better care at lower cost: principles of design (what to do and how to do it) donald m. berwick, md,...
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Better Care at Lower Cost:Principles of Design
(What To Do and How To Do It)
Donald M. Berwick, MD, MPPPresident and CEO
Institute for Healthcare Improvementwww.ihi.org
Families USA Health Action Conference
Washington, DC: January 29, 2010
Major Biomedical Successes
2
• Acute Lymphoblastic Leukemia• Coronary Heart Disease • Acute Myocardial Infarction• Erythroblastosis Fetalis• Diabetes Mellitus• Asthma• Organ Transplantation
Health Care Expenditure Out of GDP
Mortality Amenable to Health Care
4
Deaths per 100,000 population*
* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.See report Appendix B for list of all conditions considered amenable to health care in the analysis.Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
The Dartmouth AtlasRegional Variation in Medicare Spending per Capita
$10,250 to 17,184 (55)9,500 to < 10,250 (69)8,750 to < 9,500 (64)8,000 to < 8,750 (53)6,039 to < 8,000 (65)
Not Populated
Source: Elliott Fisher and the Dartmouth Atlas Project
It’s Our MoneyAverage Health Insurance Premiums and
Worker Contributions for Family Coverage, 1999-2009
Note: The average worker contribution and the average employer contribution may not add to the average total premium due to rounding.
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2009.
$5,791
131% Premium Increase
$13,375
Wage and benefits1
Increase 37%
1. Bureau of Labor Statistics Employment Cost Index
7
Aims
• Safety
• Effectiveness
• Patient-centeredness
• Timeliness
• Efficiency
• Equity
8
Types of Improvement: Noriaki Kano
• Type I: Reducing defects from the viewpoint of the customer
• Type II: Reducing cost, while maintaining or improving quality
• Type III: Providing a new product or service, or an old one at an unprecedented level
Model I: Bad Apples
10
The Problem
Quality
Frequency
The Simple, Wrong Answer
Blame Somebody
The Cycle of Fear
12
Increase Fear
Micromanage Kill theMessenger
Filter theInformation
Model 2: Continuous Improvement“Every Defect is a Treasure”
13
Quality
F
requ
ency
“The First Law of Improvement”
Every system is perfectly designed to achieve
exactly the results it gets.
14
PARISIN THE
THE SPRING
15
Preventing Central Line Infections
• Hand hygiene
• Maximal barrier precautions
• Chlorhexidine skin antisepsis
• Appropriate catheter site and administration system care
• Daily review of line necessity and prompt removal of unnecessary lines
16
Central Line Associated Bloodstream Infections (CLABs)(from Rick Shannon, MD, West Penn Allegheny Health System)
17
IHI’s “Rings” of Activity:www.ihi.org
InnovationPrototype
Dissemination
14
Sentara WilliamsburgZero Ventilator Pneumonias in Five Years!
20
Seton Family of HospitalsBirth Trauma Prevention
Palmetto Hospital Mortality Rates
The Technical Approach:How Do You Improve a
Process?
Systems Thinking
Model for Improvement
Act Plan
Study Do
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an improvement?
Repeated Use of the Cycles
Changes that Result in
Improvement
HunchesTheories
Ideas
A P
DS
A PDS
AP
DS
A P
DS DATA
Multiple PDSA Cycle RampsMaking Baseball Better
Testin
g an
d ad
apta
tion
Change Concepts
A P
S D
A PS D
A P
S D
D S
P A
A P
S D
A PS D
A P
S D
D S
P A
A P
S D
A PS D
A P
S D
D S
P A
A P
S D
A PS D
A P
S D
D S
P A
Running Hitting Fielding Conditioning
The Social System:How Do You Support Process Changes?
Breakthrough Series Collaboratives
IHI Breakthrough Series(6 to 13 months time frame)
Select Topic
Planning Group
Develop Framework & Changes
Participants (10-100 teams)
Prework
LS 1
P
S
A DP
S
A D
LS 3LS 2
Supports
E-mail Visits
Phone Assessments
Monthly Team Reports
Congress,
Guides,
Publications
etc.
A D
P
SExpert Meeting
Scottish Phase I SPI Site: Tayside
The Strategic System:How Do You Align Improvements?
