barach talk.mab.final

The Role of National Health Insurance in creating Safe,

Affordable, and High Quality Outcomes for Bahamians?

Paul Barach, MD, MPH

March 5, 2015 Medical Association of the Bahamas

NHI: Key System Drivers

Health

Social Economic

Patient

Politics, regulations and agencies

2

Vision of NHI

•  The Government of The Bahamas is committed to transforming the healthcare systems into the safest, most effective and most compassionate provider of healthcare in the region.

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Wellness Model

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Mortality rates in PMH vary for public and private patients

263 deaths/

1781 admis

17 deaths

248 admis

270 deaths 9867

admis

6 deaths 1171

admis 15 deaths 2120

admis

0 deaths

44 admis

•  Lack of coordination, with providers in silos, fragmented service models

•  Increasing Patient Expectations •  Lack of active follow-up to ensure the best outcomes •  Patients inadequately trained to manage their illnesses •  Large variation in outcomes for patients •  Very costly, unsustainable financial costs •  Severe workforce issues •  Lack of transparency of Outcomes and Scores •  Discouraged, Unhappy Workforce

Bahamian Healthcare is challenged by:

•  “…the very first requirement in a Hospital [is] that it •  should do the sick no harm.”

•  – Notes on Hospitals, 1863

Florence Nightingale

It is all about the patient!

Politics and medicine    “Medicine  is  a  social  science  and  medicine  is  nothing  but  poli4cs  on  a  grand  scale”    

 Rudolf  Virchow,  (1821-­‐1902)  Prussian  physician,  one  of  the  originators  of  the  

cell  theory,  worked  out  the  mechanism  of  pulmonary  thromboembolism,  wri4ng  

about  the  1848  typhus  epidemic  in  Upper  Silesia  

AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US

OVERALL RANKING (2013) 4 10 9 5 5 7 7 3 2 1 11

Quality Care 2 9 8 7 5 4 11 10 3 1 5

Effective Care 4 7 9 6 5 2 11 10 8 1 3

Safe Care 3 10 2 6 7 9 11 5 4 1 7

Coordinated Care 4 8 9 10 5 2 7 11 3 1 6

Patient-Centered Care

5 8 10 7 3 6 11 9 2 1 4

Access 8 9 11 2 4 7 6 4 2 1 9

Cost-Related Problem 9 5 10 4 8 6 3 1 7 1 11

Timeliness of Care 6 11 10 4 2 7 8 9 1 3 5

Efficiency 4 10 8 9 7 3 4 2 6 1 11

Equity 5 9 7 4 8 10 6 1 2 2 11

Healthy Lives

4 8 1 7 5 9 6 2 3 10 11

Health Expenditures/Capita, 2011** $3,800 $4,522 $4,118 $4,495 $5,099 $3,182 $5,669 $3,925 $5,643 $3,405 $8,508

COUNTRY RANKINGS

Top 2*

Middle

Bottom 2*

EXHIBIT ES-1. OVERALL RANKING

Notes: * Includes ties. ** Expenditures shown in $US PPP (purchasing power parity); Australian $ data are from 2010.Source: Calculated by The Commonwealth Fund based on 2011 International Health Policy Survey of Sicker Adults; 2012 International Health Policy Survey of Primary Care Physicians; 2013 International Health Policy Survey; Commonwealth Fund National Scorecard 2011; World Health Organization; and Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, Nov. 2013).

Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally

Operations performed on Fridays were associated with a higher 30-day mortality rate than those performed on Mondays through

Wednesdays: 2.94% vs. 2.18%; Odds ratio, 1.36; 95% CI, 1.24–1.49)

No  system

 beyond  this  point  

10-2 10-3 10-4 10-5 10-6

Civil Aviation

Nuclear Industry

Railways

Chartered Flight

Drilling Industry

Chemical Industry (total)

Fatal risk

Anesthesiology ASA1

Innovative medicine (grafts, oncology …) ICU Trauma centers

Very  unsafe   Ultra  safe  

Professional fishing

Unsafe   Safe  

Hymalaya mountaineering

Combat A/C, war time

Medical risk (total)

Scheduled surgery Chronic care

Radiotherapy, Biology Blood transfusion

Finance Fire Fighting Food Industry

Processing Industry

Amalberti R. et al.: 5 System barriers to achieving ultra-safe health care. Ann Intern Med. 2005;142:756-764.

Average Rate per Exposure of Catastrophes and Associated Deaths in Various Industries and

Human Activities

Assuming a system is 99.9% safe; How Safe is “Safe Enough” for surgery???

•  84 unsafe landings /day

•  1 major plane crash every 3 days

•  16,000 mail items lost/hr

•  37,000 bank transaction errors/hr

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15

IGNAZ  SEMMELWEIS  –  USE  OF  CHLORINATED  LIME  HAND  WASHING  FOR  PREVENTION  OF  PUERPERAL  FEVER  (THE  MIDWIVES’  WARD  LOWER  THAN  DOCTORS’)  

Semmelweis – the mortality rate in April 1847 was 18%; after hand washing was instituted in mid-May, the rate in July was 1%

DR  IGNAZ  SEMMELWEIS’S  FATE      

       Semmelweis  was  outraged  by  the  indifference  of  the  medical  profession  to  pa4ent  suffering  and  death  ...  

