The Robert Wood Johnson Foundation (RWJF) has awarded ICSI $150,000 to help promote greater integration of health care systems with public health and other community resources for health improvement. As part of the grant, over the next 18 months ICSI will develop multiple papers, two videos and an assessment tool that support health care system/public health integration. ICSI will also create an advisory committee to provide input and direction for this work.
Learn more about ICSI’s work to build sustainable, healthier communities.
James L. Reinertsen Lecture
Leaders or Victims? Choices We Face in the Era of Accountable Care
October 24, 2013, 4:30 – 6 p.m. Reception, 6 – 7:30 p.m. Lecture
Minneapolis Marriott Southwest, Minnetonka, MN
Plan to join us for an extra-special James L. Reinertsen Lecture, delivered by Dr. Reinertsen himself. One of ICSI’s founders, he will help us celebrate our 20th anniversary and inspire us for the work we tackle during ICSI’s third decade. We expect a large crowd so please help us plan by registering. Find out more and register by October 17.
Shared by The Incidental Economist, an eight-minute video by John Green, a New York Times bestselling author who explains why U.S. health care costs are so high. It’s entertaining and understandable!
Janet Corrigan, PhD, MBA, previous President and CEO of the National Quality Forum, recently led a discussion with the ICSI Board of Directors on efforts to build a value-based measurement framework to help achieve the Triple Aim of better health, better care and better costs.
Helps patients spend 18,280 more nights of sleep in their own beds
A broad-based coalition of hospitals and care providers working across the continuum of care has prevented 4,570 avoidable hospital readmissions between Jan. 1, 2011 and Dec. 31, 2012. As a result of the RARE Campaign (Reducing Avoidable Readmissions Effectively), it is estimated that patients spent 18,280 more nights sleeping comfortably in their own beds instead of the hospital. It’s better for patients and their families. The campaign is also estimated to have reduced inpatient costs by more than $40 million.
The RARE Campaign involves 83 hospitals and 93 community partners across Minnesota and is one of the largest coordinated improvement initiatives undertaken by the Minnesota health care community.
The campaign was initiated to address the fact that in Minnesota, nearly one in five Medicare patients is readmitted within 30 days. According to the Health Research and Education Trust, unplanned readmissions cost Medicare $17.5 billion. “Improving care transitions is part of the Minnesota health care community’s effort to mend the fragmented delivery of care and achieve the Triple Aim of improving population health, the experience of care, and the affordability of care,” said Jennifer Lundblad, president and CEO of Stratis Health, one of the campaign’s operating partners.
The campaign has gathered momentum since its launch. In the most recent time period measured, the 4th quarter of 2012, hospitals achieved a roughly 17 percent reduction in avoidable readmissions compared to baseline. These results are attributed to participants in the RARE Campaign honing their work on five key areas that, if not managed well, are known to be main contributors to avoidable hospital readmissions:
- Comprehensive discharge planning
- Medication management
- Patient and family engagement
- Transition care support
- Transition communications
For example, Swift County-Benson Hospital has achieved success through a combination of interventions including a focus on patient education, increased communication with primary care providers and improved patient transfer communication and collaboration with the area nursing home, assisted living and assisted living plus facilities, and home care agencies. Any time the hospital does have a readmission, staff conducts a thorough assessment to determine the reason for readmission and to identify what could have been done differently before the patient was discharged from the hospital.
At Essentia Health-St. Mary’s Medical Center in Duluth the Nurse Care Line program contacts patients with select diagnoses within 24-48 hours of discharge to answer questions, review medications and discuss the importance of attending scheduled follow-up appointments. The hospital is also working with its community partners including home health agencies, nursing homes and the other hospitals to improve communication across the continuum of care.
Energized by the progress to date, the operating partners have extended the campaign through 2013. “We’re excited about our progress, but we know the improvements can spread even further. We’re challenging ourselves to think beyond the hospital system and beyond a focus on disease-specific efforts,” said Lawrence Massa, president and CEO of the Minnesota Hospital Association. “Hospitals are taking specific steps to ensure a culture that is supportive of collaboration and that supports this readmissions work.”
