The Business Case for Quality Learning Session 3: 29th & 30th September 2009 The Business Case for Quality Presenter: Dr David Gozzard Learning Session 3: The Business Case for Quality

Learning Session 3: The Business Case for Quality Session Outline Definition of the Business Case for Quality Overview: Savings or loss from improving quality Case Studies Discussion Next Steps Learning Session 3: The Business Case for Quality

Definition: Business Case for Quality “A business case for a health care improvement intervention exists if the entity that invests in the intervention realizes a financial return on its investment in a reasonable time frame, using a reasonable rate of discounting. This may be realized as “bankable dollars” (profit), a reduction in losses for a given program or population, or avoided costs. In addition, a business case may exist if the investing entity believes that a positive indirect effect on organizational function and sustainability will accrue within a reasonable time frame.” The Business Case For Quality: Case Studies And An Analysis by Sheila Leatherman, Donald Berwick, Debra Iles, Lawrence S. Lewin, Frank Davidoff, Thomas Nolan, and Maureen Bisognano Learning Session 3: The Business Case for Quality

- Will - Ideas - Execution Learning Session 3: The Business Case for Quality

The Problem? “Quality has been used as a weapon in the fight against limits to healthcare funding. In one corner of the ring stands the clinician, outraged that a paper pushing manager concerned with throughputs and efficiency does not understand or care that quality of care is adversely affected by cost cutting. In the other corner stands the manager, convinced that quality is the last refuge of the medical scoundrel – a convenient, vague and all embracing term used to block any attempts to question or change clinical behaviour” Buchan 1998 In Davies H. et al. Healthcare professionals’ views on clinician engagement in quality improvement. A literature review. The Health Foundation, 2007

The Paradigm Clinicians’ primary professional focus is their own practice. At best, clinicians have little time to spare for quality agendas of their organisations. At worst, relationships are strained because the clinicians’ quality agendas conflict with those of their organisations. Very little happens without a clinician order

Reframing Managers’ Values, Habits, Beliefs… FROM TO Doctors are important customers Doctors make care decisions, we run the finances and facilities The patient is the only customer Doctors are our partners in running the system The NHS has almost done away with the term “administrator” and the usage is now in favor of “managers”. However, the sentiments are the same. In the UK we have paid clinical directorships. The medical director tends to be a board level executive position whilst clinical directors head a department. Example: Clinical Directorships

Reframing Doctors’ Values, Habits, Beliefs… FROM TO I must have complete autonomy for everything I am personally responsible for the patients I take care of directly I need autonomy for the art of medicine, but I share it with other physicians for the science of medicine I am responsible for the care given broadly throughout the system that I am part of, including my own patients The Medical Executive Committee has largely been replaced by a hospital management committee of managers and doctors (usually clinical directors in partnership. This tends to be the day-to-day management committee of the hospital. The Hospital Board oversees the management of this group. Any standardization is probably agreed through clinical governance procedures to agree clinical policy. Consequently all hospitals will have a clinical governance (or sometimes an integrated governance) committee.

Learning Session 3: The Business Case for Quality Noriaki Kano Kano I: Eliminate the quality problems that arise because the customer’s expectations are not met (patient safety) Kano 2: Reduce cost significantly whilst maintaining or improving quality (efficiency) Kano 3: Expand customer’s expectations by providing products and services perceived as unusually high in value (patient satisfaction) Learning Session 3: The Business Case for Quality

Learning Session 3: The Business Case for Quality Quality Domains Patient Centeredness Patient Safety Effectiveness Efficiency Timeliness Equity Learning Session 3: The Business Case for Quality

Learning Session 3: The Business Case for Quality Driver Diagram Patient centeredness Patient safety Effectiveness Efficiency Timeliness Equity Models of Care Adverse events The right science Eliminate waste Access Models of care for differing patient groups Pathway redesign 1000 lives Reliability Readmissions Flow/demand Preop assessment Improve Quality Learning Session 3: The Business Case for Quality

VCB CLB SLB Example for 1 - This reduction in LOS on ICU follows the introduction of the ventilator care bundle. The hassle factor here was that patients could not get admitted to the ICU because of lack of beds. Plans were repeatedly discussed between doctors and management to relocate the ICU, fund additional beds etc. The introduction of the VCB released capacity, reduced hassles and cost nothing except agreement on clinical policy.

Catheter Infections

Modified 90 day process: engagement pathway timescale 4,9, 17 Mar 4 Mar – 1 April 1 Apr - 15 Apr 15 Apr -13 May 13 May - 27 May 27 May - 24 Jun 24 Jun - 8Jul 16 July (tbc) Programme Board Wider engagement wider engagement wider engagement wider engagement Briefing Meeting with all stakeholders report report report Expert Group Expert Group Expert Group Outcome Report to NWRG Final Meeting with all stakeholders Scan Focus Summarise Project Teams Stake- holder Group Stake- holder Group Stake- holder Group report report report Wider engagement wider engagement wider engagement wider engagement

A True Measure of a Successful Quality Project 18

Case Studies: Examples from Wales and Wider afield ITU in UHW (Mike Spencer, Catherine Wood and Paul Davies) Evaluating the financial impact upon a Critical Care unit of reducing the rate of Healthcare Associated Infections (Chris Hancock and Mike Davidge) Learning Session 3: The Business Case for Quality

Lessons from the Case Studies Learning Session 3: The Business Case for Quality

Learning Session 3: The Business Case for Quality Summary: The "facts and fiction" relating to the Business Case for Quality Changes are needed in: Routine financing systems How performance is measured to include quality measures Expert support and information on how to make successful improvement, which ordinary single services or facilities cannot afford to develop Learning Session 3: The Business Case for Quality

Learning Session 3: The Business Case for Quality Next Steps Can we develop a robust business case for quality in Wales? What are the next steps to write this? Learning Session 3: The Business Case for Quality