Moving to the Next Stage: Quality and Efficiency Improvement

1
Moving to the Next StageQuality and Efficiency
Improvement

• Jerome H. Grossman, MD
• Director
• Health Care Delivery Policy Program
• Harvard University JFK School of Government
• Presentation to Mayo Clinic
• January 22, 2004

2
Scanning the Environment - Costs

• Increasing at steep rate
• Increased uninsured increased middle class
  concern
• Employers pass increasing cost to employees
• Employers pass increase onto retirees not new
  employees
• Government passes increase onto retirees and
  states (Medicaid)
• Medicare Bill includes medical savings account
• The beginning of health 401(k)
• Employers/govt. decreasing responsibility for
  health insurance

3
Quality

• Quality focus dominates media and legislation
• However progress stays in neutral
• Scattered successes balanced by new revelations
  of error
• Strategy shifting from projects to systems
  thinking
• Lack of transparency and safety oversight
  becoming larger issue
• Finance has SEC
• Civil Air Transport has FAA
• Health has JCAHO malpractice (mainly
  self-regulation)

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Implications

• Transition coming
• From professional determined public good (civil
  right)
• To market-based service industry
• Tightly integrated orgs. like Mayo have first
  mover advantage
• Have been working together on quality,
  information systems and service since inception
  (most intensely in the past decade)
• High level Brand remains quality measure
• but . . . There is a new challenge coming!

5
Productivity

• Why is medicine a special case?
• Up to now, many actors, little data, many
  outcomes
• Advances in medical information and economic
  methods (for service industry) make research
  possible
• KEY RESULT
• Integrates Costs and Quality

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For Example

• Clinical Condition
• Input
• Arthritis of Hip
• with surgery
• without surgery
• mild
• moderate
• severe

• Quality
• Output
• Technical
• Functional
• Trust
• Service

Medical
Surgical
Rehab
All Resources () Used
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Research Projects at Harvard

• Studying the History of Treatment Innovation
• Acute medical - AMI
• Chronic medical
• Diabetes
• Pediatric asthma
• Congestive heart failure
• Surgical minimally invasive surgery
• Preventive colon cancer screening

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An Engineering Agenda to Help Realize the IOM
Vision

• Two Major Interconnected Opportunity Sets for
  Engineering and Medicine
• Information and information/communication
  technologies and associated research to advance
  connectivity, information flow, coordination.
• System design, analysis and control tools
  associated research to advance understanding of
  processes and system interactions and
  improve/optimize dimensions of system performance
  in face of constraints.

9
Information and Information/Communication
Technologies

• Information and information/communication
  technologies and associated research to advance
• Connectivity
• Information flow
• Coordination

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For Example
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Data Monitoring
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Wireless Endoscopy
13
Biomonitoring Techniques
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Systems Design and Implementation

• System design, analysis and control tools and
  associated research to
• Advance understanding of processes and system
  interactions
• Improve/optimize dimensions of system
  performance in face of constraints

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Health Care System Quality
Protocols Procedures Best Practices Safety Service Timely
Credentialing EMR Staffing Facilities Volume Integrated Practice CPOE Educational Environment Teamwork Innovation Patient-Centered Systems Engineering
Process

• Patient Outcomes
• Mortality
• Morbidity
• Functional Status
• Quality of Life
• Cost of Care
• Satisfaction

• Patient Inputs
• Severity
• Comorbidities
• Age/Sex
• Socioeconomic Status
• Compliance
• Genetics
• Expectations
• Attitude

Infrastructure
Source Jim Naessens, Thesis Work
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Integration of Multiple Subsystems
PCP
Triage
Lab
Surgery
Admitting
ICU
ED
Nursing
Library
Patient Ed.
Post-OP
Specialist
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For Example
?FROM Computerized Physician Order Entry
----Process Distribution ?TO Computer Aided
Design (CAD) ----Computer Aided Manufacture (CAM)
DESIGN AUTOMATED PROCESS MANAGEMENT Orders W
hat First? What Next?
What to Do When
When to Interfere Due to Delay
(Historical Data) Design
Send Message to Delay Factor
Evidence Based Medicine
Caretaker Alters Process
Reset Process
Personal Habits
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Solving the Simultaneous Equations
Government Consumers Employers
Consumer Aggregators Insurers/Risk Disease
Management Delivery Aggregators
Regulation Safety (FED, FAA) Transparency (SEC)

• Productivity
• Better
• Cheaper
• Faster

Practices Hospitals Drugs Integrated Systems