Healthcare Reform-- Improving
Patient Care and Strategic Alliance
Activities
Why frontline staff and unions are critical for improving
patient care and transforming our healthcare delivery
systems
Peter Lazes, Healthcare Transformation Project
Cornell University
Quality Summit 2012
Nurse Alliance of SEIU PA
Harrisburg, PA
September 26, 2012
1
“ Leading organizations can not be
left solely to management”
John August
Executive Director
Coalition of Unions
Kaiser Permanente
2
How Bad Is Our Problem?
• Healthcare Issues
- U.S. citizens pays 53% more for healthcare
- Over 50 million American’s without health
insurance
- Bottom quartile in terms of quality of care
- 1.5% quality improvement over a 7 year period
• Union Density Crisis
- 1950’s 35%
- 1980’s 20%
- 2012 > 11%
3
Mirror, Mirror: Ranking of Six Nations
AUSTRALIA
OVERALL RANKING
(2007)
CANADA
GERMANY
NEW
ZEALAND
UNITED
KINGDOM
UNITED
STATES
Country Rankings
3.5
5
2
3.5
1
6
4
6
2.5
2.5
1
5
Right Care
5
6
3
4
2
1
Safe Care
4
5
1
3
2
6
Coordinated Care
3
6
4
2
1
5
Patient-Centered
Care
3
6
2
1
4
5
Access
3
5
1
2
4
6
Efficiency
4
5
3
2
1
6
Equity
2
5
4
3
1
6
Long, Healthy, and
Productive Lives
1
3
2
4.5
4.5
6
$2,876*
$3,165
$3,005*
$2,083
$2,546
$6,102
Quality Care
Health Expenditures per
Capita, 2004
1-2.66
2.674.33
4.336.0
Source: K. Davis, C. Schoen, S. C.
Schoenbaum, M. M. Doty, A. L.
Holmgren, J. L. Kriss, and K. K.
Shea, “Mirror, Mirror on the Wall:
An International Update on the
Comparative Performance of
American Health Care,” The
Commonwealth Fund, May 2007
* 2003 data
Health care reform
 Coverage for most
Americans
 Reduce percent of GDP
spending on health care
– billions of dollars!
 Deep challenges and
rich opportunities for
us
5
Major Provisions of the PPACA
•Insurance Coverage
Expansions
•Patient Protection &
Insurance
Market Reform
•Revenue Measures & Deficit
Reduction
•Spur System Delivery Changes
6
New Quality Improvement Incentives
and Penalties from CMS
- Value-Based Purchasing
- Hospital Acquired Infections
- Avoidable Re-Admissions
7
What Is Value-Based Purchasing
(VBP)?
• A Centers for Medicare and Medicaid Services (CMS)
initiative established by the Affordable Care Act
• Financially rewards hospitals for the quality of care they
provide Medicare patients rather than the quantity of
procedures
• Measures will include both clinical processes and patient
satisfaction
• Encourages hospitals to prioritize overall patient wellness as
opposed to episodic treatment
8
How Does It Work?
• CMS will create a pool of funds from which incentive payments will be
made to hospitals that perform well in a designated performance period
• Medicare will deduct1% from DRG funds in FY2013. Percentages
will increase by .25% until the maximum 2% is reached in FY2017
• Hospitals will be scored against their own baseline data and each other
on a series of measures to determine who will receive payment increases
• Information regarding the following will be made available to the public:
• The hospital’s performance on each measure that applies
• The hospital’s performance with respect to each condition or
procedure
• The hospital’s total performance score
9
What Will Be Measured?
• FY2013 will measure two domains
• Clinical Process of Care -- 70%
• Patient Experience of Care 30%
10
Clinical Process Measures
Clinical Process of Care Measures
Acute Myocardial Infarction (AMI)
Heart Failure (HF)
Pneumonia (PN)
Healthcare-associated Infections (SCIP = Surgical Care
Improvement Project)
11
Surgeries
HCAHP* Domains for Patient
Experience Measures
• Nurse communication
• Doctor communication
• Cleanliness and quietness
• Responsiveness of hospital staff
• Pain management
• Communication about medications
• Discharge information
• Overall rating
(* Hospital Consumer Assessment of Healthcare Providers and Systems Survey)
12
How Will VBP Impact Hospitals?
• CMS estimates that roughly half of participating
hospitals will receive net pay increases in FY2013
• No hospital should receive more than a 1%
decrease in net pay
13
Readmissions Penalties
• If a hospital’s risk-adjusted readmission rate exceeds the CMScalculated average risk-adjusted 30 day hospital readmission rate for
the following conditions it will be penalized:
• Myocardial infarction
• Pneumonia
• Heart failure
• Penalties apply the following year for all Medicare admissions in
proportion to the hospital’s rate of excess readmissions
• Maximum penalty for 2013 is 1% of a hospital’s Medicare payments
• Maximum penalty will ultimately be 3% of payments in 2015
• ¾ of hospitals at risk to lose money
14
Hospital Acquired Conditions
• Hospitals in the worst quartile of risk-adjusted HAC rates will lose
1% of their Medicare acute inpatient payments.
