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Quality Improvement

JOHN W. RAGSDALE, III, MDJULY 2017

DEPARTMENT OF COMMUNITY AND FAMILY MEDICINEPRIMARY CARE SEMINAR SEA PINES, SC

Goals & Objectives

uWhat is “Quality Health Care”

uWhere are the “gaps” in care

uCurrent strategies to improve care

uOutline Quality Improvement framework and implementation

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Definition of Quality

Quality Health Care: providing patients with the right medicine, treatment or test at the right time and in the right location

Quality Health Care: should be safe, effective, patient-centered, timely, efficient and equitable

IOM “Crossing the Quality Chasm” 2001

Components of Health Care Quality

u Equity - reducing gaps in health status among populations

u Adding life to years –full physical, mental and social potential

u Adding health to life – reduce disease and disability

u Adding years to life – increase life expectancy

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Changing Paradigm in Healthcareu Accelerating national epidemic of chronic

disease

u Increasingly effective treatment of chronic illnesses

u “Co-morbidity” problem

u Shift towards population management

u Movement from “individual” responsibility to“systems-based” care

Mostly Failed Promises

u IOM report in 2001 Crossing the Quality Chasmu System requires transformationu Six Aims for improvement

u CMS.gov 2015u Preventive services percent of U.S. population

uHepatitis A vaccination 12.%ucolon cancer screening: 23.6%, ucholesterol 70%ubreast cancer screening 61.6%

u Under use a greater problem than over useu Variability by chronic condition

u Obamacare: u Uninsured 2014 : 17.9%u Uninsured 2016: 12.9%

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American Health Care Act 2017

u Likely decreased numbers of totaled population insured by 23-26 million

u Likely will impact those with lower socio-economic status more than the wealthier population

u Likely will have big savings u Estimates over $330 billion over 10

years

Lots of Uncertainty….

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Basis of the Chronic Disease Epidemic:Percentage of US Population 65 Years and Older

Simple Rules for the 21st Century Health Care System

Current Approachu Care based on visitsu Professional autonomy

drives variability

u Professionals control care

u Information is a recordu Decision making based

on training and experience

u Do no harm is an individual responsibility

New Rule

u Based on continuous healing relationships

u Care customized according to patient needs and values

u Patient is source of careu Knowledge is shared and

information flows freelyu Decision making is

evidence-basedu Safety is a system

property

Source: Crossing the Quality Chasm: A New Health System for the 21st Century

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Simple Rules for the 21st Century Health Care System

Current Approach

u Secrecy is necessary

u System reacts to needs

u Cost reduction is sought

u Preference is given to professional roles rather than system

New Rules

u Transparency is necessary

u Needs are anticipated

u Waste is continuously decreased

u Cooperation among clinicians is a priority

Source: Crossing the Quality Chasm: A New Health System for the 21st Century

Quality Problems

“Crossing the Quality Chasm”

uUnderuse of beneficial services

uOveruse of procedures that are not medically necessary

uMISTAKES leading to patient injury

IOM, 2001

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Strategies for Improvement

u IHI – “The Triple Aim”

u National Committee for Quality Assurance (NCQA)u PCMHu Diabetes, Heart Stroke, Low Back Pain

u Medicare u PQRS, Meaningful Useu Hospital Core Measure

u MACRA

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The Triple Aim

u Improving the individual experience of care

u Improving the health of populations

uReducing the per-capita cost of care for a population

Berwick, et al, Health Affairs, vol. 27, 2008

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MACRA: The Medicare Access and CHIP Reauthorization Act

u Will continue to promote EMRsu Will be evaluating claims data to

see how well you and your practice are doing

u Must report at least six measures including one outcome measure u Measures under PQRS will continue to

be available

Improvement Journey

2010: Adopted Kaizen event approach for system level improvement efforts. Applied to Rooming Process

2011: Trained to and spread “standard work” concept.Developed Standard Work.

2012:Initiated Redesign Oversight Committee and used Kaizen rapid improvement approach to stabilize post maestro-implementation. Developed more standard work.

2012:Used Value stream mapping to do pilot project work on Care Management Role Redesign

Slow to spread Slow to create buy-inTraining challenges

Limited resources

Challenging to sustain

Challenged to “Continuously Improve”

Prior to 2010Used Model

for Improvement,

PDSA and collaborative

models to identify

spread change

Varying degrees of engagement

from practice

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What is Lean?“The endless transformation of waste intovalue from the customer’s perspective.”

Womack and Jones, Lean Thinking

“Every worker applying the scientific method to every part of daily work.”

“an organization’s cultural commitment to applying the scientific method to designing, performing, and continuously improving the work delivered by teams of

people, leading to measurably better value for patients and other stakeholders.”- John Toussaint, MD

Where Did it Come From?

•1930s Taichi Ohno and others at Toyota wanted the continuity in process flow

that Henry Ford had pioneered with the Model T AND be able to provide a wide variety of products.

•Their innovations developed the Toyota Production System.

