achieving the triple aim in rural south carolina 2013 SC Rural Health Conference October 16, 2013

“It is not enough to do your best, you must know what to do (and why) and then do your best” - W. Edwards Deming

Quality improvement pearls cultural transformation and behavior modification are central to sustainable quality improvement you need to know your starting point to know where you need to go (reliable baseline metrics) make the right thing to do clear and then make it easy to do for everyone engage physicians at the blunt end of care before trying to change what they do at the sharp end put a face and voice on the data (power of the story)

Quality improvement pearls take local ownership of evidence-based standards team-based care only works well if all team members have an active voice clinicians are more likely to change practice behavior if they receive active feedback on performance your performance over time on key metrics should be your primary improvement benchmark patient-centered care has to be more than a catch phrase- not just “what’s the matter” but also “what matters to you”

HHS Quality Strategy Better care: Better care: increase the overall quality, by making care more patient-centered, reliable, accessible and safe. Making care safer by reducing harm Ensuring that each person and family are engaged as active care partners Promoting effective communication and coordination of care

Vision: Vision: That all SC hospitals and providers deliver safe, high quality healthcare in a caring and compassionate manner to each patient, every time Mission: Mission: To establish a culture of continuous improvement in the quality, efficacy and safety of patient care across all healthcare organizations and providers statewide

CMS Hospital Engagement Network Inpatient Harm Events List adverse drug events (ADE) catheter associated urinary tract infection (CAUTI) central line associated blood stream infections (CLABSI) injuries from falls OB adverse events pressure ulcers surgical site infections venous thromboembolism (VTE) ventilator associated pneumonia (VAP) preventable readmissions (care transitions)

HHS Quality Strategy Healthy populations/healthy communities: Healthy populations/healthy communities: improving population health by supporting proven interventions for behavioral, social and environmental determinants of health Promoting the most effective prevention strategies for the leading causes of mortality Working w/ communities to promote wide use of best practices to enable healthy living

Increase quality and years of healthy life Eliminate health disparities Obesity- reduce by 10% Tobacco use- reduce # of smokers from 21% to 12% Heart attack/stroke deaths- reduce by 20% Cancer deaths- reduce by 10% Diabetes related deaths- reduce by 10% Healthy People 2020 Improvement Goals

HHS Quality Strategy Affordable care: Affordable care: Reduce the cost of quality healthcare for individuals, families, employers and government Making quality care more affordable by developing and spreading new health care delivery models

Health Reform Act: Improving Quality of Care Shift payment incentives to reward quality, not volume (Value-based purchasing) Focus on bundling of clinical services and the payment for those services Provide for demonstration projects around care coordination and system integration Create incentives for providers to improve quality by using safer, more cost-effective technologies like electronic medical records Increase comparative effectiveness research

Improve the safety and reliability of America’s health care system. Engage patients and families in managing health and making decisions about care. Ensure patients receive well-coordinated care across all providers, settings, and levels of care. Guarantee appropriate and compassionate care for patients with life-limiting illnesses. Improve the health of the population. Eliminate waste while ensuring the delivery of appropriate care. National Priorities Partnership: Overarching Objectives

The Bottom Line Rapidly growing “consumer” demand for:  consistent delivery of highly reliable, value- based patient-centered care  effective coordination of patient management across the care continuum (care transition)  transparency in both pricing and clinical performance/patient outcomes  expanded health system focus on improving health at the population level

Improving population health in SC

SC Health Coordinating Council Charter Vision: Lead the nation in the continuous improvement of health and health care for all people of South Carolina. Mission: Achieve the highest rates of improvement nationally in the Triple Aim of better population health, enhanced experience of care and lower per capita costs through the establishment of an accountable collaborative of South Carolina public and private stakeholder organizations committed to aligning statewide goals with their own organizational goals and objectives. Purpose: Communicate: Develop leadership capacity, promote honest dialogue, and facilitate collaboration in the implementation and coordination of Triple Aim statewide initiatives. Prioritize: Contribute to active surveillance and prioritization of improvements by identifying, assessing, and spreading both local and state-level activities positively impacting the Triple Aim. Act/Impact: Provide for the effective and efficient use of existing and newly organized resources and services for the implementation of prioritized activities. Evaluate: Engage continuous assessment and transparent reporting of progress towards established goals.

key strategic aims for a healthier SC 1.Establish highly-reliable health systems that continuously provide evidence-based, patient-centered care in a safe and efficient environment. 2.Effectively improve the health status and outcomes of our state’s population while reducing the major areas of health disparity. 3.Ensure access for every patient to well coordinated care across all care settings and all stages of life, including compassionate care at the end of life. 4.Develop and implement reimbursement models and performance incentives that effectively align with and actively promote innovations and specific improvement efforts under the other strategic aims.

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High Reliability Organizations: Collective Mindfulness A mental orientation that enables continuous learning and continuous evaluation of the environment for the expected and unexpected. Leaders at all levels constantly think in terms of how the organization can become better and avoid error. Anticipation for events that may produce harm combined with containment once an unexpected event has occurred to prevent or minimize harm.

