Best Care at Lower Cost The Path to Continuously Learning Health Care in America (2013) / Chapter Skim
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Appendix B: A CEO Checklist for High-Value Health Care
Appendix B: A CEO Checklist for High-Value Health Care
Pages 315-388
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Appendix B A CEO Checklist for High Value Health Care The following IOM Discussion Paper, "A CEO Checklist for HighValue Health Care,"was released in June 2012 by the IOM Roundtable on Value & Science-Driven Health Care. The document can also be found online at http://www.iom.edu/CEOChecklist.
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Advising the nation • Improving health
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Geisinger Health System Institute of Medicine Uma Kotagal, MBBS, MSc Kathleen Paul Jed Weissberg, MD Cincinnati Children's Hospital Virginia Mason Health System Kaiser Permanente Tom Lee, MD Brian Powers Robert Wyllie, MD Partners HealthCare System, Inc. Institute of Medicine Cleveland Clinic 2
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We have assembled these lessons here as a A CEO Checklist for High-Value Health Care to describe touchstone principles, illustrated with case examples, central not only to our work to date, but to sustaining and reinforcing the system-wide transformation necessary for continuous improvement in the face of rapidly increasing pressures, demands, and market changes.
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For 32 of the past 40 years, better outcomes at lower costs. health care costs have grown faster than the rest of the U.S.
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However improvements that reduce waste and pervasive, we cannot allow these issues to improve outcomes will maximize the value obscure the substantial gains that can be of health care delivered in the United States. achieved from the steps well within our control as leaders of our institutions.
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322 BEST CARE AT LOWER COST A CHECKLIST FOR HIGH-VALUE HEALTH CARE Just as we offer an invitation to each staff and Board member of our respective institutions to hold us accountable for fully engaging, implementing, and sustaining attention to every Checklist item, we invite you to be in touch as we work together to build the field of health care transformation and better health for all Americans. Foundational elements 3 Governance priority -- visible and determined leadership by CEO and Board • 3 Culture of continuous improvement -- commitment to ongoing, • real-time learning Infrastructure fundamentals 3 IT best practices -- automated, reliable information to and from the point of • care 3 • Evidence protocols -- effective, efficient, and consistent care 3 Resource utilization -- optimized use of personnel, physical space, and • other resources Care delivery priorities 3 Integrated care -- right care, right setting, right providers, right teamwork • 3 Shared decision making -- patient–clinician collaboration on care plans • 3 Targeted services -- tailored community and clinic interventions for • resource-intensive patients Reliability and feedback 3 Embedded safeguards -- supports and prompts to reduce injury and infection • 3 Internal transparency -- visible progress in performance, outcomes, and costs • 6
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3 Governance Priority Visible and determined leadership QUESTIONS WE ASK OURSELVES, OUR by CEO and Board SENIOR LEADERS, AND OUR BOARDS TO ASSESS PROGRESS: Senior executive leaders and Board members are the central stewards of • What is our strategy for continuous high-value care. Responsible for both our improvement in the effectiveness institutions' financial health and the quality and efficiency of care, and are we of care provided, we are inherently the reinforcing it with every member of our most visible champions for a culture of organization?
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Existing workflows must be continually refined and new opportunities for improvement continually sought. A culture of continuous improvement demands that all workers apply this method to their tasks to drive iterative improvements in the efficiency of hospital operations.
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Healthsystem Consortium) • Better care: 88 percent of safety • Lower costs: Since 2006, $158 and quality indicators improved; million in financial benefit realized 85 percent of customer satisfaction despite a 60 percent increase in indicators improved; 83 percent uncompensated care of staff engagement indicators improved Virginia Mason adapted elements • Lower costs: Days cash on hand of the Toyota Production System to increased from 180 to 202 ($36 develop the Virginia Mason Production million improvement)
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aid hospitals in automating order entry and reducing paperwork; optimizing staffing levels and scheduling; managing equipment and resources; defining care protocols and providing clinical decision support; managing billing and revenue cycles; reducing adverse drug events and duplicate tests; and improving care coordination.
