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: 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: That all SC hospitals
and providers deliver safe, high
quality healthcare in a caring
and compassionate manner to
each patient, every time
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
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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:
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
Healthy People 2020
Improvement Goals
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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%
HHS Quality Strategy
• 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
National Priorities Partnership:
Overarching Objectives
• 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.
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.
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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
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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
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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
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access and coordination of care
quality and patient safety
health disparities
mental and behavioral health
breastfeeding awareness/promotion
data management/support
Transform
Perinatal
Care
Patient and
physician
preferences
Aims:
•Eliminate
preventable
harm to mom
and baby
•Promote
evidencebased care
across
perinatal
continuum
Physician
autonomy
vs. EBC
compliance
Eliminate early elective inductions
Minimize repeat c-sections before 39 weeks
and promote VBAC where feasible
Induction and augmentation bundles
Patient
education/
engagement
Leadership
and
teamwork
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)
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26.96
25
20
15
23.58
19.3
13.5
10
7.1
5
0
YTD RATE
4.27
3.68
• 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:
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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 (1874-1965)