Engineering a Learning Healthcare System A Look at the Future: Workshop Summary (2011) / Chapter Skim
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4 Case Studies in Transformation Through Systems Engineering
4 Case Studies in Transformation Through Systems Engineering
Pages 171-236
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From page 171... ...
4 Case Studies in Transformation Through Systems Engineering INTRODUCTION Creative approaches are necessary to meet the Roundtable's goal that "by the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence." In this section of the workshop, guidance was solicited from organizations both within and outside health care that have achieved successful elements of transformation. Presenters provided accounts of their achievements and offered insights into their organization's transformation through approaches to systems engineering.
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Kizer, chair of Medsphere Systems Corporation, began by describing the condition of the veterans healthcare system in the early 1990s. Managed by the Veterans Health Administration (VHA)
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AIRLINE SAFETY John J Nance, J.D., National Patient Safety Foundation, American Medical Association Although it would be hyperbole to say that the solution to much of what troubles American health care can be found in engineering disciplines, I truly believe that engineering and the engineering community can provide unprecedented expertise and contribute substantially, if not pivotally, to the national task of creating order out of the chaos that characterizes American health care today.
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In many ways this nearly unnoticed transition can be characterized as moving from a reliance on the principles of mechanical and aeronautical engineering to an acceptance of the principles and benefits of human systems engineering. The sometimes difficult transformation from a myopic focus on mechanical reliability to a focus on overall systemic reliability was guided at every step by the discipline engineering brought to bear in helping the airlines accept the realities of the potential for human failure and the resulting ability of airline safety leaders to impose better order and function.
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From page 175... ...
In truth, the safety challenges the airline industry faced through the 1970s were perplexing. We had enjoyed great progress in airline safety from the dawn of commercial aviation in the late 1920s through the dawn of the jet age in the 1960s and into the 1970s.
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from that pivotal recognition are loosely known as human factors engineering, but they include systems engineering as well and borrow heavily from sociology, physiology, and behavioral science. Before the industry realized in the early 1980s that it had never really addressed human failure (except to ineffectually order humans not to fail)
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, to the point that any significant problem discovered in commercial aviation can be fully discussed and communicated to every operator worldwide within hours. Aviation, in other words, worked hard to learn serious lessons about maintenance and training once the FAA pushed for airline safety by working with, instead of against, the industry.
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From page 178... ...
Given events such as these, the airline industry realized by the early 1980s that such tragedies would continue unless it adopted radically different practices and, for the first time, addressed not just advertent human failure but wholly inadvertent mistakes. To that end, the industry had to do more than adopt major changes; it had to change its philosophy and, most important, to change the entire culture of airline piloting.
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From page 179... ...
In the airline industry, thousands of work-years of engineering had been devoted (with great success) to providing backup systems for even the most arcane failure modes, but when it came to engineering for human failure, the approach taken was simply to order the human not to fail.
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From page 180... ...
That one change -- the Tier 3 approach -- can be the final key to constructing a system that protects against catastrophic patient injury or death from preventable medical human mistakes. But to institutionalize such procedures requires a systemic approach that is foreign to the American healthcare
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That day it resulted in the loss of 583 lives. The third human failure is mistakes in communication, a human propensity shared by health care and aviation.
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ALCOA'S REORIENTATION: STREAMLINING THE FINANCIAL CLOSE PROCESS Earnest J Edwards, Alcoa, Inc., Martha Jefferson Health Serice World-class organizations have been breaking traditional paradigms and achieving real value by adding to their operations the use of finance organizations that embrace and act on the following five key characteristics: 1.
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From page 183... ...
Department of the Treasury, again under O'Neill's leadership, and more recently, another such project, yielding many of the same value-adding benefits and direct cost reductions, was carried out at the Martha Jefferson Hospital. This is a worthwhile leadership project that can introduce major change to any organization and serve as an example of what can be done with commitment, focus, and no major investment.
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We wanted a common chart of accounts, including setting up a worldwide common accounting and finance language, providing consistent information, and improving communication among business units, among other strategies. We wanted an accelerated closing process, by which we meant we wanted to shorten the closing cycle to three days, significantly improve processes, and provide timely performance information to management.
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We saw quality improvement at all locations. We could document productivity improvement in terms of days saved times people in the process.
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Fully accredited by the Joint Commission on Accreditation of Healthcare Organizations, the hospital has a caring tradition of more than 100 years, with close ties to its community. Its key services include a can
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2005 to reduce the financial close process from 15 to 5 business days by FY 2007. Unlike Alcoa or the U.S.
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Department of Veterans Affairs, Medsphere Systems Corporation, Inc., Kizer & Associates, LLC The veterans healthcare system administered by the VA was established after World War I to provide medical and rehabilitation care for veterans having health conditions related to their military service. Today it is the nation's largest healthcare system, although it is an anomaly in American health care insofar as it is centrally administered, fully integrated, and both paid for and operated by the federal government.