In 2013, the campaign partners will focus on further engaging community partners beyond hospital walls. Preventing avoidable readmissions requires improved patient care coordination between hospitals and community partners such as long-term care facilities, home care organizations and primary care clinics. In that regard, the RARE Campaign is helping to increase communication and improve care transitions across the health care system.
“In health care today, there is increasing emphasis on the value of care patients receive and rewarding providers for delivering high quality care as efficiently as possible,” said Sanne Magnan, president and CEO, Institute for Clinical Systems Improvement. “The value of the RARE Campaign is that, rather than individual medical associations or hospitals tackling readmissions separately, partners from various health care settings are working together. This collaborative approach enables us to accelerate positive change across Minnesota.”
The RARE Campaign is led by three operating partners: the Institute for Clinical Systems Improvement, the Minnesota Hospital Association and Stratis Health. Supporting partners include the Minnesota Medical Association, MN Community Measurement and VHA Upper Midwest.
To learn more about the RARE campaign, visit www.rarereadmissions.org.
I’ve carried an MD degree proudly for over 40 years. Being of service to those in my community in improving their health has been a badge of pride I’ve worn proudly. But for the 26+ years of practice, and my 11+ years at ICSI, I’ve had the sense we could, and must, do better…. especially as the world around us has changed drastically.
By Thomas Kottke, MD, MSPH and Nico Pronk, PhD
The advances in the treatment of cardiovascular disease in the past 50 years are remarkable. Automated external defibrillators (AEDs), the devices you see in airports and other public places, change out-of-hospital cardiac arrest from a death sentence to an event with some chance of survival. Coronary angioplasty (ballooning the blockages in the arteries that feed the heart) during a heart attack reduces deaths by about 50%. Implantable devices that pace and shock the heart when a life-threatening heart beat occurs reduce the risk of death by more than 40%.1
These statistics and the current emphasis on individualized medicine might suggest that, if a community can afford high tech health care, it doesn’t need to invest in parks, bike ways, tobacco-free homes and workplaces, access to affordable fruits and vegetables, and the other health promoting environments.2 But the data demonstrate that the path to health for every community and every individual, rich and poor alike, requires health-promoting physical and social environments.
Let’s do the math for the high-tech treatments of heart disease and two of the fundamental determinants of health–physical activity and healthy food. The best estimate of what will happen to an individual is what will happen to others in their community. It is simple to calculate the community impact of any intervention if just four parameters are known: (1) the extent to which an intervention will reduce “event rates,” (2) the event rate for eligible individuals who participate in the intervention, (3) the number of eligible individuals who have not yet taken part in the intervention, and (4) the number of people in the community who are eligible for the intervention.
For example, using deaths that might be prevented or postponed (DPP) as “the event,” we can calculate the impact of meeting the physical activity guideline for healthy Americans.
For a population of 30-84 year-old Americans:
- The mortality rate of physically active individuals is 30% lower than the mortality rate for inactive individuals;
- The death rate is 1,007/100,000;
- 70% of those able to be active are currently not active;
- In a population of 100,000, the number of apparently healthy individuals is 90,024.
Therefore, the DPP that could be achieved if the entire healthy population were to become physically active is 0.30 x 0.01007 x 0.7 x 90,024, or 190.
In 2009, we published the expected DPPs for nutrition, physical activity, tobacco and several heart disease treatments.1 We calculated the impact of improving performance from current levels to achieving 100% goal attainment. We found that the number of deaths that might be prevented or postponed in a community of 100,000 adults ages 30-84 would be:
- 1.9 if AEDs were placed in all public places and people who worked there were trained in their use;
- 15.1 if all individuals with heart attacks received angioplasty;
- 63 if all individuals who met the criteria received an implantable defibrillator or biventricular pacemaker;
- 158 if everyone met the dietary goal of five servings of fruits and vegetables every day;
- 159 if no one smoked and no one were exposed to second-hand smoke, and
- 334 if everyone met the physical activity goal of 150 minutes per week.
We found that improving care for acute heart disease events could at most prevent or postpone 8% of deaths in the U.S. population ages 30-84. Taking full advantage of the benefits of good nutrition, adequate physical activity, and elimination of tobacco would prevent or postpone 49% of all deaths. If our calculations considered the impact of all community determinants of health on all ages, the predicted impact would be considerably larger.
