Healthcare Reform-- Improving Patient Care and Strategic Alliance Activities

Why frontline staff and unions are critical for improving patient care and transforming our healthcare delivery systems

Peter Lazes, Healthcare Transformation Project Cornell University

Quality Summit 2012Nurse Alliance of SEIU PAHarrisburg, PASeptember 26, 2012

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“ Leading organizations can not be left solely to management”

John AugustExecutive DirectorCoalition of UnionsKaiser Permanente

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How Bad Is Our Problem?

• Healthcare Issues - U.S. citizens pays 53% more for healthcare - Over 50 million American’s without health insurance - Bottom quartile in terms of quality of care

- 1.5% quality improvement over a 7 year period

• Union Density Crisis- 1950’s 35%

- 1980’s 20% - 2012 > 11%

Mirror, Mirror: Ranking of Six Nations

    AUSTRALIA CANADA GERMANYNEW

ZEALANDUNITED

KINGDOMUNITEDSTATES

OVERALL RANKING (2007) 3.5 5 2 3.5 1 6

Quality Care 4 6 2.5 2.5 1 5

Right Care 5 6 3 4 2 1

Safe Care 4 5 1 3 2 6

Coordinated Care 3 6 4 2 1 5

Patient-Centered Care 3 6 2 1 4 5

Access 3 5 1 2 4 6

Efficiency 4 5 3 2 1 6

Equity 2 5 4 3 1 6

Long, Healthy, and Productive Lives 1 3 2 4.5 4.5 6

Health Expenditures per Capita, 2004 $2,876* $3,165 $3,005* $2,083 $2,546 $6,102

Source: K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, “Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care,” The Commonwealth Fund, May 2007

Country Rankings

1-2.66

2.67-4.33

4.33-6.0

* 2003 data

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Health care reform

Coverage for most Americans

Reduce percent of GDP spending on health care – billions of dollars!

Deep challenges and rich opportunities for us

Major Provisions of the PPACA

•Insurance Coverage Expansions

•Patient Protection & Insurance Market Reform

•Revenue Measures & Deficit Reduction

•Spur System Delivery Changes 6

New Quality Improvement Incentives and Penalties from CMS

- Value-Based Purchasing

- Hospital Acquired Infections

- Avoidable Re-Admissions

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What Is Value-Based Purchasing (VBP)?• A Centers for Medicare and Medicaid Services (CMS)

initiative established by the Affordable Care Act

• Financially rewards hospitals for the quality of care they provide Medicare patients rather than the quantity of procedures• Measures will include both clinical processes and patient

satisfaction

• Encourages hospitals to prioritize overall patient wellness as opposed to episodic treatment

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How Does It Work?• CMS will create a pool of funds from which incentive payments will be

made to hospitals that perform well in a designated performance period• Medicare will deduct1% from DRG funds in FY2013. Percentages will

increase by .25% until the maximum 2% is reached in FY2017

• Hospitals will be scored against their own baseline data and each other on a series of measures to determine who will receive payment increases

• Information regarding the following will be made available to the public:• The hospital’s performance on each measure that applies • The hospital’s performance with respect to each condition or procedure• The hospital’s total performance score

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What Will Be Measured?

• FY2013 will measure two domains

• Clinical Process of Care -- 70%

• Patient Experience of Care 30%

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Clinical Process MeasuresClinical Process of Care Measures

Acute Myocardial Infarction (AMI)

Heart Failure (HF)

Pneumonia (PN)

Healthcare-associated Infections (SCIP = Surgical Care Improvement Project)

Surgeries

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HCAHP* Domains for Patient Experience Measures

• Nurse communication • Doctor communication • Cleanliness and quietness • Responsiveness of hospital staff • Pain management • Communication about medications • Discharge information • Overall rating

(* Hospital Consumer Assessment of Healthcare Providers and Systems Survey)

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How Will VBP Impact Hospitals?

• CMS estimates that roughly half of participating hospitals will receive net pay increases in FY2013

• No hospital should receive more than a 1% decrease in net pay

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Readmissions Penalties

• If a hospital’s risk-adjusted readmission rate exceeds the CMS-calculated average risk-adjusted 30 day hospital readmission rate for the following conditions it will be penalized:• Myocardial infarction• Pneumonia• Heart failure

• Penalties apply the following year for all Medicare admissions in proportion to the hospital’s rate of excess readmissions

• Maximum penalty for 2013 is 1% of a hospital’s Medicare payments • Maximum penalty will ultimately be 3% of payments in 2015

• ¾ of hospitals at risk to lose money

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Hospital Acquired Conditions

• Hospitals in the worst quartile of risk-adjusted HAC rates will lose 1% of their Medicare acute inpatient payments.