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The founding of the veterans healthcare system is generally linked with the establishment of the VA (Piccard, 2005; Weber and Schmeckebiar, 1934) 3 at a time when there was essentially no public or private health insurance in the United States.
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. The VHA also partnered with most states to fund state-managed skilled nursing facilities for elderly veterans, administered a contract and fee-basis care program paying for "out-of-network" services, and managed a number of nonhealthcare concerns.7 By this time the veterans healthcare system was highly dysfunctional.
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. The veterans healthcare system is now viewed as a model of high-quality, lowcost (i.e., high-value)
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. Transforming the Veterans Healthcare System In 1994 there was widespread consensus that the veterans healthcare system needed a major overhaul, but there was little agreement about how to effect the needed change.
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modernize information management. Change Strategy 1: Create an Accountable Management Structure and Management Control System The most visible steps taken to increase management accountability were (1)
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Establishment of Veterans Integrated Service Networks After development, vetting, and requisite congressional approval of the restructuring plan, in fall 1995 the VHA's more than 1,100 sites of care delivery were organized into 22 Veterans Integrated Service Networks (VISNs, pronounced "visions") (Kizer and Garthwaite, 1997; Kizer and Pane, 1997)
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Concomitant with efforts to improve the quality of care, steps were taken to increase the knowledge base concerning clinical quality improvement and to encourage innovation. These efforts included initiation of the VA National Quality Scholars Fellowship Program (Batalden et al., 2002)
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Particularly important were the implementation of universal primary care, revision of the laws governing eligibility for care, and creation of the VISN management structure. Unsuccessful attempts were made to gain legislative authority for VA medical centers to participate in the Medicare program to help rationalize the care of dual eligibles.
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This argument was pivotal to gaining enactment of the Veterans Health Care Eligibility Reform Act of 1996 (Public Law 104-262, 1996)
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. Another important clinical quality improvement effort was the National Surgical Quality Improvement Program (NSQIP)
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, to create an organizational culture of safety, to implement safe practices, to produce new knowledge about patient safety through research, and to partner with other organizations to promote more rapid problem solving for patient safety issues. Change Strategy : Align System Finances with Desired Outcomes Another systemic problem with veterans health care in 1995 was that the Resource Planning and Management Resource Allocation Methodology used to distribute congressionally appropriated funds to the medical centers was neither predictable nor easily understandable, and it perpetuated inefficiencies.
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in 1997. When CPRS was combined with a new graphical user interface, the VHA's new EHR became known as the Veterans Health Information Systems and Technology Architecture, or VistA (Brown et al., 2003; Conn, 2004; Morgan, 2005; Parrino, 2003; Versel, 2003)
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By contrast, in the 5 FYs preceding the transformation (i.e., FY 1990 to FY 1994) , the medical care budget increased 41 percent, and in the 5 years after the transformation (i.e., FY 2000 to FY04)
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• Developed and implemented customer service standards; markedly im proved service satisfaction, with veterans healthcare service rating higher than that of the private sector every veteran since 1999, according to the annual American Customer Satisfaction Index. • Launched the largest ever translational research initiative (i.e., the Quality Enhancement Research Initiative)
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Since the feasibility of implementing NSQIP in the private sector was first demonstrated (Fink et al., 2002) , this quality improvement program has been found to be fully applicable to private-sector surgical programs and is being used increasingly by private healthcare providers (Khuri et al., 2008)
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. The VHA's service satisfaction ratings on the ACSI have been higher than those of the private sector every year since 1999 (Freedberg, 2006; National Quality Research Center, 2007a, 2007b)
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. In treating persons with substance abuse disorders, one of the VA's special populations, the VA substantially increased outpatient care and decreased its historical reliance on inpatient care (Chen et al., 2001; Humphreys and Horst, 2002; Office of the Inspector General, 1997)
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However, what has been truly transformative20 is the synergism among the EHR, performance measurement, increased accountability, aligned financial incentives, a quality improvement environment, and a delivery system focused on population health (Anderson, 2005; Greenfield and Kaplan, 2004; Jackson et al., 2005; Kupersmith et al., 2007; Young et al., 1997)
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• To improve performance or quality, leaders must show that improvement is an organizational priority and make sure that everyone in the organization knows it. • Decentralization of authority must be coupled with a full understanding of mission critical activities, clear delineation of responsibility and accountability, and monitor ing of performance to help prevent things from "falling through the cracks." • Automated information management is a critical tool for healthcare transformation and quality improvement; the electronic health record is an essential tool today.
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From page 208... ...
. In addition to mortality, seven other Priorities for Action were identified: adverse drug events, the Joint Commission on Accreditation of Healthcare Organizations' national patient safety goals, nosocomial infections, perioperative complications, pressure ulcers, falls and fall injuries, and birth trauma.
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From page 209... ...
The 8 Priorities for Action were identified by a rapid-design planning team of 38 individuals from across the system (plus our strategic partners from the Institute for Healthcare Improvement) who were asked to address the question of what work needed to be done to eliminate all preventable injuries and deaths.
