Emerging breakthroughs in regional and community centred care
-
Upload
clarissa-sawyer -
Category
Health & Medicine
-
view
65 -
download
1
description
Transcript of Emerging breakthroughs in regional and community centred care
Emerging Breakthroughs in Regional and Community-Centered Care
Tom Bigda-Peyton, Ed.DClarissa Sawyer Ed.D.
Cambridge, MAOctober 24-26, 2013
Overview
1
•Healthcare System Pressure Points
2
•Finding our way: understand paradigm shift
3
•Finding our way: making change happen
4
•IE 2013: Regional Networks of Community-Centered Care
Pressure Points
Payment Models
Clinical Outcomes &
System Performance
Measuring Innovation Rapid Change
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?
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?
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?
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?
Given these pressures, how do we find a way to make a break through?
Paradigm Shift – a change of perspective. You see a picture, what are you looking at?
Health Care is changing paradigms
American Hospital Association: Shift Economics From Volume to Value
11
How will hospitals successfully navigate the shift from first-curve to second-curve economics?
Institute for Healthcare Innovation: Shift Models of Care, Business, Infrastructure
12
13
Time
Craft Culture
Innovation Expedition View: Shift to a Second Curve Performance System
The Gap
First CurvePerformance
(Craft Model)
(Information-Age Model )
-
Second Curve Performance
“Jumping the Curve”
Per
form
ance
First Curve vs. Second CurveFirst 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 learningFragmentation 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 common
Quality, value oriented toward ideal patient care (6+ sigma), zero preventable harm
Reactive to “sentinel events” Pro-active history and pattern recognition
The evidence from Ontario
The shift to Second Curve in Ontario Phase I
Optimizing First Curve (2008- 2011)
Phase IIPreparing to Move to Second Curve
(2010- 2012)
Phase IIIMoving 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
Emergence of Second Curve in Backus Hospital, Connecticut
Phase IOptimizing First
Curve (2009- now)
Phase IIPreparing to Move to
Second Curve (2009?- now)
Phase IIIMoving 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?
We need to view health care as a complex, adaptive system
How do we do that? The picture we use affects what we see as the problem and solutions. Does this picture work?
Or this one?
Or this one?
How you see affects what you decide to do.
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 Efficiency Agility
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.
Use High Reliability as a metric for performance and roadmap for change
Less Bounded System
Adaptive Living
System
Normal Reliable High-Reliability Ultrasafe
Mechanistic Organizations
Living Organizations
More Bounded System
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/transport, military, fire/disaster response, anesthesia
Traits of HRO’sCharacteristic 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 spaceAsk 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
1 st Curve2nd Curve
So how do we actually make change happen?
The Gap
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
Change evolves through a series of iterations
Change (innovation) needs to be measured
Use both Stories and Numbers to Measure Innovation
Nature of the Task
Ambiguous/New
Routine/Familiar
Phases & Functions
IObservation
IIAssessment
IIIMeasurement
Data Format Stories Patterns Numbers
Sample Size n= 1 n = 3 n = 7
Features/Characteristics
Emergent Diagnostic Statistical
Descriptors “Anecdotal” “Qualitative” “Quantitative”31
Action Learning Systems. All Rights Reserved.
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?
The theme of this year’s Innovation Expedition in Healthcare – Emerging Breakthroughs in Regional and Community – Centered Care
Leadership
Care Models
Systems
Featured Cases: System Transformation (the Design Challenge)
• Ontario• New York• North Carolina• Connecticut• Alaska
Featured Cases: Leading Transformation
• Helen Angus, Susan Plewes, David Levine
• Rob Greenly• Helen Meldrum• David Hain, Kellan
Moore
Featured Cases: Creating the Care Model of the Future• Frank Maletz• Greg van Winkle• Paul Curry• Lou Martin• Mike Cassidy
We will use the cases to help us design and carry out learning experiments in 2014
Disruptive Inquiry Prototyping Widen and Accelerate
New models of regional networks and community-centered care
Charting a course toward innovation: the role of leadership
Creating the Future: New Roles for Hospitals and Regional Networks
Are you ready to ride the wave of change?