• Penalties will begin in FY 2015 most likely based on FY 2013

cases.

• HAC refer to the following conditions:• Foreign object retained, air embolism, blood incompatibility,

stage III and IV pressure ulcers, falls/trauma, poor glycemic control, catheter-associated UTI, surgical site infections, deep vein thrombosis, pulmonary embolism 15

Components of an Integrated Care Delivery System

Integrated Care

Coordinated Care: Patient centered care

involving collaboration among primary care

physician, nurses, patient, family and community

Information Technology: Electronic Medical

Records/History, E-Prescriptions, Interactive Patient Web Portal

Health Coach, Nurse Navigator: Staff use of electronic portals and tracking tools to monitor progress of patients, especially those

with chronic conditions

Reimbursement Reform: Restructuring of the current system used to compensate

physicians based on “fee for service” to one that is bundled/pre-paid, and quality outcome linked

Tracking Outcome Tools:

Use data to identify issues of critical care

Feedback to Physicians and Healthcare TeamMeasure clinical or service

performance by physician/practice

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Fragmented vs. Integrated Care Delivery Systems

Fragmented Care Integrated Care

• No care coordination among physician, staff, family and community

• System reacts to needs• Fee for service

reimbursement• Limited tools/processes for

preventive care or patient progress

• Patient centered coordinated care involving all parties in patients healthcare

• Needs are anticipated• Bundled/Pre-paid

reimbursements• Electronic/staff tools to track

patient progress and monitor chronic conditions

Integrated Care Reduces Costs

• Importance of improving

transitions in care, doctor to

doctor, and post-hospital

• Follow-up care following hospital

discharge could reduce re-

hospitalization

• High cost care management could

reduce errors and lower costs

• Will require restructuring Medicare

benefits and incentives

Dollars

$9,618

$6,152

Source: M.D. Naylor, Making the Bridge from Hospital to Home, The Commonwealth Fund, Fall 2003.

Effect of Advanced Practice Nurse Care on Congestive Heart Failure Patients’ Average Per

Capita Expenditures

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Current Challenges of Our Healthcare System

• Greater Access to Care and Payment

• Better Quality and Patient Safety

• Affordable Costs

• An Integrated Delivery System

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Choices of Work Systems

• Taylorism

- Keep jobs simple- Low skill Jobs- Complete management control of every step of the

process

• High Performance Work Systems- Teamwork - Consultation and worker access to information - Worker autonomy over day to day activities - Worker involvement in terms of changes including the

use of new technology

Additional Evidence:Ever worker is a change agent

Work as a learning activity is:“a radically different organizational mindset… [where people] give tough feedback and have difficult conversations—which demand trust and respect—without the need to tiptoe around the truth.”Amy C. Edmondson

Harvard Business School

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Important Outcomes from Front-Line Staff Engagement and Decisions Making

• Creating new knowledge is needed to develop breakthroughs to help redesign our work—getting rid of “work arounds”

• Members have a voice and role in greater decision-making and they like this….

• Members find ways to sustain NEEDED changes because they are part of creating the solution…they know what the problems are.

• Changes result in significant improvement in clinical and patient satisfaction outcomes

• Members feel respected as result of such participation

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“ Unions need to initiate and take the lead to improve the quality of care of patients and find ways to cut costs. Unions can’t allow themselves to be bystanders but instead must be champions for these changes.”

John AugustExecutive DirectorCoalition of Unions at Kaiser Permanente

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Why aren’t more front-line staff included in helping to improve patient care and control costs?

Can we continue to risk leaving our jobs in the hands of management?

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Important Areas of Work for Front-Line Staff

• Unit-based quality improvement

• Strategic patient safety and/or quality of care

• Patient satisfaction

• Creating integrated delivery systems 25

Current Problems

• Working on the wrong problem• Not using the appropriate process• Lacking a method to sustain results• Lack a high involvement frontline staff and

union involvement• Management resistance or lack of skills• Unions reluctance and lack of skills

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Current Approaches to Improve the Quality of Care and Care Management Solution Shops- Transforming Care at the Bedside (IHI)- Six Sigma

Value Added- Toyota Production System—Lean Manufacturing - Appreciative Inquiry

Networking, Innovation, and Disruptive Innovation to Achieve Systematic Changes

- strategic work design and new work systems as a result of front-line staff and union involvement, and networking with others.. creating “new knowledge”(a significant different mindset and skill set)

Two Approaches for Achieving an IDS

We know what is needed

• You exploit what you know• You meet current customer

needs

• You plan• You demand accountability• You impose process and

structure

Optimizing to be Efficient

Innovation/Adaptation to Create Anew

Create new processes/systems•You explore what you don’t know•You anticipate future patient needs

•You create opportunities for discoveries to occur•You encourage the discipline of innovation

© 2010 Cornell University

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Critical Approaches that are making a difference in Healthcare Institutions

• Unit-based work• Hospital-wide interventions• Delivery System Integration

Critical Areas of Work that are Emerging in Healthcare Delivery System Reform

© S

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Spea

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Complexity and Innovation

1964 2010

Nissan LEAF

Balancing Interventions

• Lean• 6 Sigma• Toyota Production Systems

• Multi-stakeholder engagement• Large group breakthrough

process• Patient experience value- chain

drives process• Front-line staff/management

involvement• Fast cycle/multi-iterations• Honoring errors

Optimizing

Innovation/Adaptation

© 2010 Cornell University

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We’ve always done it this way…..

