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

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• 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

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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

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The Problem

Quality

Frequency

The Simple, Wrong Answer

Blame Somebody

The Cycle of Fear

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Increase Fear

Micromanage Kill theMessenger

Filter theInformation

Model 2: Continuous Improvement“Every Defect is a Treasure”

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Quality

F

requ

ency

“The First Law of Improvement”

Every system is perfectly designed to achieve

exactly the results it gets.

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PARISIN THE

THE SPRING

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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

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Central Line Associated Bloodstream Infections (CLABs)(from Rick Shannon, MD, West Penn Allegheny Health System)

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IHI’s “Rings” of Activity:www.ihi.org

InnovationPrototype

Dissemination

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Sentara WilliamsburgZero Ventilator Pneumonias in Five Years!

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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

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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

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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

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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

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BURDEN

TIME

CURRENT STATE

FUTURE STATE

The Transition State – Hard for All

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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

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