It is indisputable that access to medical care saves lives, but the math demonstrates that, regardless of the resources that might be committed to health care, there is only one path to significantly healthier communities. That path is mobilizing action to improve the physical and social environments in which we live.
2. Mobilizing Action Toward Community Health (MATCH): Population Health Metrics, Solid Partnerships, and Real Incentives 2012; http://uwphi.pophealth.wisc.edu/. Accessed December 20, 2012.
It’s Not Automatically OK
It’s complicated. Changes are flying at us at an accelerating rate, clashing and clanging against what we thought was certain. Legislative measures that may or may not prevail, changes in how performance is evaluated, changes in reimbursement, changes in the roles of all involved – seemingly the only thing for certain is change. What will be the opposite and equal reaction?
Let’s take stock of the current situation. The anticipated shortfall of primary care physicians if the Affordable Care Act (ACA) remains in force is estimated to balloon to more than 60,000 by 2025. Whether or not the ACA remains in force, the active patient population will continue to grow as baby boomers age. This burgeoning patient population is adding to the strain caused by increasing multimorbidities and chronic conditions. Medicine, like aviation, is going to face greater demands and an increasing need for more experts.
This change in the environment will require changes in behavior. Parts 1 and 2 of this series explored how medicine learned from aviation’s work on changing behavior. It started with the checklist, moved into Cockpit Resource Management, and then evolved into Crew Resource Management. Aviation had made huge strides in recognizing that, in order to optimize resources in the work environment, it was essential for all crew members to be actively involved. With Crew Resource Management’s team approach widely implemented and on its way to being mastered, the fiercely competitive aviation industry (manufacturers and airlines) scanned the environment for a concept to leverage to lower training costs, improve safety and deal with the shrinking pool of already trained pilots from the military. And so they were seduced by the siren song of automation.
While automation has improved costs and safety, commercial aviation is now in the midst of the painful process of recognizing and adjusting to the unintended pitfalls of automation reliance. In a fascinating recording of an American Airlines pilot training session, Children of the Magenta, over-reliance on automation is the key concept. The trainer repeatedly demonstrates how pilots rely on automation even when they can clearly use manual controls. He cautions that “in 68% of accidents, automation dependency plays a critical part in leading crews… to allow their aircraft to get much closer to the [edge of the envelope] than they should have.” In other words, their reliance on automation has caused them to neglect their critical thinking.
Understanding why automation can lead to failure is important. One interesting study of automation’s surprises contained in Handbook of Human Factors & Ergonomics points out that the implicit promise of automation technology is that it increases precision and efficiencies while reducing the potential for human error. However, that promise can come up short because the human-machine interaction cannot replicate the “basic competencies” of human-human interaction. Humans have difficulty remaining actively engaged while monitoring – the place automation puts us. We disengage and lose situational awareness.
Moreover, automated systems tend to “switch off” in complex situations where they may be needed most. The person monitoring may not be sufficiently oriented to the situation to handle it effectively. Even worse, key bits of information can be masked by well meaning efforts to simplify matters for the human monitoring the process. One widely studied accident occurred in part because key information needed by the crew was masked.
Similarly, in medicine, technological advances have created opportunities to reduce the likelihood of error through systems design and processes. As the number and variety of ways to automate performance increases, so does the reliance on those mechanisms. Physician shortages and finite resources coupled with increasing demand create a pressure to do more with less. Automation may again seem to be the silver bullet. Aviation has learned that automation can help but it comes with its own pitfalls. Health care can avoid these potential pitfalls by learning from aviation’s experience.
So how are we in health care being seduced by automation? It’s easy to see how enticing high-tech diagnostic imaging and robotic surgery can be. Here are some more discrete real-life examples:
- Physicians increasingly request decision support to help them with clinical implementation. An example of this is clinical indicators by condition.
- Electronic medical records (EMR) are being designed so that the physician cannot digress from the protocol embedded in the EMR without documenting the reason.
- Workstations are being set up and work flows designed so that the clinician has a limited set of options for actions and activities.
Again, automation in itself is not inherently bad. It is when it is used so widely and extensively that critical thinking falls to the wayside that issues start to arise. Here are some examples of automation’s unintended consequences:
- Electronic dosing schedules that do not include maximum dosages can result in overdosing if there is an over-reliance on the system.
