1. Bipartisan Congressional Health Policy Conference January 13, 2006 Miami, FL Maureen Bisognano Executive Vice President & COO Institute for Healthcare Improvement

2. IHIs Assumptions Better care does not always mean higher cost care. Providers will face steadily increasing pressure to take cost (i.e., reduce waste) out of the system while maintaining or increasing the quality of care. This is evidenced by the following: –Health care inflation costs continue to outstrip increases in GDP; –The increasing availability, reliability, and use of information on provider quality; –The current trend whereby payors reward providers who offer both low cost and high quality care by directing patient volume to these providers (e.g., tiered networks) and by offering financial incentives (e.g., CMS/Premier Pay-for-Performance initiative; multiple initiatives by Massachusetts payors); and –The appearance of disruptive entrants (e.g., Minute Clinic) offering care that meets specific patient needs at radically lower cost than traditional providers. To achieve the goal of better care for all, it is imperative that delivery costs fall, which in turn reduces costs to patients (while providers preserve an acceptable margin).

3. Approach to Waste Reduction According to Noriaki Kano (a Japanese thinker on process-design and quality improvement), improving the quality of a product or service can be considered using three categories. Each represents a different type of quality improvement lever: –Lever 1: Eliminate the quality problems that arise because the customers expectations are not met. –Lever 2: Reduce cost significantly while maintaining or improving quality. –Lever 3: Expand customers expectations by providing products and services perceived as unusually high in value.

4. Kano 1Kano 2Kano 3 Clinical Quality Problems Verify the surgical site with the patient to prevent wrong- site surgery Open only those instruments that are used during the procedure Use robotic or minimally invasive surgery Supply ChainRelocate the staff pharmacist to the unit floor to ensure proper medication dosing Implement a distribution system to ensure that pharmaceuticals nearing their expiration date are used first Implement bar coding technology on pharmaceuticals to track their use Mismatched Services Have patients self- administer pain medication to ensure proper pain control Ensure patient admission to the proper care area (palliative care vs. ICU care) Create a new wing for palliative care services Exploring the Differences between Improvement Projects Focused on Kano 1, Kano 2, and Kano 3 Approaches

5. Primary DriversSecondary DriversProjects Dark Green Dollars Reducing Operating Budget by 1-3% a year Clinical Quality Problems Staffing Flow Supply Chain Mismatched Services Mass Purchasing Pharmaceuticals Wasted Materials Standardize purchasing Base utilization on best practices Purchase wholesale instead of retail Switch from brand-name to generic Prescribe based on industry norm Turnover/Recruitment Premium Pay Work Days Lost Due to Injury/Illness Achieve optimum performance levels Use a flexible staffing model Reduce agency usage Implement an acuity identification system Use appropriate patient lifting techniques Malpractice claims Coordination of Care Adverse Events and Complications Reduce settlements by changing process when sentinel event occurs Prevent infections (SSI, CLI, VAP) Prevent Decubitus Ulcers Prevent readmissions Waste in Admin Services End-of-Life Care Unnecessary Procedures/ Hospitalizations Stop denial rework Stop services not adding value (ex. unnecessary landscaping) Improve chronic disease management Stop performing outpatient services as inpatient services Match Capacity:Demand Hospital Throughput Ancillary Throughput Redesign care management Redesign ER processes Redesign OR processes

6. Kano Aim #2 Aim: Reduce Operating expense budget by 1% per year, year after year Start with the dark green dollars and design portfolio - Kano Aims #1 & #3 Aim: Raise the bar on… Clinical Care - Service & Systems - Work Environment - Business Case Management Systems Reinvestment strategy Clinical Care Service & Systems Great Work Environment IT / HRBottom Line A Balanced Strategy of Initiatives

7. An Assertion Society needs and would value a health system that is optimized on three dimensions: health of a defined population; experience of an individual over time especially during an episode of care; and per capita costs. Unfortunately, as structured today, most health care entities such as hospitals, physician practices, and long term care facilities operate under business models that exclude at least one of the three dimensions.

8. New Challenges: The Triple Aim Health Cost per capita Experience of care 1. The health of a defined population; 2. The experience of care by the people in that population; and 3. The cost per capita of providing care for this population.