       His  contemporaries,  including  his  wife,  believed  he  was  losing  his  mind,  and  in  1865  he  was  commiPed  to  an  asylum..    

       He  died  there  of    sep4caemia  only  14  days  later,  possibly  from  the  result  of  being  severely  beaten  by  guards    

HH: hand hygiene. OT: operating theatre. NSG: non-sterile gloves. SG: sterile gloves Annelot C Krediet, et al. Hygiene Practices in the Operating Theatre: An Observational Study., BJA, 2011

Normalized Deviance •  By a deviant organizational behavior, we refer to “an

event, activity or circumstance, occurring in and/or produced by a formal organization, that deviates from both formal design goals and normative standards or expectations, either in the fact of its occurrence or in its consequences.”

•  Once a community normalizes a deviant organizational practice, it is no longer viewed as an aberrant act that elicits an exceptional response; instead, it becomes a routine activity that is commonly anticipated and frequently used.

Diane Vaughan, 1999: 273. ; Barach, Phelps 2013

How does it start? •  The normalization literature distinguishes

between factors that lead to the genesis of organizational deviance and factors that cause deviance to become routine, rather than idiosyncratic, behavior.

• A permissive ethical climate, an emphasis on financial goals at all costs, and an opportunity to act amorally or immorally, all contribute to managerial decisions to initiate deviance.

NHI- Donabedian Causal Chain

Lilford R J et al. BMJ 2010;341:bmj.c4413

“If an error is possible, someone will make it. The designer must assume that all possible errors will occur and design so as to minimize the chance of the error in the first place, or its effects once it gets made” Norman, The Design of Everyday Things, 2001

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The 93% vs. 7% Rule

Organizational Design 93%

Knowing Violations

Human Error (People)

Reckless Conduct (People)

Negligent Conduct

(People)

(People)

Reason – Complex Systems

TeamSTEPPS--Model of Multi-disciplinary Care Teamwork

Mutual Trust

Shared Mental Models

Closed Loop Communication

Team Leadership

Team Orientation

Back-Up Behavior

Adaptability

THE CORE

Baker, D, Salas E, Barach P, 2006, 2007

Mutual Performance Monitoring

Four building blocks towards towards a “high reliability” healthcare

organization

The definition of a high reliability organization extends beyond patient safety to encompass quality care – and ultimately value.

‘High reliability’ organizations:

27

After Berg M and KPMG Report

Stages in the development of a safety culture

CALCULATIVE We have systems in place to

manage all hazards

PROACTIVE Safety leadership and values drive

continuous improvement

REACTIVE Safety is important, we do a lot every time we have an accident

PATHOLOGICAL Who cares as long as

we're not caught

GENERATIVE (High Reliability Orgs) HSE is how we do business

round here

After Ron Westrum

The Five Dysfunctions of Teams

After Patrick Lencioni, 2007

30

Absence of trust

Fear of Conflict

Commitment

Accountability

Results

PopulaIon  Health  Management  System of Care

Benefits Package Building

Health needs (BOD)

Required Health Interventions

Criteria Results Group 1: Dr. Charles Group 2: Dr. Weech Group 3: Dr. Neymour

1 Safety Essential Effective / efficacy / Cost-efficiency

2 Burden of disease Effective / efficacy Value-added

3 Essential BoD BoD

4 Cost efficiency Value-added Culture / Language

5 Efficacy Efficient / cost effective Essential

6 Resource Impact on Health System

Safety Resource Impact

7 Value added Resource impact Safety

8

9 ?Education / Prevention

Benefits Package Building

Health needs (BOD)

Required Health Interventions

Criteria Definition Inclusion/exclusion

Benefits Package Draft

Benefits Package Building

Guidelines and Protocols

Quality Assurance

Health needs (BOD)

Required Health Interventions

Protocol Building for The Bahamas

•  World Health Organization •  NICE National Health Institute for

Health and Care Excellence •  National Guidelines Clearinghouse

•  http://www.eguidelines.co.uk •  http://www.ncbi.nlm.nih.gov •  http://www.leitlinien.de •  http://www.library.nhs.uk •  http://www.guidelines.gov •  http://www.nice.org.uk •  http://medicine.ucsf.edu •  http://www.cks.library.nhs.uk •  http://www.guiasalud.es

Protocol Building for The Bahamas

Hypertension

Initial Encounter

Primary Care Enrolment

Clinical Management Age, comorbidity, medication

Phatmaceuticals, Laboratories,

Allied

Primary Health Care

Hospitals

TIMELINE

February 28

March 1 to 13 group

meetings

March 14 to April 15 BP draft definition

April 16 to 27 Presentation

and incorporation of

comments

April 27 to 30 Final

Draft Delivered

Vision of NHI

•  The Government of The Bahamas is committed to transforming the healthcare systems into the safest, most effective and most compassionate provider of healthcare in the region.

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Next frontier -- Wicked Challenges

•  Access to all •  Healing Environments •  Work sharing and team work •  Infection prevention •  Culture of safety •  Transitions of care

Conclusion

• Barriers to change-culture eats strategy for breakfast (Peter Drucker)

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References •  More on topic and references for talk

see https://www.linkedin.com/in/paulbarach

•  Key research papers are downloadable at Research Gate athttps://www.researchgate.net/profile/Paul_Barach/publications/?pubType=article&ev=prf_pubs_art

•  Email me at pbarach@gmail.com or contact me at Tel: 242 4289817

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