Crossing the-quality-chasm-briefing-1208

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

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

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

Key Points


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


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.


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


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

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

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

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

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


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


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


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

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

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

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

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.

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


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


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

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


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: joanne.bohn@clinicalhorizons.com
Website: http://www.clinicalhorizons.com
Phone: 502-645-5776


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