International Forum on Quality & Safety in Healthcare

Reducing Cost, Improving Quality:The Life Cycle Model for

Sustainability

Thursday, April 10, 2014

Lucy A. Savitz, Ph.D., MBAIntermountain Healthcare

Katharine Luther, RNInstitute for Healthcare Improvement

Key Points Well done, quality improvement (QI)

work is a core capacity for impacting cost and quality.

A learning organization recognizes that QI work is a part of the evidence chain in getting the right care to the right patient at the right time in an efficient manner.

Organizational capacity for change is sustained by strategically directed, collective QI efforts – requiring a critical mass to influence culture.

The Quality Challenge

Ensuring consistency in access and quality – but how have we impacted cost?

Deming posits that good quality leads to lower costs. This has been demonstrated.

The Right Care

For The Right Person

At The Right Time

Care Delivery Falls Short of Efficiency Potential

Well-documented, massive variation in practices

High rates of inappropriate or unnecessary care

Unacceptable rates of preventable care-associated patient injury & death

A striking inability to do what we know works

Huge amounts of waste, spiraling prices, and limited access

Waste in Healthcare

Reducing waste in health care is key to affordable, high quality health care.

Nearly half of consumed resources represent potentially recoverable waste in U.S. hospitals (44%)

Case for Continuous Improvement

Incorporating Innovation Disciplined Quality Improvement (QI) EvaluationCritical to finding new designs and

solutions to close the gaps and meet the goals of optimizing:

Patient experience Health of the population Controlling cost/reducing waste.

Need for a Healthcare System that Learns

We require a sustainable system That gets the right care to the

right person at the right timeand then Captures the results for making

improvements.

21st Century Health Care

21st Century Health Care

Information-rich, patient-focused enterprises

Information and evidence transform interactions from

reactive to proactive (benefits

and harms)

Evidence is continually refined as a by-product of

care delivery

Actionable information available – to clinicians AND patients – “just in time”

Challenges to QI Driving Change

Inadequate training in and/or appreciation for scientific process

Lack of expectation for rigor Missing science of large scale

change Unclear or do not share big

picture view

Batalden Rethinking Triple AimBetter Professional Development

Better Health Better System Performance

Scientific Approach to QIIOM: Selker, H et al., October, 2011.

Clear, measurable process & outcomes goals

Basis in evidence Iterative testing Appropriate analytic methods Documented results

QI: Role in Driving Evidence Base

Quality Improvement

ImplementationScience

Outcomes Research

Qausi-experimental

InterventionStudies(Trials)

Clinical Effectiveness

Program Evaluation

Driving the science of change/innovation…

Science of Large-Scale Change

McCannon, Berwick, Massoud in JAMA, 298(16):1937-1939, 2007

Innovation in Health Care Find or create practices (technologies)

that are better than the prevailing ones Build the evidence base in order to take to

scale Quickly make those improvements

ubiquitous Failure to deploy improved technologies

and practices widely and quickly is a form of waste

Charge is to learn about the spread of innovations

Training as a Game Changer

Consider how we allocate training resources to drive rigorous QI Is the QI training experience an

isolated or action oriented, team-based experience?

Are teams held accountable to demonstrate application of training?

Have we trained a critical mass in our organization to create change and support a learning culture?

An Organization’s QI Learning Curve

Building Capacity Slow beginning is characterized by small

number of staff, largely engaged independently in training (reflective learning, hard to sustain)

Steep acceleration is characterized by growing numbers of trained staff, engaging in team-based training (pockets of change, threat of turnover, limited leadership support, & loss of momentum)

Plateau is reached when a critical mass of staff are trained and begin to apply learning as a strategically directed collective (cultural change in the way care is delivered that is sustainable)

From the Bedside to the Balance Sheet: Engaging Front-Line and Finance Staff to Lower Costs and Drive Quality

Katharine LutherIHI Lead

Shaping Teams: IHI Integrated Model

Requires collaboration between quality, medicine, finance, patients, and researchers.

Draws on knowledge base and expertise across disciplines for a holistic approach.

“We need each other to make this work.”

Making It WorkExamples to Complement Quality Perspective: Finance/economics staff shadowing in clinical settings

Establish a business advisory service with assigned portfolios

Dual reporting relationships

Incorporating patient/family point of view.Caveats: Trust and relationship building are key

elements. It takes the right kind of people.

19

Creating Capacity:Critical Mass Training Within Care

DeliveryExamples of… Where it has been done:

Intermountain Healthcare, Brent James

Where it is happening:Hopitaux Universitaire de Geneve (HUG)Pierre Chopard

We Need to Know More About

The impact of training… On the cost and quality impact of

individual project changes. As a lever for routinizing QI into the

culture of a clinic, hospital, or system of care.

In generating evidence to promote large-scale change.

For accelerating the spread of evidence-based interventions.

Professional Development Opportunities for

Researchers Academy Health Delivery System Science

Fellowship Program is aimed at developing leaders in the field to conduct operationally meaningful research to support Triple Aim activities.

http://www.academyhealth.org/Training/Training.cfm?ItemNumber=9295 The Health Foundation Improvement Science

Development Group is a network of international experts from disciplines within the field, working on the development of improvement science as an international discipline through the sharing of ideas and knowledge.

http://www.health.org.uk/areas-of-work/improvement-science/improvement-science-development-group/

Your Challenge Moving Forward

Strategically plan and develop your learning journey for continuous improvement to impact cost, quality, and value.

Assess your organizational cultural needs and stage of learning for action planning.

Consider how to sustain past, present, and future culture change driven by training/educational investments.