New York City Health and Hospitals Corporation: Providing Health Care Quality and Value for New York City Residents Anne-Marie J. Audet, MD, MSc, FACP Senior Vice President for Quality New York City Health and Hospitals Corporation April 24 th 2008

HHC’s Role in NYC Healthcare Landscape 1.3 million New Yorkers treated 1 out of 6 New Yorkers; 400,000 uninsured Very diverse patient population; over 100 languages spoken 43% Hispanic, 35% African American, 6% Asian, 9% other minority Socioeconomically diverse and socially complex patients 220,000 discharges; 23,000 deliveries 5 million outpatient visits (more than 2 million primary care) 1 million ED visits; 30 percent of city’s trauma services 41% of city’s mental health inpatient services; 27% of city’s chemical dependency inpatient capacity 1 million skilled nursing facility patient days 11 designated AIDS centers Inpatient and specialty provider for correctional services HHC is one of over 100 urban safety net health systems nationwide providing comprehensive care in their communities.

HHC at a Glance Public Benefit Corporation Governing: 7 regional networks serving 5 boroughs 11 Acute Care Facilities (4,859 beds) 4 Skilled Nursing Facilities (2,835 beds) 6 Diagnostic and Treatment Centers 88 Community Health clinics A certified home health care agency A managed care organization (300,000 enrollees) Affiliations with all major NYC Medical Schools 39,000 employees, 3,000MDs, 8,486 Nurses

Achieving Value through Quality and Safety: Crossing the Quality Chasm Leadership and Governance Culture – Just, Safe, Transparent Incentives Reengineering care processes Knowledge and skills – workforce support and development Robust QA/PI infrastructure Effective use of information technologies Development of effective teams Coordination of care across services, sites of care over time

Clinical Strategic Priorities Ensure care continuum for patients and the community Staying Healthy – prevention Getting better when sick – acute care Living with disabilities and chronic conditions – chronic disease management Coping with end of life Ensure clinical quality (IOM Dimensions) Access - timeliness Effectiveness, Safety Patient-centeredness Cultural competence Efficiency Equity

Transparency

Benchmarking: Collaboration and Competition

Strategies to Improve Safety, Quality and Efficiency Learning organization – Patient Safety Officer Training (CEO), Nurse Leadership Academy, culturally and linguistically appropriate services department Team-based collaboratives – e.g. infections, diabetes, pressure ulcers, chronic disease model Effective use of IT – EMR, CPOE, interoperability (smart card), telehealth, registries Ambulatory care redesign – open access, cycle time, care management teams Breakthrough Initiative – based on Toyota “Lean Thinking” – better allocate resources to patient care needs, bring services closer to patients

Bottom Line: Impact on Patient Outcomes Improved Performance in preventive, acute, chronic, and long term care Acute Care In-hospital Mortality – Consistently lower than national Hospital acquired infections – (see chart on VAP, CLIs) CMS Hospital Care Indicators – HHC outperforms national performance Long Term Care – 50% reduction in pressure ulcers, falls Preventive care (see chart on smoking cessation) Chronic disease (see chart for DM, asthma)

Acute Care

Long Term Care

Preventive Care

Chronic Care Management

Impact on Access to Care Ensuring patients get the care they need, when they need it 50% reduction in “no show” rate Reduction in wait time – 4-5 days Cycle time < 60 minutes Co-location of specialty care

Challenges Achieving and sustaining consistent performance throughout the system Reliability – the right care for the right person at the right time, every time - hardwiring quality and safety Coordination of care across services, sites of care, especially for patients with complex conditions

Policy Implications Support for new Models of care Patient-centered care: tailored to patients with complex set of clinical conditions; multi-disciplinary teams of MD, nurses, community based workers, case managers; models that go beyond the traditional one on one MD patient visit Tools Ensure that safety net health systems have the tools for performance improvement Health Information Technologies – decision support Technical assistance for performance improvement and redesign Incentives Ensure that quality reporting and payment policies capture care services for all patient populations – acute, preventive, chronic care Break the cycle of supply driven healthcare - reward providers for improving public and patient health outcomes.