mhs vision - translating strategy to action in a complex...

MHS Vision - Translating Strategy to Action in

a Complex system

Mike Dinneen, MD, PhD Director, Office of Strategy

Management OASD(HA) and DHA

[email protected]

mailto:[email protected]

Critical Decision Making for Medical Executives: Keys to Improving Healthcare Delivery 2

“It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”

- Charles Darwin

DISCLOSURE PRESENTER(S) HAS NO FINANCIAL INTEREST TO DISCLOSE. THIS CONTINUING EDUCATION ACTIVITY IS MANAGED AND ACCREDITED BY PROFESSIONAL EDUCATION SERVICES GROUP IN COOPERATION WITH THE MEDXELLENCE PROGRAM. PESG, AND MEDXELLENCE STAFF, AND ACCREDITING ORGANIZATION DO NOT SUPPORT OR ENDORSE ANY PRODUCT OR SERVICE MENTIONED IN THIS ACTIVITY. PESG AND MEDXELLENCE PROGRAM STAFF HAVE NO FINANCIAL INTEREST TO DISCLOSE.

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OBJECTIVES 1. RECOGNIZE THE NEED FOR YOUR OWN LEADERSHIP DEVELOPMENT PLAN AND IDENTIFY AT LEAST THREE COMPETENCIES THAT YOU WILL COMMIT TO DEVELOPING IN THE NEXT YEAR 2. COMMIT TO ADVANCING YOUR LEADERSHIP STYLE SO THAT YOU DEMONSTRATE RESPECT FOR PEOPLE EVERY DAY 2. BE ABLE TO PARTICIPATE IN DEVELOPING A STRATEGIC PLAN FOR YOUR ORGANIZATION 4. BE ABLE TO DEFINE VALUE FOR THE MHS AND FOR YOUR PART OF IT 5. BE ABLE TO READ A STRATEGY MAP OF VALUE CREATION AND CRITICALLY EVALUATE IT 6. BE FAMILIAR WITH THE 30 MHS ENTERPRISE CORE MEASURES 7. BE ABLE TO IDENTIFY 5 MEASURES THAT YOU CAN AFFECT WHICH WILL DRIVE IMPROVEMENT IN THE MHS CORE MEASURES 8. BE ABLE TO TRANSLATE STRATEGY TO ACTION AT YOUR ORGANIZATION (MTF, DIRECTORATE, CLINIC)

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National Defense Strategy – Our Purpose

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Strategic Construct – Linking the National Security Strategy to Joint Health Services

Joint Concept for Health Services

Capstone Concept for Joint Operations

National Military Strategy

MHS Health Benefit Delivery CONOPS

Operational Medicine CONOPS*

Problem Statement (JCHS): How can the Joint Force provide comprehensive health services to deployed forces in an operating environment characterized by highly distributed operations and minimal, if any, pre-established health service infrastructure?

TRICARE Benefit

National Health Strategy & Priorities (Examples) • Affordable Care Act • National Quality Strategy • National Prevention Strategy

Health delivery that supports operational

medicine

*Refers to a Family of JROC Approved Documents

The Joint Concept for Health Services

Ends: Globally Integrated Health Services – strategic management and global synchronization of joint operational health services that are sufficiently modular, interoperable, and networked to enable the Joint Force Commander to quickly and efficiently combine and synchronize capabilities

Ways: • Integrated Joint Requirements in Medical Force Development • Leaders Integrating Joint Medical Capabilities • Tailored Medical Forces and Operations • Improved Performance • Global Synchronization of Health Services • Global Network of Health Service Nodes • Modular and Interoperable Medical Capabilities

Means: Interoperable Service capabilities guided by common standards and procedures with the ability to tailor support to meet a wide variety of operational and strategic requirements

Strategic Construct – We must support both the National Defense Strategy and the National Health Strategy

Problem Statement (MHS Health Benefit Delivery CONOPS): How will the Military Health System deliver effective and efficient health services for all eligible beneficiaries in support of Joint Force health readiness and Globally Integrated Operations in future security environments?


