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  • The Future of Value: Three Surgeons’ Perspectives
    rapid rise in publicly reported data on cost and process measure outcomes associated with pressure on health care entities to self report Demand by all purchasers of health care products for pricing transparency A rise of consumerism in health care whereby patients are becoming price sensitive and will therefore demand data on actual true cost of delivering their services Increasing involvement of the large self funded employers and their consortiums in health care reform initiatives using leverage and patient preference to influence this process and finally New payment methodologies such as episode based payments bundled payments and reference based pricing that will replace traditional fee for service models Thriving in this new environment which links payments to outcomes is risky without knowing the true cost of care delivery and outcomes achieved at the level of the clinical condition and over the full cycle of care What we need is a methodology for measuring true costs and patient centered outcomes and a way to link clinical and financial performance as we move forward Over the past year our care teams worked with 29 other organizations in IHI s Joint Replacement Learning Community to understand our costs improve outcomes and redesign care delivery In preparing for the changes ahead we learned together how to push forward in improving value The program and our colleagues that joined us provided us with the tools we needed to measure both costs and outcomes as well as identify opportunities for improvement Our collective experience in the Joint Replacement Learning Community solidified the need for every health care organization to imbed the value equation health care value patient reported outcomes cost of delivering those outcomes in their institutional culture Any services deemed not to be consistent with added health care value must be stripped from the condition specific care plan to reduce costs Patient reported outcomes related to their particular medical condition must be measured analyzed and employed to improve the patient s experience To survive and grow profitably health care entities will need to redesign their delivery processes This entails both an overhaul of clinical programs as well as perhaps for the first time taking stock of the outcomes they achieve and the actual cost of the services they provide Tags Quality Cost and Value Cost Containment and Reduction Health Reform in the US Blog Home Older Average Content Rating 1 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by William Fuller 3 26 2015 1 58 35 PM The value equation health care value patient reported outcomes cost of delivering those outcomes remains in my opinion largely undefined except in vague qualitative terms We are talking about pay for performance here and I have yet to see an equation that allows me as a patient to determine how much value I received for an episode If a patient reports no change in condition after treatment is the health care value 0 Should

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=130 (2016-02-01)
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  • A Simple Fix That Will Save Hundreds of Lives
    MD Senior Vice President Institute for Healthcare Improvement IHI Malawi It s amazing what a patient walk through can teach you Last week I went to a district hospital in central Malawi the prototype site for a 10 hospital quality improvement QI Collaborative to dramatically cut the death rate for preterm infants IHI recently was awarded a grant from the Bill and Melinda Gates Foundation to support our Malawian partner MaiKhanda and the Ministry of Health to tackle this problem Newborn death rates are about eight times higher here than in the US About half of these deaths occur in small or preterm infants The walk through took me to the Kangaroo Mother Care Unit a newly painted well fitted sanctuary for mothers and their newborn preterm infants Inspired by marsupials researchers in Colombia showed that death rates in preterm infants could be cut by 30 percent if a baby was swaddled 24 hours a day between its mother s breasts With only two neonatal intensive care units and few incubators in Malawi this is a simple no cost life saver Before and after a life saving intervention with Kangaroo Mother Care At first the room looked empty not a good sign since the six bed room should have been full based on the hospital s rate of prematurity On second look we saw a mother sitting on the floor between beds cradling a blanketed bundle Inside was a scrawny 1000g cold and dehydrated one week old infant transferred from an outlying clinic the previous day My sense was that he had less than a 50 50 chance of survival But it could and will be so different At my next visit in six months the room will be full because nurses inspired by new systems knowledge and the empowerment

