.
Traditional Culture Lean Culture
Function Silos Interdisciplinary teams
Managers direct Managers teach/enable
Benchmark to justify not
improving: “just as good”
Seek the ultimate performance,
the absence of waste
Rewards: individual Rewards: group sharing
Volume lowers cost Removing waste lowers cost
Guard information Share information
Internal focus Customer focus
Expert driven Process driven

33. Value is a Matter of Perspective
Raphael, 1509-1511, The School of Athens, Fresco, Apostolic Palace, Rome, Vatican City

34. References and Resources
 Porter ME. What is value in health care? N Engl J Med 2010;363:2477-81
 “Value in Health Care: Current State and Future Directions” Healthcare Financial
Management Association, June 2011.
 Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes and
Innovation: Workshop Summary. Institute of Medicine . Washington, DC: The
National Academies Press. 2010
 Crossing the Quality Chasm: A New Health System for the 21st Century. Committee
on Quality of Health Care in America, Institute of Medicine. Washington, DC, USA:
National Academies Press. 2001
 “Organizational Structure for Addressing the Attributes of the Ideal Healthcare
Delivery System”. Cowen, ME et al. Journal of Healthcare Management; Nov/Dec
2008; 53, 6
 DM Berwick. A User’s Manual for the IOM’s “Quality Chasm” Report. Health Affairs
2002. Volume 21, #3
 “Going Lean in Health Care.” Institute for Healthcare Improvement. 2005.