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The 26th Annual IHI National ForumOn Quality Improvement in Health Care
L29: Southcentral FoundationHealthcare 3.0 ‐ Nuka System of Care
Douglas Eby, VP of Medical Services
Steve Tierney, Medical Director of QI
Presenters have nothing to disclose
Review the transformational journey of an entire health care system from physician‐centered to patient‐centered to customer‐owned
Describe how redesigning and rebuilding a health care system from the perspective and ownership of the community results in better outcomes than seeking a faster and leaner version of the current medical system
Review approaches to moving beyond the PCMH to "Healthcare 3.0," including workforce and information management from data systems and sustaining relationships
Session Objectives
Operational Principles
Relationships between customer‐owner, family and provider must be fostered and supportedEmphasis on wellness of the whole person, family and community (physical, mental, emotional and spiritual wellness)
Locations convenient for customer‐owners with minimal stops to get all their needs addressed
Access optimized and waiting times limitedTogetherwith the customer‐owner as an active partnerIntentionalwhole‐system design to maximize coordination and minimize duplicationOutcome and process measures continuously evaluated and improvedNot complicated but simple and easy to useServices financially sustainable and viable Hub of the system is the familyInterests of customer‐owners drive the system to determine what we do and how we do itPopulation‐based systems and servicesServices and systems build on the strengths of Alaska Native cultures
At 591,000 square miles, Alaska is as wide as the lower 48 states and larger than Texas, California
and Montana combined.
Incorporated in 1982
Employees• 1987: 24 staff
• 2014: More than 1,750
Operating Budget• 1987: $3 million
• FY 2014: $241 million
Serving 65,000 Customer‐owners• 55,000 Anchorage and Valley
• 10,000 55 villages
From 1987 to 2014…
Operating Budget
1987 FY 2014
$3m
$241m
RAISE Programs
Administrative Support Training Program
Nuka Institute
Elder Program
Complementary Medicine
Behavioral Health Learning Circles
The Pathway Home
Quyana Clubhouse
Dena A Coy
• Residential
• Outpatient
• Willa’s Way
SCF Programs and Services
Primary Care Clinics
Laboratory
Pediatrics
Audiology
Health Education
McGrath Health Center
Pharmacy
Health Information Services
OB‐GYN Nilavena Subregional Clinic Radiology Empanelment
Emergency Department Home Based Services Valley Native Primary Care Center Anchorage Service Unit Ops Support Optometry
SCF Programs and Services
Behavioral Health
• Fireweed
• PCC
BURT
Denaa Yeets’
TRAILS and FASD
Behavioral Health Service McGrath
Therapeutic Family Group Homes• Cottonwood• Rendezvous• Cleveland• Alaska Womens Recovery
Project (AWRP)• Access To Recovery (ATR)
SCF Programs and Services
Dental (ANMC and Fireweed)
Research
Facilities
General Counsel
Budget Planning and Management
Contracts
Financial Operations
Patient Accounts
Payroll
Reimbursement
Seattle Office
Board Support
Tribal Relations and Village Initiatives
Planning Grants
Communications & Public Relations
Information Technology
Special Assistant Program
Corporate Office Support
Compliance
Data Services
Organizational Development
Development Center
Human Resources
Quality Assurance
SCF Programs and Services
Office of the President• Divisional structure
Executive and Tribal Services, Medical Services, Behavioral Health, Resource and Development and Organizational Development and Innovation
• Line Authority
Functional committee structure • 4 areas of focus to get to high performance
Operations– effective day to day operations
Quality Assurance– compliance with standards etc.
Process Improvement– improving systems and structures
Quality Improvement– improving clinical and educational services
Organizational Structures
Utilization• 75% decrease in hospital admissions since 1999
• 71% decrease in hospital days per 1000 since 1999
• 36% decrease in outpatient visits per 1000 customer‐owners
Clinical quality• Level 3 NCQA Patient Centered Medical Home
• 75 or 90 percentile for HEDIS outcome measures o Diabetes
o Cancer
o Cardiovascular disease
Measures of Success
Customer‐owner satisfaction• Overall 93%
Employee satisfaction• Overall 94%
• Response rate 90%
Employee Turnover • 11%
Baldrige National Quality Award ‐ 2011
Measures of Success
Medical care is too big and too complex with way too many services, agencies, and offerings to be left uncoordinated and without a strong navigator/coordinator role
Doctor‐centric Medical Model primary care has failed – need to rethink everything
Poor ‘primary care’ = ineffective system
Current model actually does HARM
Primary Care needs changing
Limited capability if fundamental platform is not rethought
• Think like a business, managed care, safety
• Case Management 2002‐2007
• Then – Six Sigma, TPS, flow, reliability, spread, bundling, P4P, E.H.R
•Now ‐ PCMH, ACO, Affordable care, single payer
Previous Healthcare Fixes ‐ USA
Medical Model – not questioned
Each piece of healthcare optimizing their financial position – very sophisticated financially and bankrupting society
Better, faster, safer version of what we have – no fundamental change
The result of previous fixes
Risk of Reductionism
Attempting to isolate a single intervention as the approach to change within a complex dynamics system assumes all other processes, events and participating remain static over time.