- When processes are developed to reduce error and ensure the clinician “does the right thing,” opportunities for critical thinking are being designed out of the process.
- Over-focus on the processes may cause the obvious to be missed. One patient shared her recent experience with a hospital room not being tended as it should. It escaped the floor nurse’s attention although the nurse’s station was in close proximity to the room because there was no “check room cleanliness” prompt on her computer screen.
Aviation and health care’s shared draw to automation and the potential for negative unintended consequences has not escaped notice of those straddling both industries. One such individual, a clinician from Sydney, pointed this out on a pilot’s forum. He commented, “You know, this is a broader cultural issue. We are seeing the exact same paradox in medicine. Everything is being reduced to autopilot with clinical pathways and guidelines. This approach inevitably de-emphasizes critical thinking, and clinical decision making skills are being lost as a result.”
The impact of a loss of focus on critical decision-making skills now may have a large impact in the future. The commenter continues by pointing out that medicine is like an apprentice system where students and junior physicians model their future practices after what they observe. They are likely to practice what they learn.
He points out that while the benefits of automation may be immediate, the true cost may not be realized for years, and cautions, “This is like aviation. All the airlines have followed this path for years – in part due to regulatory requirements, but also due to significant economic benefits. But people are now starting to question the consequences.”
The risk for error in both health care and aviation increases when the automation is highly complex or inconsistent. Additionally, the visual and tactile cues that can increase situational awareness are often casualties of automation design process. For example, debates have continued to wage for years about the value of a flight yoke versus a side stick because of the related loss of visual and tactile clues provided by the yoke to all the crew in the cockpit. Similarly, there are scores of unintended consequences from each design choice and philosophy. Perhaps one salient lesson is to design these cues in to the process instead of out.
Health care has benefited from incorporating aviation’s quality and safety improvement tactics into our industry, but often only after the long passage of time, many lost lives and wasted resources. We have an opportunity to head off the worst of automation’s unintended consequences by designing automation in a way that fosters critical thinking skills.
We’ve all heard the term “bucket lists.” The idea of creating a wish list of activities or experiences we’d like to accomplish in our life is often raised, both in the cinema, as well as in daily conversations. I must admit that while I’ve considered this, I’ve been far too focused on my work, and maximizing the impact which I might have in creating a desirable change. Starting with my undergraduate days, and progressing through medical school, residency, and practice, there was always an excuse—too busy, no time, there’s always later, someday when the time is right…. It was a never-ending list of rationalizations, and made sense to one who felt that time would always be there later to relax.
Continued from Part 1 – Aviation Beyond Checklists
Part 1 of this blog detailed how integrating knowledge and experience from aviation into medicine was straightforward in the case of checklists. This installment explores why now is the time to move beyond checklists to a more comprehensive approach – Care Resource Mobilization.
Care Resource Mobilization (CRM) is the optimal mobilization of available resources to engage clinicians and patients for better health, better care, and lower health care costs. There are existing resources that we can use, right now, to help that happen. Many of these resources may be unconventional, and many are available at no added cost to the health care system and are currently underutilized.
Discovering and leveraging these underutilized resources is the key to CRM. Overlooked resources can include communities, peers, families, friends. It often requires expanding the focus from just the patient to the circle of influence within which this individual dwells. Folks may be waiting in the wings ready and willing to help. They offer a resource base for everything from moral support to help with rehabilitative exercise.
Harnessing these additional resources is the reasonable and responsible thing to do. This may require changes in both clinician and patient behavior as we increasingly recognize there are areas of expertise on both sides of the exam table. Moving from the familiar paternalistic model may feel uncomfortable to all involved. Yet the complexity of medicine and the prevalence of co-morbidities has created a situation too big for clinicians to handle alone. Following the trail already blazed by aviation, we can leverage CRM in medicine to mobilize all our available resources.
The first installment of this blog explained how checklists have been readily adopted in both aviation and medicine. Adopting CRM will require broader changes in behaviors to develop a highly functioning team. This is made even more complex in medicine because we are dealing with two sets of CRM: intra-care team and care team + patient.