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. site of contact for all clinical content • Better care: Fewer adverse drug for faster dissemination of best events; reduced length of stay practices, new medical information, • Lower costs: 58.5 percent reduction and new medical science in the total number of liability claims related to medication errors Cleveland Clinic has integrated a "hard stop" function into their Veterans Health Administration's computerized physician order entry Adverse Drug Event Reporting System system to reduce medically unnecessary (VA ADERS)
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What is our strategy for filling treatment of various conditions improve the these gaps and keeping others current? reproducibility and standardization of care • Which of our care protocols are not yet while allowing for tailoring to the unique integrated into provider workflows via needs of individual patients.
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Kaiser Permanente's Healthy Bones • Lower costs: $68 million in system Program, conceived by KP orthopedists, wide annual savings; 75 percent is a set of measures to identify and reduction in malpractice claim costs proactively treat patients at risk Virginia Mason embedded pre- for osteoporosis and hip fractures. established evidence-based decision Physicians participating in the program rules into the existing workflow of implemented a number of initiatives, providers at the point of ordering including increasing the use of bone an advanced imaging test to reduce density tests (DXA scans)
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stress, lower patient and staff satisfaction, reduced access to care, and higher costs.10 Strategies such as Queuing Theory and Variability Methodology can be used to eliminate sources of artificial variability, improving occupancy without increasing staffing or capacity or reducing lengths of stay. Furthermore, systematic processimprovement efforts such as Lean can be used to make more efficient use of personnel and other resources.
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avoided due to best outcomes. improved patient flow • Better care: 2.3 percent reduction in catheter-associated bloodstream Virginia Mason used the tools infections and methods of the Virginia Mason • Lower costs: More than $200 Production System to reduce million in savings during the past 5 inefficiencies in the workflow of nurses.
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care programs, and other models aimed • How do we assess which care setting is at ensuring that care is delivered in the most cost-effective and appropriate to the most appropriate setting can help reduce patient experience and outcome? costs and improve outcomes.
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clinics, home telehealth, secure • Better care: 51 percent reduction in messaging, and mobile apps. HF hospital readmission; 44 percent • Better care: 15 percent increase in reduction in non-HF hospital same-day access to primary care readmission physicians • Lower costs: More than $10 million • Lower costs: 8 percent reduction in savings to date ($8,155 per in urgent care visits; 4 percent patient)
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evidence-based care plan free of duplication and waste. Once properly informed about their care options, patients often reveal preferences for lower-cost and lessintensive treatments, which can reduce costs associated with overuse.
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single plan of care. • Better care: 1.5-day reduction in • Better care: Average length of stay average length of stay; 3 percent dropped 10 to 15 percent; medication improvement in 30-day survival; reconciliation errors were 28 percent improvement in eliminated and compliance with patient satisfaction with clinician care protocols improved; patient communication satisfaction scores rose to 95 percent • Lower costs: 6 percent reduction in (from 68 percent)
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Current inadequacies in the safety net and reimbursement hurdles for nontraditional models of care make this challenging, but we have found several viable strategies for targeting services to those who need them most. Care coordination, case management, and improved transitions can all enhance the care experience while reducing the costs associated with readmissions and visits to the emergency department (ED)
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best practices for care management; • Better care: 14.8 percent 93 percent of parents rate their child's improvement in physical function; 17.6 asthma as under control percent improvement in timeliness of • Lower costs: In the past year, 92 care avoided admissions ($322,000 in • Lower costs: 33 percent reduction savings) and 266 avoided ED/urgent in per capita claims; 56.5 percent care visits reduction in work days missed Partners HealthCare System Kaiser Permanente, in conjunction participated in a 3-year demonstration with the President's Advisory Council project to test strategies to improve the on HIV/AIDS, the VA, and NCQA, coordination of high-cost Medicare developed and piloted a series of patients.
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Transparency costs in internal metrics helps organizations encourage a culture of high-value care through good stewardship of resources and improved performance on outcomes indicators. 3 Embedded Safeguards Supports and prompts to reduce QUESTIONS WE ASK OURSELVES AND injury and infection OUR SENIOR LEADERS TO ASSESS PROGRESS: Reducing preventable patient harm is a fundamental aspect of high-value care.