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=17e9894b-377a-4f7f-8278-e2b17d86b4c6&ID=18 (2016-02-01)
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  • Meet a Regional Leader: Five Questions for Andy Carson-Stevens, MD
    get sick During my training to become a doctor I witnessed so many deviations from great care that I would not want for my own loved ones Sometimes the health care providers were conscious of those deviations and other times they were blinded by the norms of the system So what would it look like for an entire workforce to be driven to provide the kind of care they would want for their own loved ones A dream I think the IHI Open School can help make this dream come true When I discovered the Open School I found the courage to confront the status quo but peacefully Thought leader and educator Helen Bevan talks about rocking the boat and staying in it This is exactly what the Open School helped me to do it gave me the skills to identify an opportunity for improvement and to generate ideas for change that made sense to the multi professional teams I worked with as well as the tools to measure whether those changes made a difference all via a series of small developments and tests called PDSA cycles I learned that data and stories were powerful allies for driving improvement The IHI Open School course L 101 Becoming a Leader In Health Care taught me how to appear a helpful maverick rather than an unhelpful troublemaker As a community we can learn so much together that will help us improve the lives of so many more patients learning with from and about the experiences of other Open Schoolers who have rocked the boat and stayed in it Consider sharing your experiences today in the comments of this blog post 3 What was your best moment with the Open School community I was part of a group of Open School leaders that organized a patient safety campaign called Check a Box Save a Life to raise awareness and encourage uptake of the WHO Surgical Safety Checklist Researchers at Harvard had shown a checklist that promoted communication between multi professional teams in operating rooms could reduce harm by about 60 percent and avoidable deaths by nearly half We organized ourselves to mobilize the IHI Open School community to action This was back in 2009 when the Open School community only had a couple of thousand members We had no resources so used what we did have our fellow Open Schoolers to help build and spread the campaign to raise awareness and find ways for teams in hospitals to test out the checklist We shared some simple ideas via a launch call and then it really took off More than 2 000 students from different disciplines contributed to the campaign including public health nursing health administration IT medicine and others People found their own role in the campaign giving talks about it sharing copies of the journal article with department chiefs data collecting to demonstrate the need for change as well as creating apps to support this and even testing the checklist in operating

    Original URL path: http://www.ihi.org/education/ihiopenschool/blogs/_layouts/ihi/community/blog/itemview.aspx?List=9f16d15b-5aab-4613-a17a-076c64a9e912&ID=166 (2016-02-01)
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  • Struck by a Golf Ball — and by How Inefficient Emergency Departments Can Be
    the coffee tastes but how efficiently the coffee is delivered to her customers and how pleasant their experience is Another Saturday activity Visiting the ED One Saturday after my morning errands while playing a supposedly non contact game golf I was unfortunate enough to be hit by a golf ball The injury required attention at an emergency department Emergency departments just like banks car washes coffee shops and drugstores are queuing systems Each needs to match relatively fixed capacity to unscheduled demand notice I didn t say unpredictable demand As I waited in the emergency department that day I wondered if the people managing the department understood the science of operations management Did they understand the service time needed to match the predicted demand that Saturday for different acuity levels of patients Did they have the right models and staffing for lower acuity patients like me Did they apply the science to patient segments such as psychiatric patients and observation patients And did they have improvement projects underway to reduce the average service time and variation in service time There Is a Science to ED Operations The Institute for Healthcare Improvement IHI has focused on spreading the science of operations management to EDs for almost 10 years We have seen leaders in select emergency departments realize that good clinical care is not enough to ensure a safe and satisfying experience for patients These leaders especially when faced with increasing volumes also realize that they need to focus on the efficient and effective delivery of care that minimizes waits We think more emergency departments can benefit from this realization I finally did receive stiches that Saturday from a very competent clinician for an injury caused by a not so competent golfer Although I was pleased with the outcome I knew my experience in the emergency department could have been so much more satisfying just as my experience could be on any routine Saturday morning if the science of operations management had been optimally deployed Tags Quality Improvement ED Emergency Department Improvement Capability Blog Home Older Average Content Rating 1 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by Kevin Nolan 5 7 2015 1 45 46 PM Dorothy Thank you for the comment There is a financial impact of people leaving an emergency department here in the US More importantly though waiting in any emergency department is a safety issue People needing emergency care should not be sitting in a waiting room loading Did you find this user comment useful people found this user comment useful Report This by Dorothy Carson 3 25 2015 4 09 41 PM Hi Kevin Although I intuitively understand the notion of a satisfying experience for patients like most people I hate waiting too but from a rational perspective it is much easier for me to relate to a coffee shop needing to consider not only how good the coffee tastes but how

