"the nuka system of care: lessons for healthcare redesign in wales" - dr stephen tierney
DESCRIPTION
1000 Lives Improvement hosted Dr Stephen Tierney of Southcentral Foundation, to discuss how they transformed a system of care in Anchorage, Alaska, and how their lessons could help in transforming healthcare in NHS Wales.TRANSCRIPT
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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 systemCurrent model actually does HARM
Primary Care needs changing
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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
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Medical Model – not questionedEach 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
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Who really makes the decisions?
Acuity
“Control”
The “System”
Customer-Owner/Family
0Low
High
100%
1. Control – who makes the final decision influencing outcome?2. Influences – family, friends, co-workers, religion, values, money3. Real opportunity to influence health costs/outcomes – influence on the
choices made – behavioral change4. Current model – tests, diagnosis, treatment (meds or procedures)
Copyright © 2011 Southcentral Foundation. All Rights Reserved.
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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.
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Severe dental caries ADHD Anxiety Disorder Domestic Violence
Severe dental cariesHypertension
Disease Approach to Improvement
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Outcome not income Person not diseasePopulation not process Service not practice
Approaching the Philosophic Thought Process of Redesign
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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 interruptions MUST fix basic, underlying primary care platform first or nothing else will work well
Reality
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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
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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
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Data and Measurement Key Improvements
Multiple levels Mission, Vision, Key Points Data experts Data and sharing story Data Mall
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Information to Knowledge% SCF Central Pharmacy customer-owners requesting other
medications at dispensing
0%
10%
20%
30%
40%
50%
8/5/10 8/12/10 8/19/10 8/26/10 9/2/10 9/9/10 9/16/10 9/23/10 9/30/10
Percent
Average
Better
Source: Central Pharmacy-Pharmacy tic-sheet 9.27.10
Change Tested
Change Implemented
% Employees with Current Annual Disaster Tng
53
74
94 98 100
0
50
100
2005 2006 2007 2008 2009
%
SCF Industry Best (100%)
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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
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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 Focus Key Improvements
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Interview /Hiring Onboarding (ASTP, etc) Leadership
development Development Center Career Ladders Job Progressions Mentoring Employee Wellness
Workforce FocusKey Improvements
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Would You Like to Live in Alaska?
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Are You Sure?
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