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Prevention Initiative 57.4 percent decrease in hospital was implemented in 2007 to decrease acquired bloodstream infections MRSA infections acquired at acute within the ICU since 2006; 80 HCA care facilities nationwide. The program facilities with zero hospital-acquired focused on a bundle of evidence bloodstream infections based best practices known to prevent • Lower costs: $17.5 million saved MRSAs and the leadership of a MRSA system-wide annually ($44,000 per Prevention Coordinator (MPC)
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and external benchmarks, institutions can • What are our procedures for using guide providers' behavior toward improved performance data to improve outcomes value. Additionally, making health care and reduce variability, costs, and waste?
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quality, and a sustained change in • Better care: During the past 3 culture. years, colorectal cancer screening • Better care: >40 percent reduction rates nearly doubled; breast cancer in central-line infections; 50 percent screening rates increased by 20 reduction in urinary-tract infections percent; hypertension control rates (UTIs)
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If the various items in the Checklist, because these results could be scaled nationally, the each is interrelated and, as discussed, some effect would be truly transformational. are fundamental enablers of more targeted BETTER CARE 67% decrease in HIV mortality rate half Up to 200 lives saved LIVES elective CABG the national average at at HCA from reduced SAVED mortality at Geisinger Kaiser Permanente CLABSIs 50% reduction ~60% reduction in ICU ~20% reduction in heart failure MRSA rates at VHA in admissions and HEALTH readmissions at readmissions for GAINED Partners medical-home patients at Geisinger 95% percent More than 90% ~18% improvement in of patients at satisfaction with timeliness of care at the PEOPLE ThedaCare's Geisinger's medical home Virginia Mason IOCP SATISFIED Collaborative Care program Unit rate it 5 out of 5 LOWER COSTS $10 million saved $17.5 million saved $6.3 million saved from ($8,000 per patient)
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Patients, and employers who share already been made Employers are in paying for their care, should be to the challenges attempting to rein provided information and incentives faced by each of us in health care costs to seek out institutions that provide at the individual by contracting high-value care, and delivery sites and institutional with providers should be reimbursed in accordance levels, and the and insurers, with the value of care delivered. challenges to redesigning the efficient operation of the system as a benefit plans, and providing incentives and whole.
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. The populations -- plan to enroll all beneficiaries Innovation Center already launched in managed-care plans within the next programs for the development of ACOs and several years.14 Patient-Centered Medical Homes, as well as bundled payment initiatives for acute care.
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This has been a critical approximation of the interventions key to step for many of us as we have attempted improving health care while lowering costs, to improve the value of care delivered in and to weathering impending regulatory and our institutions. Our experiences with reporting changes and shifting purchaser these initiatives have brought to light demands.
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4. Kaiser Family Foundation.
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At VM, this means that: • The Board receives regular education about health care quality issues • The Board is structured to emphasize quality • The Board spends significant time at each of its meetings attending to quality • Executive review and compensation are tied to specific quality metrics • The organization can demonstrate improvements in quality and outcomes during the last 3 years • Focus on quality is evidenced in the Board's approach to finance -- both in terms of capital allocation and operating priorities RESULTS Virginia Mason received the inaugural Leapfrog Governance for Quality Award (an award given to one hospital or health system in the country annually) for the work its Board has done to mobilize the organization to improve the quality of patient care.