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Toyota Production System

Kaizen 3P 6Sigma Leveling Reliability Value Stream Mapping FMEA 8 Wastes Standard Work Gemba A3/PDSA 5S & Visual Management

Hoshin Kanri 5Whys Quality -Error Proofing

DUHS Values

Excellence Safety Integrity TeamworkDiversity

CaringforOurPatients,TheirLovedOnes,&EachOther

Performance Excellence

Quality&PatientSafety PatientExperience Finance&Growth WorkCulture

Physicians, Providers & Direct Care Staff

Deliver great, compassionate patient care efficiently and effectively; constantly seek

innovations in safety and quality

Support Care Staff Improve the patient

experience; support optimal care delivery; excellence in

operational execution

All Providers, Staff, Volunteers

Demonstrate values-based behaviors and

decision-making

Lean Systems & Principles

Revolutionizing Care DeliveryPatient-Centered Care

Maestro Care Implementation“Right patient, right place, right time”

Innovating in Clinical GrowthPrimary/Specialty Network Development

Access Improvement Duke Medicine Pavilion

Cancer Center

Reinventing care design & payer strategies

Population health management Clinically Integrated Network

Care “bundles”

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What is it about?• Define Value for the customer- putting the patient/ customer first

“patient-centered healthcare”

• Respect for People“respectful of our community, providers and staff”“Caring for our patients, their loved ones and EACH OTHER”

• Identify & Eliminate Waste: remove process steps that are waste“respectful of our community, providers and staff”

• Create continuous flow by eliminating the root cause of the waste

• Continuously Improve

Duke Primary Care provides comprehensive, patient-centered healthcare in an environment that is respectful of our community, providers and staff.

Caring for Our Patients, Their Loved Ones, and Each OtherExcellence | Safety | Integrity | Diversity | Teamwork

Lean Is Value-Creatingand Waste Reduction

u Value added: any activity the patient is willing to pay for or deems necessary

u Non-value added: activities the patient deems unnecessary or are unwilling to pay for

u Non-value added but necessary: activities that support the patient as necessary today but are not considered of value by the patient

Check IN

Wait Intake Wait Provider Visit Wait Lab Wait Check

Out

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Lean is an Attitude of Continuous Improvement

Take nonstandard work processes and transform them into standard processes that improve performance and then continue to improve the standard work design through PDSA

How do we Solve Problems?Our Natural Human Tendency?

Perception of a

ProblemThe

SOLUTION

Impressions & Assumptions

TheoryFACTS

BLACK HOLE

Why do we do this???

Courtesy of LEI

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How should we Solve Problems?Ask Questions to Help Ourselves SEE:

What is actually happening?What do I actually know?

The Real or Main Problem

A SOLUTION

Impressions & Assumptions

Theory

FACTSFACTSFACTSFACTS

Courtesy of LEI

Lean is a Unity of PurposeBalanced Scorecard

Quality&PatientSafety PatientExperience Finance&Growth WorkCulture

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Lean is Respect for People Who do the Work

“Toyota has average people, brilliant processes, and produce superb results.

“You have brilliant people, broken processes and produce mediocre results”.

Fujio Cho to Jim Womack

We squander workers’ brilliance passing patients across the gaps in our processes.

It’s not the people…it’s the process!

Lean is Visual

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Success Relies on Leader Standard Work at All Levels

Lean Enterprise Institute

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How do we make improvements and reduce waste?

Evaluating Health CareSelecting Evaluation Measures

u Relevanceu Meaningfulness or interpretabilityu Scientific or clinical evidenceu Reliability or reproducibilityu Feasibilityu Validityu Health Importance

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Quality and Patient Safety

February 2016 February 2017

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Division Family Medicine:Patient Experience

February 2016 February 2017

How did we do this ?

u Found a system to look at how we were doing as a practice

u Rinse, wash repeat u Demanded quality data from EMRu Embraced the practice from front

staff to MD’su Celebrated small victories u Transparency

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Summaryu Measurement leads to Quality Improvement

u Quality health care gap is LARGE

u Avoidable deathsu Avoidable sick daysu Avoidable hospital costu Lost productivity

u Public reporting leads to higher performance - TRANSPARANCY

u Employers/purchaser wants/demand Quality & at provider/practice level

u P4P will link quality & $$$

u ONLY JUST BEGINNING…

In Closing…People build the systems. People innovate. People work

collaboratively. People create. People use the tools. People apply the methods. People solve problems. People lead.

But people need help. They need methods. They need tools. They need systems. They need to be empowered to solve

problems. They need coaches. They need leaders.

This is where it all comes together—it’s the heart of Lean and the opportunity for realizing the full potential of this

amazingly adaptive system.

Source: Erika Fox, An Adaptive System

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Referenceswww.cms.orgwww.commonwealthfund.org/Crossing the Quality Chasm, Institute of Medicine, National Academy Press, Washington, DC. 2001 (www.nap.edu/books) To Err is Human, Institute of Medicine, National Academy Press, Washington, DC. 2000. (www.nap.edu/books)www.cms.hhs.gov/pvrpThe Quality Assurance Project, 7200 Wisconsin Avenue, Bethesda, MD (USAID) QA Brief Vol 9, number 1, Spring, 2001.www.qaproject.org Quality Improvement Series, Family Practice Management, March, April, May 1999.www.aafp.org/fpmwww.ahqr.govwww.ihi.orgMedscape 7.2015

www.lean.org/