• Penalties will begin in FY 2015 most likely based on FY 2013 cases.
• HAC refer to the following conditions:
• Foreign object retained, air embolism, blood incompatibility,
stage III and IV pressure ulcers, falls/trauma, poor glycemic
control, catheter-associated UTI, surgical site infections, deep
vein thrombosis, pulmonary embolism
15
Components of an Integrated Care
Delivery System
Coordinated Care:
Health Coach, Nurse Navigator:
Patient centered care
involving collaboration
among primary care
physician, nurses, patient,
family and community
Staff use of electronic portals and tracking tools
to monitor progress of patients, especially those
with chronic conditions
Information Technology:
Electronic Medical
Records/History, E-Prescriptions,
Interactive Patient Web Portal
Integrated
Care
Tracking Outcome
Tools:
Use data to identify issues
of critical care
Feedback to Physicians
and Healthcare Team
Measure clinical or service
performance by
physician/practice
Reimbursement Reform:
Restructuring of the current system used to compensate
physicians based on “fee for service” to one that is
bundled/pre-paid, and quality outcome linked
16
Fragmented vs. Integrated Care
Delivery Systems
Fragmented Care
• No care coordination
among physician, staff,
family and community
• System reacts to needs
• Fee for service
reimbursement
• Limited tools/processes for
preventive care or patient
progress
Integrated Care
• Patient centered
coordinated care involving
all parties in patients
healthcare
• Needs are anticipated
• Bundled/Pre-paid
reimbursements
• Electronic/staff tools to track
patient progress and
monitor chronic conditions
Integrated Care Reduces Costs
Effect of Advanced Practice Nurse Care on
Congestive Heart Failure Patients’ Average Per
Capita Expenditures
Dollars
• Importance of improving
transitions in care, doctor to
doctor, and post-hospital
• Follow-up care following hospital
$9,618
discharge could reduce re$6,152
hospitalization
• High cost care management could
reduce errors and lower costs
• Will require restructuring Medicare
benefits and incentives
Source: M.D. Naylor, Making the Bridge from Hospital to Home, The Commonwealth Fund, Fall 2003.
Current Challenges of Our
Healthcare System
• Greater Access to Care and Payment
• Better Quality and Patient Safety
• Affordable Costs
• An Integrated Delivery System
19
Choices of Work Systems
• Taylorism
• High Performance
Work Systems
- Keep jobs simple
- Low skill Jobs
- Complete management
control of every step of
the process
- Teamwork
- Consultation and worker
access to information
- Worker autonomy over
day to day activities
- Worker involvement in
terms of changes
including the use of new
technology
20
Additional Evidence:
Ever worker is a change agent
Work as a learning activity is:
Amy C. Edmondson
Harvard Business School
“a radically different organizational
mindset… [where people] give tough
feedback and have difficult
conversations—which demand trust
and respect—without the need to
tiptoe around the truth.”
21
Important Outcomes from Front-Line Staff
Engagement and Decisions Making
• Creating new knowledge is needed to develop
breakthroughs to help redesign our work—getting rid
of “work arounds”
• Members have a voice and role in greater decisionmaking and they like this….
• Members find ways to sustain NEEDED changes
because they are part of creating the solution…they
know what the problems are.
• Changes result in significant improvement in clinical
and patient satisfaction outcomes
22
Unions need to initiate and take the lead to
improve the quality of care of patients and find
ways to cut costs. Unions can’t allow
themselves to be bystanders but instead must
be champions for these changes.”
“
John August
Executive Director
Coalition of Unions at Kaiser Permanente
23
Why aren’t more front-line staff
included in helping to improve
patient care and control costs?
Can we continue to risk leaving our
jobs in the hands of management?
24
Important Areas of Work for FrontLine Staff
• Unit-based quality improvement
• Strategic patient safety and/or quality of
care
• Patient satisfaction
• Creating integrated delivery systems
25
Current Problems
• Working on the wrong problem
• Not using the appropriate process
• Lacking a method to sustain results
• Lack a high involvement frontline staff and
union involvement
• Management resistance or lack of skills
• Unions reluctance and lack of skills
26
Current Approaches to Improve the Quality of
Care and Care Management
Solution Shops
- Transforming Care at the Bedside (IHI)
- Six Sigma
Value Added
- Toyota Production System—Lean Manufacturing
- Appreciative Inquiry
Networking, Innovation, and Disruptive Innovation to Achieve Systematic
Changes
- strategic work design and new work systems as a result of front-line staff
and union involvement, and networking with others.. creating “new
knowledge”
(a significant different mindset and skill set)
27
Two Approaches for Achieving an IDS
Optimizing to be Efficient
We know what is needed
• You exploit what you know
• You meet current customer
needs
• You plan
• You demand accountability
• You impose process and
structure
Innovation/Adaptation to Create Anew
Create new processes/systems
•You explore what you don’t
know
•You anticipate future patient
needs
© 2010 Cornell University
•You create opportunities for
discoveries to occur
•You encourage the discipline
of innovation
Critical Areas of Work that are Emerging in
Healthcare Delivery System Reform
Critical Approaches that are making a
difference in Healthcare Institutions
• Unit-based work
• Hospital-wide interventions
• Delivery System Integration
29
Complexity and Innovation
2010
© Steven J. Spear 2010
1964
Nissan LEAF
Balancing Interventions
Innovation/Adaptation
Optimizing
• Lean
• 6 Sigma
• Toyota Production Systems
© 2010 Cornell University
• Multi-stakeholder engagement
• Large group breakthrough
process
• Patient experience value- chain
drives process
• Front-line staff/management
involvement
• Fast cycle/multi-iterations
• Honoring errors
We’ve always done it this way…..