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=113a95c2-dffe-41ec-abee-93b4088068ac&ID=26 (2016-02-01)
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  • Hurting for Answers: The Challenge of How to Improve Pain Management
    what works for their patients Effective clinicians and teams help to improve the health literacy and competency of their patients They also communicate that they will consider the patient s safety first and foremost before an immediate quick fix These clinicians and teams are generally willing to use what works as long as the treatments have a very low risk of harm to the patient We need more and better options for treating pain but a lot of things can work For example there is evidence that indicates that acupuncture works for certain kinds of pain There is also extensive evidence that therapeutic exercise can help alleviate most kinds of chronic pain There s also some evidence that chiropractic and osteopathic manipulative therapy works for certain conditions and pains The most effective teams ultimately teach the patient to self manage their pain typically with the lowest possible dose of medication Most patients with chronic pain will tell you that they fear loss of control more than anything so giving the patient control can be an important component of effective pain management I want to be clear I am not suggesting that we should let patients determine what and how much they are prescribed Instead you describe the options that are safest the limits the pros and cons how much each option would be expected to impact pain and function and the consequences of each therapy on daily living Whether it is an opioid therapy meditation exercise or other option giving the patient the ability to weigh in on what they think they need to self manage within the constraints of safety can be empowering and very effective Q How do we find the right balance between addressing clinicians concerns about abuse addiction etc while also preventing unnecessary suffering There is no simple answer As a clinician you have to ask What are the factors contributing to this person s pain In patients on opioids we should ask why this person is taking or seeking an opioid Are they afraid of withdrawal Are they addicted In some patients we have to determine if they re seeking substances for non medical use This occurs infrequently but those who prescribe opioids for pain must consider it Everyone who takes opioids for long enough periods of time develops tolerance In some patients opioids can have long term implications even with relatively short duration of use So what do you do for the patient who says the only thing that will work is an opioid You treated them with pills before but now the patient is saying the pills aren t working like they did at first and they want a higher dose You aren t comfortable with that because you re worried about harming the patient You may be frustrated because you re not sure what to do next To help reduce non medical use and identify addiction monitoring is required with urine or blood testing pain contracts refill policies and database monitoring However

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=0f316db6-7f8a-430f-a63a-ed7602d1366a&ID=47 (2016-02-01)
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  • The One Thing You Need to Know about Match Day
    working toward a goal let a computer decide the outcome of these years of effort and then give the results out in a public forum It is a recipe for nausea and tears My own experience of Match Day was relatively benign I didn t have to walk alone across a stage open an envelope in front of hundreds of people and announce whether I had managed to match at the place that I wanted Thankfully instead my classmates and I walked into the auditorium together Lining the entryway were our families and friends cameras flashed babies cried and spouses looked excited and nervous Inside on rectangular tables lining the walls were the envelopes containing our futures With my husband at my side I pulled out the piece of paper with shaking hands While stress is inevitable in this unveiling the truth is that we medical students are part of what makes Match Day so upsetting It s hard to get to the end of medical school without being a control freak There are good reasons for that We skip the Thursday night party to study for our final in organic chemistry because we believe that our efforts control the outcome of that exam When we achieve the desired result time and time again it s easy to believe that we re the masters of our destiny We start thinking that if we just try hard enough our medical careers can proceed on the exact path that we desire But that is a dangerously seductive mirage Part of what makes Match Day so terrifying is that we re forced to watch that image dissolve Our futures are palpably out of our control and we re not good at handling that While the experience might be unnerving it is important Medicine is a career that deals in uncertainty You re about to encounter patient after patient whose life course has been abruptly and sometimes brutally diverted Your patients will live in the uncomfortable unknown So what can you learn from them that might help you cope with Match Day First some perspective On the spectrum of life problems these are good ones Really good ones Second that there is joy in embracing the moment Match Day is cause for celebration because it represents the culmination of years of hard work a triumph no matter what is written on the piece of paper you are handed And finally that if you think your life has been forced off track just hold on because sometimes these detours end up being pretty spectacular In life and in medicine your ability to turn challenges into opportunities your willingness to work hard your compassion for your colleagues and your patients these are the things that will bring you success and acclaim no matter where you end up Honestly My friends and I didn t all match at our top choices but I don t know a single one who isn t content with where she or