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RESULTS As a result of the QSA process and ongoing Board engagement and leadership, Kaiser Permanente has been able to: • Improve patient satisfaction • Achieve nation-leading performance in quality of care • Identify the gaps between the perspectives of leaders and the front line • Improve awareness of quality and accountability throughout the organization • Develop a culture of patient- and family-focused care FOR MORE INFORMATION Please contact: Jed Weissberg, MD ( jed.weissberg@kp.org)
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• Widespread employee acceptance of Lean philosophy -- 78 percent of employees understand how Lean enables Denver Health to meet its mission FOR MORE INFORMATION Please contact: Phil Goodman (philip.goodman@dhha.org)
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RESULTS • Steadily improved financial health -- multiple years of 4 to 5 percent margins • Patients spend more value-added time with providers • Better patient safety, less delay in seeing physicians for care and more timely results and treatments • Reduction of waste in administrative processes FOR MORE INFORMATION Please contact: Diane Miller (diane.miller@vmmc.org)
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RESULTS • 88 percent of safety and quality indicators improved; 85 percent of customer satisfaction indicators improved • 83 percent of staff-engagement indicators improved • 50 percent of financial indicators improved • Days cash on hand increased from 180 to 202 (a $36 million improvement) from 2008-2011 • Cash-flow margin improved from 10.5 percent to almost 12.5 percent from 2008-2011 • 4 percent profit margin in 2011, despite a doubling of Medicaid volume FOR MORE INFORMATION Please contact: ThedaCare Center for Healthcare Value (info@createvalue.org)
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RESULTS During the past 5 years: • $1.7 million saved from reduced chart pulls • More than $600,000 saved from reduced printing and faxing • $500,000 saved from reduced cost of management of outside documents • More than $500,000 saved per year from reduced nursing-staff time through ePrescribing • More than $1 million saved from reduced transcription FOR MORE INFORMATION Please contact: James M Walker, MD, FACP ( jmwalker@geisinger.edu)
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RESULTS • 58.5 percent reduction in the total number of liability claims related to medication errors • Readiness for Stage 2 Meaningful Use requirement for secure bedside medication administration • Improved data capture for billing on administration and accuracy of charges • Improved inventory control FOR MORE INFORMATION Please contact: Karla Miller, PharmD (karla.miller@hcahealthcare.com)
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Overall, VA ADERS' function is integral to the VA's contemporary pharmacovigilance efforts, and it plays an important role in many VA pharmacy benefits and formulary management decisions. RESULTS • Seven-fold increase in reported ADEs • Ability to generate standardized reports on adverse drug reactions and events with breakdowns by region and by facility FOR MORE INFORMATION Please contact: Michael Valentino, RPh, MHSA (michael.valentino@va.gov)
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. RESULTS Development of Intermountain's EDW has allowed for: • The ability to track individual patient results in real time • The ability to monitor patients across all of their concurrent conditions • Full integration of clinical, financial, and care-process data FOR MORE INFORMATION Please contact: Lucy Savitz, PhD (lucy.savitz@imail.org)
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All standard order sets were updated, and after background collection of data, Cleveland Clinic initiated a same-day block or "hard stop" of eight laboratory tests. When duplicate orders were placed within the electronic medical record, providers were notified of the current day's result or that the test was pending.
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RESULTS • Contains data from thousands of medical texts and journals, and includes a full array of recommended best practices, proven care protocols, and advice • More than 10,000 uses per day of the electronic medical library by KP clinicians FOR MORE INFORMATION Please contact: Jed Weissberg, MD ( jed.weissberg@kp.org)
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RESULTS • 67 percent reduction in operative mortality • 1.3-day decrease in length of stay • Revenue minus expense improved by more than $1,900 per case • Cost per case for Geisinger Health Plan decreased by 4.8 percent • 23 percent increase in contribution margin for the episode of care (decision to operate to 90 days post discharge) FOR MORE INFORMATION Please contact: Alfred Casale, MD (ascasale@geisinger.edu)
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RESULTS • 75 percent reduction in malpractice-claim costs since 2010 • $68 million in system-wide annual savings • Maternal death rate of ~6.5 per 100,000 births (compared to national average of 13) FOR MORE INFORMATION Please contact: Janet Meyers, RN, MBA ( janet.meyers@hcahealthcare.com)
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RESULTS • The MRI rate for headache decreased by 23.2 percent; the lumbar MRI rate decreased by 23.4 percent; and the sinus CT rate decreased by 26.8 percent • No added provider time, no waits or delays to patient care, and minimal administrative cost FOR MORE INFORMATION Please contact: Robert Mecklenberg, MD (robert.mecklenburg@vmmc.org)