Organizations and Leadership
Organizational Elements
Strategy
Culture Technique
Leaders’ Tasks…
• Will
• Ideas
• Execution
The Basic Principles
• Continual Improvement – Never-ending
• Systems Thinking
• Customer Focus
• Involve the Workforce
• Learn from Data and Variation
• Learn from Action - “Plan-Do-Study-Act”
• Key Role of Leaders
CareScience Observed minus Expected Mortality Rate per 100 DischargesAscension Health System
-0.9000
-0.8000
-0.7000
-0.6000
-0.5000
-0.4000
-0.3000
Apr
-03
May
-03
Jun-
03
Jul-0
3
Aug
-03
Sep
-03
Oct
-03
Nov
-03
Dec
-03
Jan-
04
Feb-
04
Mar
-04
Apr
-04
May
-04
Jun-
04
Jul-0
4
Aug
-04
Sep
-04
Oct
-04
Nov
-04
Dec
-04
Jan-
05
Feb-
05
Mar
-05
Apr
-05
May
-05
Jun-
05
Jul-0
5
Aug
-05
Sep
-05
Oct
-05
Nov
-05
Dec
-05
Obs
erve
d m
inus
Exp
ecte
d R
ate
per 1
00 D
isch
arge
s
Actual Monthly Difference p-bar (Center Line for Difference) LCL UCL
Baseline
1,038 Mortalities Avoided (Year 2)
374 Mortalities Avoided(9 mos. of Year 3)
1,412 Mortalities Avoided Since Baseline Period
Ascension Health Mortality ReductionAscension Health Mortality Reduction
33
Health Care Expenditure Out of GDP
Drivers of a Low-Value Health System
Low Value
High Cost Low Quality
Supply-Driven
Demand
No mechanismto controlcost at the
population level
New drugsand
tech ≠outcomes
Over-Reliance
On Doctors
Under-valuing
“system”design
Insignificant role for
individuals and families
The “Triple Aim”
PopulationHealth
Experienceof Care
Per CapitaCost
36
10 HRRs We StudiedPrice-Adjusted per Capita Medicare spending
$10,250 to 17,184 (55)9,500 to < 10,250 (69)8,750 to < 9,500 (64)8,000 to < 8,750 (53)6,039 to < 8,000 (65)
Not Populated
Everett, WA
Sacramento,CA
Temple, TXTallahassee,
FL
La Crosse,WI Cedar
Rapids, IA
Sayre,PA
Portland, ME
Richmond, VA
Asheville, NC
Source: Elliott Fisher and the Dartmouth Atlas Project
Price Adjusted Spending
2006
Increase in Spending
1992 – 2006
Annual GrowthRate
Ten High-Performing HRRs
$7,924 $2,297 3.0%
232 Other HRRs $9,695 $3,376 3.6%
Potential Annual Savings: 12.7% - 16.2%
What Are They Doing?
The High-Performing HRR’s per capita Spending – and Spending Growth – Are Lower.
Source: Elliott Fisher and the Dartmouth Atlas Project
Cedar Rapids Spends 27% Less than the Average Community
Drivers of a Low-Value Health System
Low Value
High Cost Low Quality
Supply-Driven
Demand
No mechanismto controlcost at the
population level
New drugsand
tech ≠outcomes
Over-Reliance
On Doctors
Under-valuing
“system”design
Insignificant role for
individuals and families
Health Care Reform: The Apparent Choice
Spend More. Accomplish Less.
Health Care Reform: The Better Choice
Spend More. Accomplish Less.
Change the System.
Design Concepts for High ValueCare: A Regional Perspective
1. Primary Care: Redefined, Higher Capacity2. Decrease Dependence on Highest Cost
Care3. Reclaim Wasted Hospital Capacity4. Pursue Individual Patient Goals at Lowest
Total Cost5. Focus on the High Cost, Socially or
Medically Complex Patients6. Integrate Regional Resources
44
Designing for a High-Value Regional Health Care System
Low Value Health Care
Primary Drivers
“More Is Better” Culture Mitigated by: 1, 2, 4
Supply Driven DemandMitigated by: 2, 3, 6
No Mechanism to ControlCost at the Population Level
Mitigated by: 3, 5, 6
Over-Reliance on DoctorsMitigated by: 1, 4, 5
Lack of Appreciation fora System
Mitigated by: 1, 2, 6
Design Concepts1. Primary Care: redefined, higher capacity
• General medical practice connected to other resources
• Self-care designed by “lead patients and families”
2. Reverse the cost-flow gradient
• GP - specialist compacts
• Make the expensive places the bottlenecks
3. Reclaim wasted hospital capacity
• Flow optimization
• Chronic disease care
4. Patient goals at least total cost
• Patient reported outcomes
• Decision aids and peer to peer support
5. Focused segment: High cost, socially or medically complex
6. Integration of regional resources• Negotiate fair arrangements• Ostrom’s design concepts
High
The Future State –Most Can Be Winners
46
BURDEN
TIME
CURRENT STATE
FUTURE STATE
The Transition State – Hard for All
47
BURDEN
TIME
CURRENT STATE
FUTURE STATE
TRANSITION STATE
The Big Question for Our Nation:Will We Pursue the “Triple Aim”?
PopulationHealth
Experienceof Care
Per CapitaCost
48
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