Getting to the “Right Process”

“I’m astounded by people who want to know the universe, when it’s hard enough to find your way around Chinatown”

Woody Allen

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* Top down: Management driven

* Consultant driven

* Unions as bystanders

* Unions leading change

• Union and Management leading

changes

Approaches to Solve Issues

• Incremental > unit-based

• Systemic > hospital- wide > integrated delivery systems

Areas of Work Approaches

Fletcher Allen Health Care

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1115 Waiver - Implications for CCHHS employees

CCHHS Multi-Union Training5-7pm, September 11, 2012

Source: Cook County Health & Hospitals System FY2013 Preliminary Operating Budget, CCHHS Finance Committee, Friday August 24, 2012

ACA Opportunities

The CCHHS Labor Management Council

“Unionized front-line doctors, nurses and ancillary staff must come to be seen, treated, and act as part of the solution rather than as part of the problem.”

Source: SEIU “Cut to the Bone” November 29, 2010

• History• Goals• Progress

CCHHS Labor-Management Process

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Cornell Consultants

Union Staff

Labor-Management Council (LMC)

Patient-Centered Medical Homes

Improving the Patient Experience

Wellness Program

Improvement Tools

• Process mapping

• Problem solving

• Cause and effect analysis

• Microsystems 41

Design Tools

• System intervention not project based

• Core functions/Core Practices

• Accelerated engagement of the whole system

• Working on breakthroughs with an iterative process

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4-Work System Design 6-Data collection for review

Strategic targets and adjust Plan of work

1-Leadership 7-Review and adjust 2-Strategy 8-Re-configurability 3-Quality Lab 5-Launch teams

Training Standardize processes Network/innovation

MOBILIZE

ACT

ADAPT

Cornell’s Labor-Management Change Process

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Patient care outcomes: • Decrease Patient Fall by 50% for cardiac and med/surgical patients

• Reduce Call Bell response by 50% to < 1 min.

• Alarm and Monitors responded to in < 1 min.

• Reduction in medication errors by 50% on all medicine floors

• Unions involved in floor layouts, move to a new building, and purchasing of new equipment

Union Building Outcomes

Recent Outcomes

- PAC contributions increased 32% (from 58% to 89%)

- Active delegates increased by 426 % (from 23 to 98)

- Reductions in inappropriate grievances and arbitrations by 63% (from 103 to 38)

- Internal organizing – physician assistants, tech repres.

- Significant access to budgets and quality/performance indicators

- Over 100 Joint Hiring Committees have been conducted 45

Quality standards

Business strategy

Budgets

Service

Marketing

We need to bargain and operate outside the NLRA box and Re-Engineer our union

Overtime

Seniority

Grievances

Wages

Differentials

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A train wreck about to occur.

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Three Important Strategies

• Work with allies– friendly manager…make them winners

• Do research on where the system is vulnerable: (e.g. Value-Based Purchasing, Patient Satisfaction scores)

• Leverage grievances and arbitrations to get management’s attention

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Best Strategic Alliance Practices1) Active Union and Management Leadership

2) A clear governance structure with clear collective bargaining agreement

3) Part-time or full union staff to oversee and support joint work

4) Getting results in a timely manner

5) Strong engagement and education of members 49

Best Practices Continued

6) Acknowledging that there will be issueswhere labor and management will not agree

7) An effective monitoring and tracking process

8) Redesign labor relations practices

9) Re-engineer and retool unions

10) Continue to conduct research and learn from others

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Other Significant Findings

• Significant Upfront Costs

• 25 to 30 % Cost Reductions when fully implemented

• Rand Study- Congestive Heart Failure patients have 35% fewer hospital days, Asthma and Diabetes Patients were more likely to receive appropriate therapy

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“No doubt that a small group of thoughtful citizens can change the world. Indeed, it’s the only thing that ever has.”

Margaret Mead

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A tradition of Militancy

Workers created the middle class by fighting. Nothing came without a fight!

Unions made sense; union success linked to social mission

Our Website:

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http://www.ilr.cornell.edu/healthcare