How do we get to breakthroughs in healthcare delivery system redesign? This opening presentation from the Innovation Expedition in Healthcare that took place in Cambridge, October 24-26 provides frameworks and case examples to address this question.

1. Emerging Breakthroughs in Regional and
Community-Centered Care
Tom Bigda-Peyton, Ed.D
Clarissa Sawyer Ed.D.
Cambridge, MA
October 24-26, 2013

2. Overview
1
2
3
4
• Healthcare System Pressure Points
• Finding our way: understand paradigm shift
•Finding our way: making change happen
• IE 2013: Regional Networks of CommunityCentered Care

3. Pressure Points
Payment
Models
Clinical
Outcomes &
System
Performance
Measuring
Innovation
Rapid
Change

4. Pressure Point 1: Payment Models
• Emerging shift to become population health managers but how do we pay for it? (executives and providers)
• What are the best opportunities for value-based
contracting?
• Is there an economically sustainable model on the
horizon? Are we in the “pre-Model T” phase of
disruptive healthcare system innovation?

5. Pressure Point 2: Clinical Outcomes and
System Performance
• How do we leverage efforts to work with
complex, high-needs patients?
• How do we advance toward highly reliable clinical
care?
• How do we accelerate competency development
in patient and provider satisfaction?

6. Pressure Point 3: Challenges of
Measuring Innovation
• We have data but lack understanding and results (payors)
• We are in a craft model- we have stories but lack
outcomes (providers)
• Can we design and practice a systematic process for
making innovation operational?

7. Pressure Point 4: Rapid Change
• How do we get ahead of the curve and stay relevant as
providers?
• Where will the next wave of change come from - the
market, the government, both, neither?
• How can we invest in new business models when they
may be obsolete before they are launched?
• Can we reduce costs, improve quality, and develop new
products and services at the same time?

8. Given these pressures, how do we
find a way to make a break through?

9. Paradigm Shift – a change of perspective. You
see a picture, what are you looking at?

10. Health Care is changing paradigms

11. American Hospital Association: Shift Economics
From Volume to Value
How will hospitals successfully navigate the shift from first-curve to secondcurve economics?
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12. Institute for Healthcare Innovation: Shift
Models of Care, Business, Infrastructure
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13. Innovation Expedition View: Shift to a Second
Curve Performance System
Second Curve Performance

Performance
First Curve
Performance


(Craft Model)


(Information-Age
Model )
The Gap
Craft Culture
Time            
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14. First Curve vs. Second Curve
First Curve
Second Curve
Evolved around medical and hospital practices
Designed around patient/ community,
population need
Disease focus, one patient at a time
Health prevention focus, patient plus
population
Hierarchical care, physician controlled
Team-based care, collaborative controlled
Performance problems are people-caused
Performance problems are system-based
“Culture of blame”
Culture of shared accountability and
continuous adaptive learning
Fragmentation of care givers and health care
functions, “hand-off” gaps common
Integration of all system elements, care
“seamless” for patients
Medical records: paper, fragmented, “owned”
by caregiver
Medical records: electronic, “smart cards”
owned by patients
Complexity = frequent errors, harm to patient
Integration of reliable system sciences
minimizes error, harm
Quality is compliance-oriented, 2-4 sigma
Quality, value oriented toward ideal patient

15. The evidence from Ontario

16. The shift to Second Curve in Ontario
Phase I
Optimizing First Curve
(2008- 2011)
Phase II
Preparing to Move
to Second Curve
(2010- 2012)
Phase III
Moving to Second
Curve
(2013-2018?)
• Implement strategic
alignment, learning
programs in hospitals
(ED-PIP, HTLP)
• Achieve operating
efficiencies to balance
budgets and generate
margin (Lean)
• Prepare for next stage:
Local Health Integration
Networks, Community
Care Access Centers
• Excellent Care For All
• Ontario Quality
Council
• Prep for primary care
reform
• Mosaic of Stroke,
Care Connections
• Health Links
• Redesigned payment
model: activity-based
funding, population
risk management,
money follows the
patient
• Active community
engagement, shared
accountability, and
system wide resilience

17. Emergence of Second Curve in Backus Hospital,
Connecticut
Phase I
Optimizing First
Curve (2009- now)
Phase II
Preparing to Move to
Second Curve
(2009?- now)
Phase III
Moving to Second
Curve
(2013-2018)
• Achieve operating
efficiencies (Lean?)
to generate margin
• Build bank account
to cover the gap
• Obtain ACO status with
potential for gainshare
• Hartford affiliation
• Prep for regional
medication management
• Prep for Family Health
Centers
• Recruit interest from
large self-insured
employers (and work
through them to engage
payors)
• Deploy family health
centers
• Demonstrate impact as
economic magnet zone?
• Create new jobs and
transition others?
• Redesigned payment
model: from “insurance”
to population risk
management?