33
Getting to the “Right Process”
“I’m astounded by people who want to
know the universe, when it’s hard
enough to find your way around
Chinatown”
Woody Allen
Approaches to Solve Issues
Areas of Work
Approaches
* Top down:
•Incremental
> unit-based
•Systemic
> hospital- wide
> integrated
delivery systems
Management
driven
* Consultant driven
* Unions as
bystanders
* Unions leading change
• Union and
Management leading
changes
35
Fletcher Allen Health Care
36
o
1115 Waiver - Implications for CCHHS
employees
CCHHS Multi-Union Training
5-7pm, September 11, 2012
ACA Opportunities
Source: Cook County Health & Hospitals System FY2013 Preliminary Operating Budget, CCHHS Finance
Committee, Friday August 24, 2012
The CCHHS Labor Management Council
“Unionized front-line doctors, nurses and ancillary staff
must come to be seen, treated, and act as part of the
solution rather than as part of the problem.”
Source: SEIU “Cut to the Bone” November 29, 2010
• History
• Goals
• Progress
CCHHS Labor-Management Process
Labor-Management
Council (LMC)
Union Staff
Patient-Centered
Medical Homes
Cornell
Consultants
Improving the
Patient Experience
Wellness
Program
40
Improvement Tools
• Process mapping
• Problem solving
• Cause and effect analysis
• Microsystems
41
Design Tools
• System intervention not project based
• Core functions/Core Practices
• Accelerated engagement of the whole
system
• Working on breakthroughs with an
iterative process
42
Cornell’s Labor-Management Change Process
4-Work System Design
 Strategic targets
6-Data collection for review
and adjust
 Plan of work
1-Leadership
2-Strategy
MOBILIZE
7-Review
and
adjust
ACT
ADAPT
8-Re-configurability
3-Quality Lab
5-Launch teams
 Training
 Standardize processes
 Network/innovation
Patient care outcomes:
• Decrease Patient Fall by 50% for cardiac and
med/surgical patients
• Reduce Call Bell response by 50% to < 1 min.
• Alarm and Monitors responded to in < 1 min.
• Reduction in medication errors by 50% on all
medicine floors
• Unions involved in floor layouts, move to a new
building, and purchasing of new equipment
44
Union Building Outcomes
Recent Outcomes
- PAC contributions increased 32% (from 58% to 89%)
- Active delegates increased by 426 % (from 23 to 98)
- Reductions in inappropriate grievances and arbitrations by
63% (from 103 to 38)
- Internal organizing – physician assistants, tech repres.
- Significant access to budgets and quality/performance
indicators
- Over 100 Joint Hiring Committees have been conducted
45
We need to bargain and operate outside
the NLRA box and Re-Engineer our union
Quality standards
Overtime
Budgets
Marketing
Seniority
Wages
Differentials
Service
Grievances
Business strategy
46
A train wreck about to occur.
47
Three Important Strategies
• Work with allies– friendly manager…make them
winners
• Do research on where the system is vulnerable:
(e.g. Value-Based Purchasing, Patient
Satisfaction scores)
• Leverage grievances and arbitrations to get
management’s attention
48
Best Strategic Alliance Practices
1) Active Union and Management Leadership
2) A clear governance structure with clear collective
bargaining agreement
3) Part-time or full union staff to oversee and
support joint work
4) Getting results in a timely manner
5) Strong engagement and education of members
49
Best Practices Continued
6) Acknowledging that there will be issues
where labor and management will not agree
7) An effective monitoring and tracking process
8) Redesign labor relations practices
9) Re-engineer and retool unions
10) Continue to conduct research and learn from
others
50
Other Significant Findings
• Significant Upfront Costs
• 25 to 30 % Cost Reductions when fully
implemented
• Rand Study- Congestive Heart Failure patients
have 35% fewer hospital days, Asthma and
Diabetes Patients were more likely to receive
appropriate therapy
52
“No doubt that a small group of
thoughtful citizens can change the world.
Indeed, it’s the only thing that ever has.”
Margaret Mead
53
A tradition of Militancy
Workers created
the middle class
by fighting.
Nothing came
without a fight!
Unions made
sense; union
success linked to
social mission
54
Our Website:
http://www.ilr.cornell.edu/healthcare
55