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Since its implementation in 2001, the guidelines and protocol continue to be refined. RESULTS • Inappropriate elective induction rate fell from 28 percent to less than 2 percent • Over c-section rate approximately 40 percent lower than the national average; overall cost savings of $50 million • $10 million reduction in maternal and newborn variable costs per year • Women spend 750 fewer hours in delivery per year, freeing up resources for the delivery of an additional 1,500 infants FOR MORE INFORMATION Please contact: Lucy Savitz, PhD (lucy.savitz@imail.org)
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RESULTS During the course of 5 years, the Healthy Bones Program has: • Tracked more than 625,000 male and female patients over the age of 50 in Southern California who had specific risk factors for osteoporosis and/or hip fractures • Reduced hip fracture rates for at-risk patients by nearly 50 percent FOR MORE INFORMATION Please contact: Tadashi Funahasi, MD (tadashi.t.funahashi@kp.org)
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RESULTS • $100 million in capital costs (75 new beds) avoided due to improved flow and patient placement • Decrease in variability of new elective surgical admissions • Decrease of diversion of patients to other units and delay/cancelation of surgical procedures • Elimination of occasions in which beds in the pediatric ICU were not available when needed for urgent medical or surgical use FOR MORE INFORMATION Please contact: Uma Kotagal, MBBS, MSc (uma.kotagal@cchmc.org)
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Steps walked per day were reduced from 10,000 to approximately 1,200 FOR MORE INFORMATION Please contact: Charleen Tachibana, RN (charleen.tachibana@vmmc.org) xviii
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RESULTS • Overall: More than $200 million in savings during the past 5 years from supply chain improvements • For CLABSI: 2.3 percent reduction in the rate of infections; 32 percent reduction in cost per line FOR MORE INFORMATION Please contact: Lucy Savitz, PhD (lucy.savitz@imail.org)
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• 51 percent reduction in HF hospital readmission and 44 percent reduction in non-HF hospital readmission • Improved patient understanding of heart failure and self-management skills • High levels of clinician and patient receptivity and satisfaction FOR MORE INFORMATION Please contact: Joseph Kvedar, MD ( jkvedar@partners.org)
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that care for more than 300,000 lives. RESULTS Data from the past 5 years on 80,000 GHP members were analyzed and yielded: • 7.1 percent reduction in the total cost of care during 5 years • 91 percent of patients rate the quality of care as better than in the past • 93 percent of physicians would recommend PHN as a model to other primary care physicians • 18.2 percent decrease in risk-adjusted acute admissions • 20 percent decrease in risk-adjusted re-admissions • 99 percent of the patient population agrees that care management works with them effectively FOR MORE INFORMATION Please contact: Thomas Graf, MD (trgraf@geisinger.edu)
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have been trained • 16 percent increase in total PACT encounters in FY 2011 (e.g., face-to-face, phone, group, secure messaging) • 15 percent increase in same-day access to primary care physicians in FY 2011 • Overall, urgent care visits by primary care patients decreased by 8 percent and admission rates decreased by 4 percent since the implementation of PACT FOR MORE INFORMATION Please contact: Richard Stark, MD (richard.stark@va.gov)
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. RESULTS • 18 percent decrease in surgical mortality • 17 percent decrease in surgical morbidity • 25 percent decrease in operating room adverse events FOR MORE INFORMATION Please contact: Robin R
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When they detect a barrier to the progression, it is the nurse who contacts the team's physician with recommendations, not the other way around. RESULTS • 25 percent reduction in direct and indirect costs of inpatient care • Average length of stay dropped 17 percent • Elimination of all medication-reconciliation errors and near 100 percent compliance with care protocols • Patient satisfaction scores rose to 95 percent rating their care as 5 out of 5 (from 68 percent previously)
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decrease in the ICU length of stay • 6 percent decrease in costs of care • 28 percent improvement in patient satisfaction regarding clinician communication • 30-day survival improved by 3 percent (93.8 to 96.8 percent) FOR MORE INFORMATION Please contact: Robert Wyllie, MD (wyllier@ccf.org)
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• Reduction in commercially insured asthma-related ED/urgent care visits: savings estimated at $93,000 for the most recent 12-month period (266 ED/ urgent care visits avoided) FOR MORE INFORMATION Please contact: Uma Kotagal, MBBS, MSc (uma.kotagal@cchmc.org)
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To help the primary care physicians manage these patients, MGH integrated 12 care managers into their primary care practices. The care managers developed personal relationships with enrolled patients and worked closely with physicians to help identify gaps in patient care, coordinate providers and services, facilitate communication (especially during transitions)