18. We need to view health care as a
complex, adaptive system

19. How do we do that? The picture we use affects what
we see as the problem and solutions. Does this
picture work?

20. Or this one?

21. Or this one?

22. How you see affects what you decide
to do.

23. Comparing the Traditional System vs. Complex
Adaptive System View
Features
Traditional System
Complex Adaptive
System
Roles
Management
Leadership
Methods
Command and
Control
Incentives & inhibitions
Measurement Activities
Outcomes
Focus
Agility
Efficiency
Relationships Contractual
Personal commitments
Network
Hierarchy
Heterarchy
Design
Organizational design Self-organization
Source: (2008) Rouse, W. Health Care as a Complex
Adaptive System, The Bridge.

24. Use High Reliability as a metric for performance
and roadmap for change
Mechanistic
Organizations
Living
Organizations
Less Bounded
System
Adaptive
Living
System
Normal
More Bounded
System
Reliable
High-Reliability
Ultrasafe

25. Highly Reliable Organizations / Systems
•
•
Operate in a complex
environment where
accidents might be
expected to occur
frequently, but manage
to avoid or seek to
minimize catastrophes.
Examples:
energy, aviation/transpor
t, military, fire/disaster
response, anesthesia
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26. Traits of HRO’s
Characteristic
Example
Sensitivity to operations
•Get more transparent
•Make rounds to view operations
•Don’t assume – ask questions
Reluctance to simplify
•Examine data and metrics, be willing to challenge
long-held beliefs
Preoccupation with failure
•Identify what is working correctly
Deference to expertise
•Redefine "meetings.“ Observe processes and meet
with employees in their actual work space
Ask about prior experiences.
Resilience
•Use better evaluation tools (leadership evaluation,
report cards, action plans).
•Emphasize skill development.
•Help people reconnect to the "why" behind what
you ask them to do.

27. So how do we actually make
change happen?
The
Gap
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28. Change evolves in Phases across Levels
of the system (organization or network)
Strategic
Create/Build
Transfer
Maintain/Sustain
Operational
Create/Build
Transfer
Maintain/Sustain
Tactical
Create/Build
Transfer
Maintain/Sustain

29. Change evolves through a series of
iterations

30. Change (innovation) needs to be
measured

31. Use both Stories and Numbers to
Measure Innovation
Nature of the
Task
Ambiguous
/New
Routine
/Familiar
I
Observation
II
Assessment
III
Measurement
Data
Format
Stories
Patterns
Numbers
Sample
Size
n= 1
n=3
n=7
Emergent
Diagnostic
Statistical
“Anecdotal”
“Qualitative”
“Quantitative”
Phases &
Functions
Features
/Characteristics
Descriptors
Action Learning Systems. All Rights
Reserved.
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32. Story: “Hot Spotting” in Connecticut
Hospital CEO: “I was rounding in ER when the nurse said, ‘Oh, Joe’s
here. I know his voice.’ I thought, ‘If the nurse knows him by the
sound of his voice, we’re in trouble [because it means he’s here a
lot].”
“This man had gone to the ED 68 times in 9 months, with no admits!
No pattern of chronic disease. So, we visited him using Homecare.
We discovered he had behavioral issues and diabetes, but no pattern
[to explain him going] to ER so often. Until we discovered he had no
access to food! He was coming to get the free sandwiches at the ER.
After we coordinated with Meals on Wheels, we changed that.”
Is this a Second Curve story? What are your thoughts?

33. The theme of this year’s Innovation Expedition in
Healthcare – Emerging Breakthroughs in Regional and
Community – Centered Care
Systems
Leadership
Care Models

34. Featured Cases: System Transformation (the
Design Challenge)
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•
•
•
•
Ontario
New York
North Carolina
Connecticut
Alaska

35. Featured Cases: Leading
Transformation
• Helen Angus, Susan
Plewes, David Levine
• Rob Greenly
• Helen Meldrum
• David Hain, Kellan
Moore

36. Featured Cases: Creating the Care
Model of the Future
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•
•
•
•
Frank Maletz
Greg van Winkle
Paul Curry
Lou Martin
Mike Cassidy

37. We will use the cases to help us design and
carry out learning experiments in 2014
Disruptive Inquiry
New models of
regional networks
and communitycentered care
Charting a course
toward innovation:
the role of
leadership
Creating the Future:
New Roles for
Hospitals and
Regional Networks
Prototyping
Widen and
Accelerate

38. Are you ready to ride the wave of
change?