Capstone Concept for Joint Operations

National Military Strategy


Operational Medicine CONOPS*

TRICARE Benefit

National Health Strategy & Priorities

(Examples) • Affordable Care Act • National Quality Strategy • National Prevention

Strategy

Health delivery that supports operational

medicine

*Refers to a Family of JROC Approved Documents

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Operational Medicine CONOPS* Health delivery that

supports operational medicine

*Refers to a Family of JROC approved documents

MHS Strategy – Link health benefit delivery to delivery of joint health services for the combatant commanders

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Figure 4: Health Benefit Delivery Challenges

Rapid Aggregation

Lower Echelon

Integration

Alignment of Incentives

Access Consistent Practice of

Evidence-Based Care

Unhealthy Lifestyles

Dispersed Over Long Distances

Shared Challenges

2 Integrating

Partners

Avoiding Harm to Patients

Increased Medical Capabilities

Fiscal Constraints

1

3

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Our Strategy on One “Simple” Page

Desired End State

Health Readiness Health Readiness consists of a Medically Ready Force and a Ready Medical

Force. Achieving Health Readiness requires a global network of hospitals and clinics providing health services that keeps the force medically ready to deploy and prepares a ready medical force to support Globally Integrated Operations

while effectively and efficiently providing care to all other TRICARE beneficiaries.

Enablers Integrated learning health system focused on readiness.

Lines of Effort

MEDICAL FORCE

DEVELOPMENT

BETTER HEALTH

BETTER CARE

LOWER COST

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Our “System’s” Structure : Current State

DOD Deployed Healthcare

Combat Casualty Care

Humanitarian Assistance

Global Health Engagement

Disaster Relief

Limited System

Integration

MTF-Anchored Markets Mission-Driven Markets

With MTF Presence

Primary training platforms for ready medical force; military delivers majority of care to

population in market.

Focus on primary care and occupational medicine for the Total Force and their families.

Greater reliance on network providers for specialty care.

Military-Operated Medical Center and/or

Large Hospital

Military-Operated

Clinics

Civilian Hospitals

and Clinics Military-Operated Hospital and/or

Clinics

Civilian Hospitals and Clinics

Markets Without MTF Presence


All care is purchased for the Total Force and their families.

~16 Markets: • Eligibles: 3.09M • Enrolled: 1.76M • Military Physicians:

3,913 • DC Beddays: 622K • Residents: 2,478

~109 Markets: • Eligibles: 2.87M • Enrolled: 1.87M • Military Physicians:

1,688 • DC Beddays: 109K • Residents: 227

• Eligibles: 3.06M • Enrolled: 0.77M • Military

Physicians: 0

One Vision- “Become a fully integrated premiere LEARNING health system focused on military readiness within five years ”

Or - “Deliver the best care anywhere to those who have volunteered to serve “

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Structural Concept: Achieving Full Integration

DOD Deployed Healthcare

Combat Casualty Care

Humanitarian Assistance

Global Health Engagement

Disaster Relief

MTF-Anchored Markets Mission-Driven Markets

With MTF Presence

Military-Operated Medical Center and/or

Large Hospital

Military-Operated

Clinics

Civilian Hospitals

and Clinics Military-Operated Hospital and/or

Clinics


Markets Without MTF Presence


All care is purchased for the Total Force and their families.

Shared measures and standards

Real-time access to

knowledge

Leadership-instilled culture of learning

Focus on primary care and occupational medicine for the Total Force and their families. Greater

reliance on network providers for specialty care.

Primary training platforms for ready medical force; military delivers majority of care to

population in market.

Integrated Learning Health System Focused on Readiness

Incentives aligned for

value

Common support services

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For Official Use Only

A STORY OF HEALTHCARE

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8-18

Creating Value in Healthcare – Jessie’s Story

18 yo college freshman with first episode rectal bleeding, anemia

Diagnosis: • Evaluated by PA at Bethesda, referred immediately for colonoscopy at

Walter Reed. • Team of Gastroenterologists reviews biopsy –

• Dx: Possible Crohn’s vs. Ulcerative Colitis – Medications initiated • No education provided --- Patient is terrified.

