Leadership for Quality and Safety

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Leadership for Quality and Safety

• David B. Nash, MD, MBAThe Dr. Raymond C. and
  Doris N. Grandon
• Professor of Medicine and
• Chairman, Department of Health Policy
• www.jefferson.edu/dhp

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• all hospitals are accountable to the public
  for their degree of success
• If the initiative is not taken by the medical
  profession, it will be taken by the lay public.
• 1918 Am Coll Surg

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Imperatives of the New Century

• Accountable for the health status of defined
  populations
• Global Budgets/Targets
• Incentives to actively manage clinical care
• Incentives to provide a coordinated continuum of
  care
• Incentives for continuous quality improvement
• The demand for value

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The Seamless Continuum of Care
Community
Patients
Preventionand Wellness
Primary Care
AcuteCare
ChronicCare
RehabilitativeCare
SupportiveCare

• Rehab Units
• Physical Occupational Therapy Centers
• Recovery Centers
• Home Health Centers

• Hospices
• Home Health Agencies

• Hospitals
• Nursing Homes
• Home Health Agencies

• Occupational Health
• Wellness Centers
• Physician Offices

• Physician Groups

• Physician Groups
• Hospitals
• Ambulatory Surgery Centers

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Effective Efficient Safe, etc.
Greater Market Sensitivity
Performance Comparison
(Apologies to Tom Lee and Arnie Milstein)
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Definition of Quality Institute of Medicine
The degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional knowledge.
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FIGURE 5-1 Making change possible.
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Ten CommandmentsCrossing the Quality Chasm

• New Rules
• Care is based on continuous healing relationships
• Care is customized according to patient needs and
  values
• The patient is the source of control
• Knowledge is shared freely
• Decision making is evidence-based

• Current Rules
• Care is based primarily on visits
• Professional autonomy drives variability
• Professionals control care
• Information is a record
• Decision making is based on training and
  experience

Don Berwick 2002
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Ten Commandments (cont.d)

• Current Rules
• Do no harm is an individual responsibility
• Secrecy is necessary
• The system reacts to needs
• Cost reduction is sought
• Preference is given to professional roles over
  the system

• New Rules
• Safety is a system property
• Transparency is necessary
• Needs are anticipated
• Waste is continuously decreased
• Cooperation among clinicians is a priority

Don Berwick 2002
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A need for unified governance
No American Quality Improvement Community
Certify Performance Measures
Implement Performance Measures
NCQA AQA, HQA CAHPS
NQF
JCAHO CMS Plans
Multiple Public and Private Sector
Stakeholders 100 different P4P Programs
PricewaterhouseCoopers
Source Tooker/ACP
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Hospital Accountability for Quality

• External Forces
• Leapfrog
• CMS, the MMA, the OIG
• National programs like Premier
• Employer-based Pay for Performance
• State-based error reporting

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Medical Staff Structure

• Anachronistic referral pattern preservation
• Not agile who is in charge for CPOE?
• Limiting privileges needed, not expanding
• New drugs and biotechnology products

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Needed Physician Leadership

• Home-grown vs. new managerial class
• What is the skill set? (ACPE)
• Cross Cultural agents

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Tools for Physician Leaders

• Treatment standards and protocols
• Leapfrog criteria
• Hospitalist programs
• Technology CPOE, ambulatory EMR
• Practice Profiling
• Safety culture engineering
• External benchmarking

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Governance Support for the Leadership Standards

• Put quality and safety on every agenda
• Ask to see a dashboard of quality and safety
  indicators
• Support investment in system improvements that
  will improve safety even in light of weak
  financial ROI
• Link executive compensation to quality and safety
  improvements

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Governance Structure for Quality and Safety

• Explicitly link a Board level strategic Vision
  Metric to quality and safety
• Ex A 75 reduction in medical errors over three
  years
• Ex A 50 reduction in unexplained clinical
  variation in 3 major DRGs over 2 years

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Effective Efficient Safe, etc.
Greater Market Sensitivity
Performance Comparison
(Apologies to Tom Lee and Arnie Milstein)
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Nashs Immutable Rule
High quality care costs less!
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Autonomy and Accountability

• A Zero Sum Game?

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Its always better to have them in the tent
pissing out, than outside the tent pissing in.
President Lyndon Baines Johnson
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The institutionalization of leadership training
is one of the key attributes of good leadership.
John P. Kotter, Harvard Business School
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Is this physician on your medical staff?
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• David B. Nash, MD, MBA
• Chair, Department of Health Policy
• Thomas Jefferson University
• 1015 Walnut Street, Suite 115
• Philadelphia, PA 19107
• Tel [phone]
• Email david.nash_at_jefferson.edu
• Website www.jefferson.edu/dhp