Whether in aviation or medicine, the focus of CRM is less on technical knowledge and skills than “cognitive and interpersonal skills needed to manage resources within an organized system. In this context, cognitive skills are defined as the mental processes used for gaining and maintaining situational awareness, for solving problems and for making decisions. Interpersonal skills are regarded as communications and a range of behavioral activities associated with teamwork.”
As mentioned, integrating CRM into medicine is going to be more challenging than it was in aviation. On the one hand, intra-care teams, like flight crews, have the advantage of common work space, training, jargon and knowledge base.
On the other hand, care team + patient does not have a common lexicon nor a common experience to build upon. They will need to “train” each other to achieve common expectations of their roles in this partnership. As is often the case, the hardest part will be getting started.
Permission and a Path
The ultimate goal of CRM in medicine, like aviation, is to have fully functional partners bringing their expertise to the situation. The realization of that goal in medicine is the Self-Mobilized Patient. A Self-Mobilized Patient feels confident they can be an active partner in making decisions about their health, carrying out those choices, and taking responsibility for their decisions.
Today, however, even if patients and physicians want to begin to work toward this goal, they may be reluctant or uncertain how to honestly and safely share their perspectives and information.
I’ve seen this in action myself. One of my work groups for a palliative care initiative included a cancer survivor and oncologist who had not previously met. When asked about their experience with palliative care discussions, the patient piped up with, “I could never ask my doctor about palliative care. I don’t want to disappoint him.” To which the oncologist remarked, “I could never talk to my patient about palliative care. They’d think I gave up.” Both of them needed permission and a path to honestly exchange information that they knew best.
Thus, the first and foremost means to access the resources available through patient self-mobilization is communication. The challenges associated with improving communication can seem immense, but so are the benefits. Aviation’s move from checklists to cockpit resource management to crew resource management was in response to the recognized need to improve flight crew communication. Changes in behavior were required by all crew members, regardless of their place in the hierarchy. This necessitated more than an intuitive leap and training was created to address the needed changes in behavior and culture. Fortunately, medicine’s Collaborative Conversation™ can play the same role.
There are many established approaches available to facilitate the other cultural and behavioral changes required for clinicians and patients. However, to maximize their effectiveness, the clinician must understand the patient’s level of engagement.
One tool that can be used to do this is the Patient Activation Measure (PAM) developed by Dr. Judith Hibbard. This tool helps clinicians understand where the patient feels they are on the continuum between needing to be passive to wanting to be an active participant in their health care. Modifying the interaction to the patient’s specific needs and abilities helps jumpstart the patient on their journey towards self-mobilization.
Once the initial level is understood, there are three broad categories of approach that make effective care resource mobilization: Patient Mobilization, Provider Mobilization, and Co-Creation. These approaches can work by themselves or in combination and vary in effectiveness depending on the patient’s level of engagement and activation.
Patient Mobilization methods include Motivational Interviewing, Shared Decision-Making and the Collaborative Conversation™ (for more details, follow the link to Collaborative Conversation™).
Provider Mobilization techniques include Practice Coaching, which helps practices improve in a variety of areas such as patient access, care coordination, team building and patient centeredness. These are areas of focus because improvement in these areas is proven to improve patient experience and outcomes. Another approach is Adaptive Leadership training, which can help clinicians recognize and take advantage of the opportunities embedded within changes in culture that occur as patients are increasingly self-mobilized.
Co-Creation melds the activation of patients into creating enhanced patient involvement. Peer coaching for chronic disease patients is one example.
At the core, all of these components need explicit permission from the experts to be part of the process. Remember there are two sets of experts involved here – clinicians and patients.
Whether it’s Crew Resource Management in aviation or Care Resource Mobilization in medicine, using all available resources on the team is a path to better outcomes. As medicine adopts this approach, it gets closer to its destination of better patient experience and population health at an affordable cost. Expediency is needed for the sake of our nation’s health and financial well-being.
But remember, CRM in aviation was introduced 30 years ago. What is aviation dealing with today and how can its failures and lessons help us face tomorrow (or should I say later today) in medicine? Part 3 will explore the next great challenge.
Read about the next great challenge in Part 3 – It’s Not Automatically OK.