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The new outcome measure became the observed minus the expected mortality rate per 100 discharges (the difference, rather than the ratio, was selected to maintain a constant relationship between the number of deaths avoided and the percentage decline in the mortality rates each year)
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This work, including its content, may not be used, reproduced, duplicated, displayed, or distributed absent express written permission from Ascension Health. 211 FIGURE 4-3 landscape
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are plotted against one y axis, and the increasing case mix index over time is plotted against the other y axis. Although the majority of deaths have occurred in patients expected to die during their hospitalization, the declines have been significant enough to show an improvement in the observed mortality rates despite the increasing severity of illness among patients admitted (measured by the case mix index)
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is 74 percent lower than the national reference rate. Figure 4-7 shows the neonatal mortality rates per 1,000 live births for the individual hospitals.
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. The proposed elimination of preventable pressure ulcers across Ascension Health represented a significant commitment by the organization, as it would entail such actions as the replacement of all inappropriate mattresses and frames (a $60 million capital investment)
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System rate is 0.6882 birth traumas per 1,000 live births (based on the AHRQ birth trauma patient safety indicator definition and clinical case review)
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NOTE: This graph represents data F4-7.eps that are self-reported and self-validated in accor dance with the definitions and guidelines adopted by the Ascension Health Perinatal Safety Affinity Group.a a Neonatal mortality is a death during the first 28 days after birth and prior to discharge of a live-born inborn infant ≥ 24 weeks of gestational age born without lethal malformation or abnormality. The estimated national rate is 4.52 neonatal mortalities per 1,000 live births based on 2004 data (CDC, 2007)
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the national benchmarks cited. Although comparisons with national benchmarks in many cases require significant extrapolation, the results clearly demonstrate that it is possible to make remarkable progress in improving patient safety in a large, geographically dispersed health system.
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NOTE: This graph represents data that are.eps F4-9 self-reported and self-validated in accor landscape by the Ascension Health Pressure dance with the definitions and guidelines adopted Ulcers Affinity Group.a a A facility-acquired pressure ulcer is an observable pressure-related alteration of intact skin that was not identified and documented within the first 24 hours after admission. The estimated national incidence rate is 7 percent of discharges or ~18.35 facility-acquired pressure ulcers per 1,000 inpatient days (Whittington and Briones, 2004)
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This work, including its content, may not be used, reproduced, duplicated, displayed, or distributed absent express written permission from Ascension Health. our hospitals.
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This work, including its content, may not be used, reproduced, dupli cated, displayed, or distributed absent express written permission from Ascension Health. beginning of the end, but it may be the end of the beginning." Viewed in the context of this workshop, many of our approaches have focused on standardizing specific processes in high-risk areas, using systems engineer ing methods where possible.
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This work, including its content, may not be used, reproduced, dupli cated, displayed, or distributed absent express written permission from Ascension Health.
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From page 222... ...
This work, including its content, may not be used, reproduced, dupli cated, displayed, or distributed absent express written permission from Ascension Health.
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Ascension Health uses the National Database of Nursing Quality Indicators Falls and Falls with Serious Injury definitions, which exclude certain units. The estimated national rate is (median of "All Falls" indexes)
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This work, including its content, may not be used, reproduced, duplicated, displayed, or distributed absent express written permission from Ascension Health. 10 0% 10 0% 10 0% 10 0% 90 % 90 % 85% 83 % 80 % 76 % 80 % 73 % 70 % 70 % 60 % 60 % 48 % 50 % 50 % 44% 40 % 40 % 30 % 30 % 20 % 20 % 10 % 10 % 0% 0% FY 2004 FY 2005 FY 2006 FY 2007 Cost of Malpractice $/equivalent discharge FIGURE 4-16 Risk management program reductions in the overall cost of malpractice and the cost per equivalent discharge from fiscal year (FY)
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2006. Reinventing Veterans Health Administration: Focus on primary care.
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2002. The Veterans Health Administration and the Institute for Healthcare Im proement's adanced clinic access initiatie 2001–2002.
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2003. Rapid improvement in pain management: The Veterans Health Administration and the Institute for Healthcare Improvement collaborative.
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2003. From profession-based leader ship to service line management in the Veterans Health Administration: Impact on mental health care.
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2004. Informatics resources to support health care quality improvement in the Veterans Health Administra tion.
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2008. Successful implementation of the Department of Veterans Affairs' National Surgi cal Quality Improvement Program in the private sector: The Patient Safety in Surgery study.
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Washington, DC: Veterans Health Administration.
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2007b. Veterans Health Administration -- Outpatients, Veterans Affairs customer satisfaction study: Final report 200.
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2002. National Hepatitis C Surveillance Day in the Veterans Health Administration of the Department of Veterans Affairs.
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2004. Improving patient access to the Veterans Health Administration's primary care and specialty clinics.
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1998. Oncology management by the "New" Veterans Health Administration.
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2007. The evolution of changes in primary care delivery underlying the Veterans Health Administration's quality trans formation.
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