Severe dental caries
ADHD
Anxiety Disorder
Domestic Violence
Severe dental caries
Hypertension
Disease Approach to Improvement
Outcome not income
Person not disease
Population not process
Service not practice
Approaching the Philosophic Thought Process of Redesign
Segmented measurement by individual
Integration of traditionally separate work types
Team dynamic optimization
Including Customer as an equal partner
Data Modeling and pattern recognition
“Smart Systems” that suggest both diagnoses and plans
Stages of PCMH Evolution(not to be confused with levels)
Changing from organizational level data to segmentation down to the work team or individual level.
Operational and business model unchanged
Measurement is segmented but not responsibility for measurement which still stays with leadership
Resources are still allocated and analyzed from a system wide level
Leadership still focused on system wide measurement
Stage 1 PCMH
Integrating teams with roles traditionally separated in older work systems
More customer focused work flow prospective
Usually accompanied by changes in floor plan and office space
Often results in more wide variation in performance between teams
Professional staff often not prepared or trained to work in interdisciplinary environment
Stage 2 PCMH
Shift to team dynamics and team skill building
Move away from traditional workflows with visit basis or clinical focus toward team awareness and optimization
Reorganize data to discover variance in team performance and spend efforts to understand reasons around variance
Focus more on outcome as opposed to process
Stage 3 PCMH
Recognizing the value of the customer
Understanding patterns of use and non use are instructive and are comments on the ease, effectiveness and satisfaction with your larger system
Adding infrastructure to learn directly from the customer base, more than just advisory or focus groups
Stage 4 PCMH
Data modeling for pattern recognition as a tool/strategy
Segmenting costs and work volume by methods other than disease
Adding new methods of intervention to address variance within new segments
Reorganizing workforce to more effectively manage newly exposed performance gaps
Stage 5 PCMH
Using previously identified patterns to trigger smart systems that suggest best approach or plan
Incorporating these smart systems into infrastructure available to both consumers and staff
Stage 6 PCMH
Health is a longitudinal journey• Across decades• In a social, religious, family context
• Highly influenced by values, beliefs, habits, and many ‘outside’ voices.
Office visits are brief, reactive stop‐gaps
Hospitalizations are brief, intense interruptionsMUST fix basic, underlying primary care platform first or nothing else will work well
Reality
We are a Service Industry – NOT a product industry –coaching, teaching, partnering are central – pills and procedures supportive
Changes what we think we do, who we hire, how we train, how we structure, how we reward, and how entire system is constructed as a system.
We must optimize relationship – personal, trusting, accountable – minimize barriers
Purpose of Primary Care
Unquestioning belief in the medical model and professionalism
Firm basis in science, technology, industrial manufacturing models, body as physical
Many people making a whole lot of money in current system – as independent pieces
Current system allows/supports/rewards independence and entrepreneurial thinking – no common purpose, framework, principles
Very weak workforce and management theory, knowledge, skill in healthcare
Challenges
Unfriendly and rude staff
Guinea pig for new doctorsCustomers waited for everything
• Long waits for scheduled appointments
• Four‐ to six‐hour waits common Long waits on phone, pharmacy, everywhere
Inconsistent treatment
Risky place to go
The Drive to Change
Customers frustrated – waiting, impersonal, paternalistic, crowded, unfriendly
Clinical staff frustrated – too many people, not enough time, no personal relationships, too many demands
Management frustrated – lots of unhappy people, hard to motivate staff, poor financial performance, challenging facilities
Everyone Was Frustrated …
Government recognized that:
If the people receiving the health service are involved in the decision making processes, better yet, if they own their own health care – programs and services have a potential for enhancement and the people and their health statistics will improve.
Indian Self‐Determination and Education Assistance Act 1975
Alaska Native people were given this choice and we chose to assume the responsibility for our own health care
• Change everything
• Total redesign
• With our choices and values
Our Choice
Southcentral Foundation uses the term customer‐owner instead of:
• Patient
• Client
• Customer
Customer‐owner
Mission, Vision and Key Points
Relationships across the organization
Customer‐owner input
Strategic Planning Key Improvements
LinkagesEVERYTHING TIES TOGETHER!