    Original URL path: http://www.ihi.org/education/ihiopenschool/blogs/_layouts/ihi/community/blog/itemview.aspx?List=9f16d15b-5aab-4613-a17a-076c64a9e912&ID=165 (2016-02-01)
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  • “78% of Americans have talked about advance care planning”: Too Good to Be True?
    advance care planning needs to operate as a system There need to be discussions about the person s preferences for end of life care a written plan and a named health proxy To respect and act upon these wishes this important information needs to be reliably available across health settings Too often a person has completed a document but it isn t available to health professionals or they haven t spoken to their loved ones about it Often the services that they value like palliative care hospice care or social supports aren t available Too often the health system isn t ready or able to respect their wishes because clinicians haven t been supported to develop the important skills needed for end of life care An effective advance care planning system requires all of these interdependent elements to be available Think of Susan a 45 year old woman with lung cancer who is allergic to penicillin She s well known to the health professionals caring for her Imagine that she tells no one about her allergy Or that she tells someone about it but it isn t recorded in her electronic medical record Susan gets pneumonia and is taken to the emergency room unconscious unable to speak for herself There she is given a penicillin based antibiotic by those who have cared for her for years and are wanting to do their best by her but don t have this important information Care which she doesn t want and which will be harmful to her It s hard to imagine this happening We provide excellent training for health professionals on allergies We have systems for checking and tracking allergies ensuring we treat each patient the way they need to be cared for The electronic medical record allergy field can t be blank If it was clinicians would be outraged I don t know how to care for this patient without knowing what their allergies are is the likely comment The reality is that we wouldn t let this happen with an allergy so why do we let it happen at the end of life our final opportunity to get care right Part of the reason is that many find these conversations difficult to initiate There are some great initiatives encouraging and supporting families to have these conversations including The Conversation Project with resources to help people explore what s important to them and talk about their wishes with their loved ones Initiating and having the conversation is difficult for health professionals as well They need support to have end of life discussions to develop the skills to manage these conversations well They need the time to have the conversations Medicare now has a code for these conversations but has yet to pay for them Proponents say the way to start valuing these conversations is to pay for them requiring input from policy makers and funders Ensuring that an individual s preferences are conveyed to everyone caring for them means this

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=113a95c2-dffe-41ec-abee-93b4088068ac&ID=25 (2016-02-01)
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  • There’s a Hole in the Bucket
    and then taking progressive action that a better system can be built There are parallels with the implementation of electronic health records EHR EHR and advance directives are both useful tools and both are prone to the wishful thinking that the tool itself will somehow reconfigure all the standard work needed to reliably provide excellent care When responding to the colleague who posed the question my mind bounced between the children s book If You Give a Mouse a Cookie and the children s song There s A Hole in the Bucket because as in the story and the song one thing inevitably leads to another For the work undertaken by the Conversation Ready teams there are many parts to consider when working to improve processes From the patient s perspective They have or have not thought about their own end of life care wishes They have or have not shared these wishes with their loved ones and their health care providers They have or have not recorded these wishes formally in some legal document From the provider s perspective They have or have not proactively engaged with their patients about this topic They have or have not asked if their patients have had any end of life conversations with their loved ones They have or have not asked for any documents the patients may have executed to document their end of life wishes If the providers have information it is or is not stored in the patient s record If the information is stored it is or is not readily accessible and clear I f the information is readily accessible it is or is not referenced at the appropriate time which could be years after it was first generated Have you started to hum There s A Hole in the Bucket With what shall we fix it Ultimately there are many ways to become Conversation Ready Organizations can start where they have the greatest amount of will and strategic synergy and they can align their actions with projects already in motion e g tackling readmissions strengthening relationships with up and down stream health care partners improving patient centered care and building partnerships with community agencies beyond health care The trick is to start somewhere Start digging Follow a patient through their admission and learn what they are and are not asked about advance directives and what is done if anything with the information provided Go through the charts of the last few deaths in your organization search for information about those patients end of life care wishes and see if those wishes were part of their care Start to ask your colleagues about their own experiences in having end of life care conversations with patients and with their own loved ones Start somewhere In the months ahead we look forward to sharing the learning of the two years of Conversation Ready work more formally through the publication of an IHI White Paper If you have started this work in

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=128 (2016-02-01)
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