1. 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

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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

14. 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.

16. Catheter Infections

17. 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

18. A True Measure of a Successful Quality Project18

19. 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

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

21. 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

22. 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