Our vision
Shared Responsibility
Operational Principles
Core Concepts
Board of Directors
Role model
National, regional and local partners
Functional Committee Structure
Leadership Key Improvements
Core Concepts Training Three‐day training, ALL employees
Led by SCF President/CEO
Build and sustain healthy relationships
How we impact others
How to articulate story from your heart
Partnered with Society for Organizational Learning to develop
Core Concepts
Work together in relationship to learn and grow
Encourage understanding
L istenwith an open mind
Laugh and enjoy humor throughout the day
Notice the dignity and value of ourselves and others
Engage others with compassion
Share our stories and our hearts
Strive to honor and respect ourselves and others
Governing board
Advisory committees
Elders Council
Focus Groups
Annual Gathering
24‐ hour hotline
Community gatherings
Personal interaction with employees
Satisfaction surveys
Comment cards
Customer FocusKey Improvements
Interview /Hiring
Onboarding (ASTP, etc)
Leadership development
Development Center
Career Ladders
Job Progressions
Employee Wellness
Workforce FocusKey Improvements
Training center
Annual reorientation – reaffirm core philosophy (online & manager led components)
All staff meeting (annually)
• CEO led session
• Peer teaching on topics chosen by employees
Departments of learning based on workforce competencies
• More than 150 course offerings
• Partnership with university to award college credits
• Partner with other learning organizations to develop trainings
• Courses designed on adult learning theories including experiential learning
• Instructional designers partner with subject matter experts to develop training
Internships (RN, Behavioral health clinicians)
Scholarship program
Development Center
Traditional Healers – Tribal Doctors
Complementary Medicine –Chiropractors, Massage Therapists, Acupuncture
Behavioral Health Redesign
Facilities and work areas
Family Wellness Warriors Initiative
Operations FocusKey Improvements
Microsystem Optimization ‐teams• Primary Care: Physician, RN, Certified Medical Assistant,
CM Support, Behaviorist, Dietician, Pharmacist, office redesign
• Behavioral Health teams: Physician, Master Level Therapist, Case Manager
• Human Resources teams: HR Generalist and Assistants –Same day service, etc.
Home Health, Nutaqsiivik, Waiver Care Coordination, Home Visiting Physician
Operations FocusKey Improvements
Data and MeasurementKey Improvements
Multiple levels
Mission, Vision, Key Points
Data experts
Data and sharing story
Data Mall
Information to Knowledge
% Employees with Current Annual Disaster Tng
53
74
94 98 100
0
50
100
2005 2006 2007 2008 2009
%
SCF Industry Best (100%)
No longer a hero but a partner• Control does not equal compliance
• Replace blaming with understanding
• Give customer options, not orders
• Provide customer with resources
• Make it simple
Health care provider changes
Be active, not passive
Take responsibility for your health
Get information about your health
Ask questions about advice
Ask for options
Customer‐owner changes
Core Concepts – WELLNESS
Role model
Willingness to share story
Willingness to hear story
Admit mistakes
Leadership Changes
Who really makes the decisions?
Hitting Target: Rock vs. Bird
Low Highcomplexity - variables
Complexity
Low
High
Cer
tain
ty o
rA
gre
emen
t
Protocols & Stds
ChaosExperimenting
Get together and have dialogues
An allowing/positive environment
Multidimensionalimprovements with target
focus Creativity
Approach to improvement
PCP – primary care provider ‐MD, DO, NP/PA Nurse Case Manager Case Management Support Certified Medical Assistants
Behaviorists and Dieticians Pharmacist (partially implemented) Nurse Midwife (partially implemented) Coverage NP/PA/CM’s Co‐located Psych Coders, data entry, etc
The Integrated Care Team
Wellness Care Plans for the highest utilizing 5% ‐facilitated by BHC’s and placed in the E.H.R to drive whole system behavior
Co‐Located Psychiatrist and MH care coordination for long term co‐management of CMI population, pain, addictions
Data Mall – Revitalization/Full Transparency
Redesigned Behavioral Health – Learning Circles, Tribal Doctors, FWWI
IA/IS Capability
Service Level Agreements
ICT Current Work
Information to Knowledge
% Employees with Current Annual Disaster Tng
53
74
94 98 100
0
50
100
2005 2006 2007 2008 2009
%
SCF Industry Best (100%)
200
400
600
800
1000
1200
1400
1600
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year
Num
ber
of
Vis
its
Day per 1000 Night per 1000
Better
Alaska Native ownership begins
Anchorage Area PatientVisits to ER/Urgent Care Per 1000
Beginning in 2008 Benchmarking to HEDIS
Emergency Department Utilization
42.7631.71 26.61 27.57
48.6 47.538.4
0
50
100
2008 2009 2010 2011 2012 2013 Jun14
Visits per 1000
Emergency Dept Visits per 1000 Member Months
SCF 2013 HEDIS 10th Percentile (44.6)
2011 ‐12 increase due to EHR registration changes
Better
Excludes Newborns and Delivery Moms and Length of Stay must be more than 1 day
Anchorage Area PatientsAdmits per 1000
p
40
50
60
70
80
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year
Num
ber
of
Adm
its
Admts per 1000
Better
Alaska Native ownership begins
5.72 5.98 5.73 6.10
8.507.40 6.80
0
5
10
15
2008 2009 2010 2011 2012 2013 Jun14
Disch
arges per 1000
Total Inpt Discharges per 1000 Member Months
SCF 2013 HEDIS 10th Percentile (5.88)
2011 ‐12 increase due to EHR registration changes
Better
Inpatient Utilization
Beginning in 2008 Benchmarking to HEDIS
Questions?