2003: Improvements and Other Changes

Francois de BrantesMay, 2003

Founded by The Business RoundtableSupported by the Robert Wood Johnson Foundation

To Err Is Human:

Building a Safer Health System Institute of

Medicine

Committee on Quality of Health Care in America

Anesthesia During Surgery

44,000 - 98,000 Preventable

Hospital Deaths (IOM)

The Quality Imperative

1,000,000

100,000

10,000

1,000

100

10

1

DPMO

1 2 3 4 5 6© 1994 Dr. Mikel J. Harry - V4.0

SIGMA

93% good

99.4% good

99.98% good

Low Back Treatment Overuse

Mammography Screening Underuse

Post Heart Attack Medications Underuse

Antibiotic Overuse

LOW HIGH

HIGH

LOW

Effectiveness of Care

Efficiency

Breaking The Status Quo

Provider Universe Today

Provider Universe Tomorrow

Removing The Barriers To Change

Meaningful Measures

Engage Consumers

Engage Hospitals

Three Leaps – 1st Generation

An Rx for Rx– Computer Physician Order Entry (CPOE)

– 85% serious drug errors prevented

– Net cost savings

Practice Makes Perfect– Evidence-based Hospital Referral (EHR)

– > 20% mortality reduction for 7 complex treatments

Sick People Need Special Care – ICU Daytime Staffing with CCM Trained M.D.

– > 10% mortality reduction

– Net cost savings

Leap Refinements

FROM TO

CPOE Implementation targets

2004/2005 2005/2006

IPS Implementation targets

2002/2003 2004/2005

IPS Telemedicine

In development

Allowed

Strong emphasis on integrated Information Systems

Leap Refinements – EHR

FROM TO

CABG 500 per year 550 for last 12 mos or as annual avg over 24 mos

PCI Coronary Angioplasty

All PCIs, 400 for last 12 mos or as annual avg over 24 mos

AAA repair 30 per year 50 for last 12 mos or as annual avg over 24 mos

Carotid Endarterectomy

100 per year Eliminated

Esophageal cancer surgery

7 per year 8 for last 12 mos or as annual avg over 24 mos

Pancreatic cancer surgery

Not measured 6 for last 12 mos or as annual avg over 24 mos

R/A State-reported outcomes not allowed for VA

Leap Refinements – Process

Revised survey ready

All hospitals asked to re-submit in Q2

New results posted in Q3 & Q4

Same process on-going

Leapfrog“2 + 6”

NQF Group 1 ~ “ORYX”

31

NQF Group 28

Measures – Beyond Leapfrog

5

44 Unique Measures:• 8 outcomes – infections or r/a

mortality• 6 volumes – number of

procedures or patients• 3 structural processes – CPOE,

ICU, discharge plans• 27 clinical indicators –

medication admin, interventions

+ a number of other structural safe practices measures to create a comprehensive overview of hospital performance.

CMS/AHA“Pilot 10”

UCSF/AHRQ

“Top 11”

Engage Consumers

Heart NEJM 12-12-2002

– NEJM survey results

– FACCT Toolkit

Engage Consumers

Heart– FACCT Toolkit

– NEJM survey results

Mind– Web Hits

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

Subimo

DQ

SQC

HealthGrades

2002

Engage Consumers

Heart– FACCT Toolkit

– NEJM survey results

Mind– Web Hits

Wallet– Co-pays,

co-insurance, PBAs

Engaging Hospitals

Mind– Thousands of press hits

– Letters from plans

Almost 60% of hospitals in targeted regions fill out survey…30% of all targeted Hospitals

Engaging Hospitals

Mind– Thousands of press hits

– Letters from plans

Wallet– Direct

– Indirect

Making The Business Case

Determine impact of mechanisms to close net shortfall:– Direct $$

– Intensivist reimbursement

– Bonus payments (e.g. x + x%)

– Award

– Volume shift

– Indirect $$

– Cost of capital

– Reduced liability/malpractice premiums

Pilots underway now…more to come!

Measuring Results

Missing Appropriate Leaps per Patient (n) per Hospital Stay

Appropriate Leaps per Patient (n) per Hospital Stay

ΣΣ

n

n

= % Defects

“all missing” for non-reporting

hospitals

Counting down to Zero

Make all accountable: plans, purchasers, providers, and patients

Reducing Avoidable Deaths

Leap CPOE CABG Angio AAA Endart Esoph NICU IPSObservations 28,324 307 425 30 122 2 80 2,405Defects 27,134 145 100 15 77 1 39 1,881Leap-specific Defect Rate

95.80% 47.20% 23.50% 50.00% 63.10% 50.00% 48.80% 78.20%

Differential Risk (deaths) per 1000 Defects

0.2 9 2.8 25 1.4 99.1 43.3 18

Avoidable DeathsFull Adoption 5.7 2.8 1.2 0.8 0.2 0.2 3.5 43.3Remaining 5.4 1.3 0.3 0.4 0.1 0.1 1.7 33.9

Weighted Defect Rate

57.543.1

75.00%

TotalsAvoidable Deaths – full adoptionAvoidable Deaths – remaining

Modify and refine model to reflect Leap changes … and continue the countdown to zero.

That’s one small step for all of us, one giant leap for patient safety.