Initiation of Care: • Enrolled at NNMC but, since in college, “you should change your

enrollment site” • 20 phone calls by patient and patient’s mother, unable to transfer

enrollment site • Patient’s mother flies to Chicago to change enrollment and find PCM

• Initial visit with PCM to get GI referral – PCM states - “Why don’t you just quit college, you need a GI guy”

• Initial Specialty Visit– “Excellent” but rushed; • Treatment focused on medications and diet • No educational provided

8-19

Creating Value in Healthcare – Jessie’s Story • Hospitalization one - flu symptoms – GI specialist defers to PCM;

PCM not available; • ER Visit – Hospitalized for “Crohn’s Flare” • Put on prednisone – “I got really crazy, I didn't know who to call”

• Hospitalization two –bleeding, (Hct 28), abdominal pain for 3 days, • PCM not available, ER visit - repeated all labs and two more CTs • After 3 days, released to dorm, falling behind in school

• Hospitalization three –abdominal pain, vomiting and HA, (PCM /GI not available) • ER Visit – Lumbar Puncture and Admitted – after two days, HA

worse, “when I stand up” but discharged anyway --“I lost the chance to take my finals”

• Readmitted for 3 days, received blood patch after caffeine unsuccessful

• Patient initiates talk with PCM – about availability and self care, obtains e mail, direct phone number – no more hospitalizations for 18 months.

8-20

July 2009 – Happy Birthday – “You are no longer eligible for TRICARE and have been dropped from PRIME” Several hours to reestablish PRIME but, needed new referral for gastroenterologist. Had to be there in person.

• Waited 2 hours in PCM office, seen for 3 minutes, to get referral, no exam.

• Referral lost by TRICARE or PCM? Pain returns, PCM not available, referral not done so could not see gastroenterologist.

• ER, Hospitalized, returned home but, no F/U, ER again one week later. (10.23 then 10/31)

Creating Value in Healthcare – Jessie’s Story

8-21

ER Visit 11/01 • Med Sur $112 • Lab/Chem $587 • Lab/Hem $91 • Lab/Bact $295 • Lab/Uro $60 • Ultrasound $893 • ER $1,134 • Pul Fxn $112 • Drugs $305 • Per Vasc $1,531 • Other Rx $1,104 • Total $6,224

Cost of Care – Actual Billed Charges Hospitalization 10/22-10/24 Med-Surg $1,109 Pharm $556 IV $11 Supplies $109 Lab $58 Lab/Immun $378 Lab/Hem $301 Lab/Micro $75 Lab/Uro $143 CT Scan Body $4,263 ER $1,668 Pulmonary Fxn $224 Drugs $360 Other Rx $1,249 Total $11,677

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Discussion Questions • How did our current incentive design help or hinder the care experience

and outcomes for Jessie? Can you give one or two examples where current incentives conflicted with desired outcomes?

• How well did TRICARE (private sector care) work for Jessie. How could we make contracts that are better aligned to create value for our patients?

• What support processes failed for Jessie. Was it just access or were other healthcare support processes inconvenient and possibly harmful.

• Were there safety issues in the care of Jessie? Was the LP standard of care. Was the spinal headache a harm event?

• What prevented Jessie from having a good experience in primary care? Were the services she received “comprehensive”. What was missing?

• Was anyone managing the pathway of care for Jessie? Who is responsible for the outcomes in inflammatory bowel disease a hospital/MTF? In your Service? In the MTF? Who is tracking the cost of care for people with Inflammatory Bowel Disease?

MHS Health Benefit Delivery CONOPS Problem Statement: How will the Military Health System deliver effective and efficient health services for all eligible beneficiaries in support of Joint Force health readiness and Globally Integrated Operations in future security environments?

DRAFT VERSION 1.4 (30 October 2015)

EN

DS

WAY

S

Medical Force

Development Better Health

Better Care

Lower Cost

MEA

NS

Readiness Ready Medical Force Medically Ready Force

LINES OF EFFORT

MH

S SU

PPO

RTE

D O

BJE

CTI

VES

Support Healthy and Safe Environments

Deliver Evidence-Based, Patient- Centered Care Provide Healthcare Anywhere

Support Healthy Behaviors

Support TRICARE Reform Enhance Culture of Safety

Maximize the Health of Wounded, Ill, and Injured

Integrated Learning Health System

Improve Healthcare Outcomes and Experience

Improve Access and Other Care Support Processes

Lines of Effort Supported Objectives

Desired Conditions

A

B

C

D

End State

Ready Medical Force

& Medically

Ready Force

Current State

MHS Operational Approach

Medical Force Development

Better Health

Better Care

Lower Cost

Current Conditions

1 - 8

Desired Conditions A. Medical Force Optimized to

Support Current and Future Missions

B. Improved Beneficiary Health Status

C. Better Care Resulting in Improved Outcomes

D. Reduced Rate of Per Capita Cost Growth

Supported Objectives 1. Improve Reliability of Processes 2. Align Incentives to Achieve Outcomes 3. Recruit, Train, and Develop the Total Force to