High Reliability– Five Key Concepts Sensitivity to Operations (situational awareness) – Focus on systems and processes and how they affect patient care. Reluctance to Simplify – Systems are made simple, but the explanation for failure is rigorously pursued and understood. (take nothing for granted) Preoccupation with Failure – Relentless pursuit of perfection and a constant search for what might go wrong. (focus on timely notification and evaluation of near misses) Deference to Expertise – Information is freely shared and staff are engaged at all levels. – In a crisis, the person with the most expertise leads. Resilience – The organization quickly contains and mitigates errors.

High Reliability Organizations: Four Leadership Elements (1) Executive Leadership Support – A culture of safety is pervasive throughout organization. – Transparency is the key to changing culture. – Safety must be the overarching strategy that drives efficiency and effectiveness, rather than the opposite. – Leaders take ownership for setting the climate and focusing the work. “

High Reliability Organizations: Four Leadership Elements (2) Alignment with Business Case – Align the business case for quality/safety with financial performance. (CFO on board) (3) Linking Staff Behavior with Desired Outcomes – Introduce changes only when fully linked with policies and aligned with incentives. – Ensure there are clearly defined owners for system implementations. – Link quality and safety to operations.

High Reliability Organizations: Four Leadership Elements (4) Just Culture – The reporting of errors, near misses, mistakes, waste, etc. is relentlessly pursued by the organization. – The person reporting does so without fear of reprisal or personal risk. – Reporting becomes the responsibility of all individuals in the organization. – The errors and events are used to improve performance. – Personal accountability for behaviors remains.

High Reliability Slide Used with Permission of HPI

Keys Steps on the Climb to High Reliability Board establishes patient safety as the system’s core value and zero harm as a primary system goal Senior leaders embrace and actively promote a just and safe organizational climate and culture Mid-level and frontline leaders are formally trained to be high reliability experts Front line staff and patients/families feel safe to speak up, including near miss notification 27

Keys Steps on the Climb to High Reliability An objective system for reporting and evaluating near miss and harm events is in place and actively utilized at all levels of the organization Common platform for robust process improvement is instituted and fully supported (training and funding) Patients and families are actively engaged at the strategic, operational and clinical levels Highly reliable performance is recognized, celebrated and rewarded throughout the organization 28

SC Birth Outcomes Initiative a public/private partnership focused on improving the health and healthcare for all moms and babies in our state all 43 birthing hospital CEOs signed a formal commitment to the BOI led by a core vision team w/ senior representatives from key stakeholders workgroups for each major improvement aim unified data team supporting each workgroup and aim/performance goal

SC BOI- Specific Workgroups access and coordination of care quality and patient safety health disparities mental and behavioral health breastfeeding awareness/promotion data management/support

Transform Perinatal Care Aims: Eliminate preventable harm to mom and baby Promote evidence- based care across perinatal continuum Patient and physician preferences Physician autonomy vs. EBC compliance Patient education/ engagement Leadership and teamwork Eliminate early elective inductions Minimize repeat c-sections before 39 weeks and promote VBAC where feasible Induction and augmentation bundles Hard stop for elective delivery scheduling Operative vaginal delivery protocol Comparative performance data trended by provider and over time Neonatal evaluation and transfer protocols for high risk newborns Promotion and active support of breastfeeding Proper sleep position and location for infants Key immunization and infection prevention measures Create a just and safe culture for all Actively promote team-based care coordination and communication Safety rounds and huddles

SOUTH CAROLINA AFFINITY GROUP EARLY ELECTIVE DELIVERY YTD RATE (PFP-OB-1)

Vision: Improving the health of South Carolinians through telemedicine Mission: Facilitate healthcare access across SC through the utilization of innovative technology that allows remote provision of qualified medical and other clinical services from various disciplines Purpose: To expand existing telemedicine and telehealth applications and develop new applications that work to improve health care access and coordination for all South Carolinians

Priorities Build a sustainable statewide telehealth network Work with rural communities/providers to ensure they have access to quality health care Serve as a clearinghouse for telehealth and telemedicine information/resources Assist providers in accessing and navigating the telemedicine system Advocate for reimbursement of telemedicine consultative services by all payors

SC Healthy Outcomes Plan 46 community-based rapid cycle improvement pilots focused on:  building sustainable community health improvement networks through  active partnerships between hospitals, primary care providers and other key community resources to  more effectively manage healthcare access, delivery and coordination for and health status of uninsured high risk/high utilizer patients using  a total population health framework to address both clinical and social determinants of health outcomes

Other Major Triple Aim Efforts in SC Health promotion and chronic disease prevention: SC Obesity Council Healthy SC Initiative (CDC grant program) Working Well Innovative delivery and reimbursement programs: Patient-Centered Medical Home pilots(BCBS &DHHS) Pregnancy Centering group prenatal care pilots ACO projects in Greenville and Columbia regions Community Health Worker initiative through DHHS Care coordination and advance care planning: PART Care Transition Program SC Coalition for Care of the Seriously Ill (CSI)

Which Road Will We Take “ To every person there comes in life that special moment when one is tapped on the shoulder and offered the chance to do a very special thing. What a tragedy if that moment finds you unprepared or unqualified for the work which would be your finest hour." Sir Winston Churchill ( )