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RESULTS • 33 percent reduction in annual per capita claims • 14.8 percent improvement in patients' physical function; 16.1 percent improvement in mental function • 17.6 percent improvement in timeliness of care • 56.5 percent reduction in patients' work-days missed FOR MORE INFORMATION Please contact: Ingrid Gerbino, MD (ingrid.gerbino@vmmc.org) xxviii
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• HIV mortality rates that are half the national average FOR MORE INFORMATION Please contact: Michael Horberg, MD (michael.horberg@kp.org) xxix
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Additionally, a bundle compliance-monitoring form, designed to be completed by nurses, helped to build quality improvement into daily work. RESULTS • Reduced average length of stay per case to 10 days, resulting in an average savings of $27,000 per case • Six-year savings of $6.3 million • An estimated 233 surgical site infections were prevented in the past 6 years FOR MORE INFORMATION Please contact: Uma Kotagal, MBBS, MSc (uma.kotagal@cchmc.org)
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RESULTS • $44,000 in savings per case -- $17.5 million saved system-wide annually • 57.4 percent decrease in hospital-acquired bloodstream infections within the ICU since 2006 • Up to 200 lives saved • More than 400 fewer infections annually since 2006 • 80 HCA facilities with zero hospital-acquired bloodstream infections FOR MORE INFORMATION Please contact: Jason Hickok, RN, MBA ( jason.hickok@hcahealthcare.com) xxxi
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Kaiser Permanente nursing, physician, informatics, and quality leaders translated existing guidelines into specific competencies, practices, and roles for the care delivery staff. Changes in patient care protocols in the ED and ICU provided early recognition and treatment intervention opportunities.
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• 31 percent reduction in serious medication-administration errors • An annual savings of $2.2 million from decreased adverse drug events • Increased on-time medication availability on nursing units FOR MORE INFORMATION Please contact: Tejal Gandhi, MD, MPH (tgandhi@partners.org) xxxiii
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RESULTS • From October 2007 to June 2010, MRSA HAI rates declined by 62 percent in VHA ICUs nationwide • During this same period, non-ICU MRSA HAI rates fell by 45 percent • Approximately 1,000 MRSA HAIs were prevented during this period • Currently, more than 70 percent of VHA facilities report zero MRSA HAIs monthly FOR MORE INFORMATION Please contact: Martin Evans, MD (martin.evans@va.gov) xxxiv
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of performance by site of primary care and by PCP, which has driven reduced variation and improved overall performance. RESULTS • Colorectal cancer screening rates nearly doubled in 3 years after starting at 32 percent • Breast cancer screening rates increased by 20 percent in 3 years after many years of flat performance • Hypertension control rates increased from 60 percent to 72 percent in 3 years FOR MORE INFORMATION Please contact: Tom MacKenzie, MD (thomas.mackenzie@dhha.org)
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RESULTS • >40 percent reduction in ICU central line–associated bloodstream infections (CLABSIs) • 50 percent reduction in ICU urinary tract infections per 1,000 patient days • Cost avoidance of $30,000 for each CLABSI and $5,000 for each urinary tract infection • Increased compliance in administration of pneumonia vaccinations to a sustained level near 100 percent • 13 percent increase in operating room on-time first starts • 10 percent improvement in transferred patients assigned to a receiving bed within 12 hours or less • 10 percent reduction in blood units used per 1,000 patient days FOR MORE INFORMATION Please contact: Robert Wyllie, MD (wyllier@ccf.org)
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Don't prescribe antibiotics for pharyngitis unless the patient tests positive for streptococcus 2. Don't obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors 3.
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Using MRI rather than mammography as the breast cancer screening test of choice for average-risk women 12. In asymptomatic women with previously-treated breast cancer, performing follow up complete blood counts, blood chemistry studies, tumor marker studies, chest radiography, or imaging studies other than appropriate breast imaging 13.
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Performing imaging studies, rather than a high-sensitivity D-dimer measurement, as the initial diagnostic test in patients with low pretest probability of venous thromboembolism 33. Measuring D-dimer rather than performing appropriate diagnostic imaging (extremity ultrasonography, CT angiography, or ventilation–perfusion scintigraphy)
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1. Don't perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
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, obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don't obtain imaging studies as the initial diagnostic test.
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1. Don't perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present.
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