Meet Future Challenges 4. Improve Information and Analytics

Infrastructure 5. Optimize Support Functions for Integrated

System 6. Enhance Strategic Partnerships 7. Align Facilities, Personnel, and Capabilities to

Optimize Readiness 8. Align Resources Against Strategic Priorities

and Ensure Fiscal Accountability

9 10 11 12

21 19 14 18 13 15 17 20

19 14 16 18 13 15 17 22 20

14 16 18 13 23

9. Enhance Emerging Medical Capabilities for a Joint Environment while Increasing Interoperability

10. Improve Leadership Development 11. Fully Support Medical Deployment

Cycle While Optimizing Healthcare Delivery

12. Build and Sustain Essential Medical Capabilities

13. Enhance Culture of Safety 14. Support TRICARE Reform 15. Support Healthy and Safe

Environments

16. Improve Access and Other Care Support Processes

17. Provide Healthcare Anywhere 18. Deliver Evidence-Based, Patient-

Centered Care 19. Support Healthy Behaviors 20. Maximize the Health of Wounded,

Ill, and Injured 21. Improve Resilience, Health, and

Human Performance 22. Improve Healthcare Outcomes

and Experience 23. Improve Stewardship



EN

DS

WAY

S

Align Resources

Against Strategic

Priorities and Ensure Fiscal Accountability

Align Facilities, Personnel, and Capabilities to

Optimize Readiness

Improve Information

and Analytics Infrastructure

Improve Healthcare Outcomes and

Experience

Improve Leadership Development

Fully Support Medical Deployment Cycle While Optimizing Healthcare

Delivery

Recruit, Train, and Develop

the Total Force to Meet

Future Challenges

Improve Stewardship

Optimize Support

Functions for Integrated

System

Medical Force


Better Care

Lower Cost

Build and Sustain Essential Medical

Capabilities

Enhance Strategic

Partnerships

MEA

NS


LINES OF EFFORT

Enhance Emerging Medical Capabilities for a Joint

Environment While Increasing Interoperability

MH

S SU

PPO

RTE

D O

BJE

CTI

VES


Deliver Evidence-Based, Patient- Centered Care


Provide Healthcare Anywhere

Align Incentives to Achieve Outcomes

Improve Resilience, Health, and Human

Performance


Support TRICARE Reform

Improve Reliability of Processes

Enhance Culture of Safety




END

S W

AYS

Improve Leadership Development

Fully Support Medical Deployment Cycle While

Optimizing Healthcare Delivery

Medical Force


Better Care

Lower Cost

Build and Sustain Essential Medical Capabilities

MEA

NS


LINES OF EFFORT

Enhance Emerging Medical Capabilities for a Joint Environment

While Increasing Interoperability

MH

S SU

PPO

RTE

D O

BJE

CTI

VES

Enhance Strategic Partnerships




EN

DS

WAY

S

Medical Force


Better Care

Lower Cost

MEA

NS


LINES OF EFFORT

MH

S SU

PPO

RTE

D O

BJE

CTI

VES



Improve Resilience, Health, and Human Performance








EN

DS

WAY

S

Medical Force


Better Care

Lower Cost

MEA

NS


LINES OF EFFORT

MH

S SU

PPO

RTE

D O

BJE

CTI

VES




Support TRICARE Reform Enhance Culture of Safety



Improve Healthcare Outcomes and Experience




EN

DS

WAY

S

Medical Force


Better Care

Lower Cost

MEA

NS


LINES OF EFFORT

MH

S SU

PPO

RTE

D O

BJE

CTI

VES

Deliver Evidence-Based, Patient- Centered Care Support Healthy Behaviors





Improve Stewardship

Exercise: What do you want from your

health system?