Download OES / Organización Para la Excelencia de la Salud

Primer foro regional : “Logrando
la triple meta en salud”
Ciudad de Pasto, HUDN
Febrero 8 de 2013
OES / Organización Para la Excelencia
de la Salud
• Antes conocidos como Centro de Gestión Hospitalaria
• Somos una organización privada y sin ánimo de lucro
• Somos un centro de conocimiento para el mejoramiento de los
resultados de salud
• Hacemos investigación en salud con el ánimo de hacer mejores
preguntas
• Hacemos asistencia técnica en mejoramiento de la calidad como
parte de nuestro compromiso por desarrollar metodologías
aplicables y replicables
• Somos un centro de innovación de tecnologías de información
en salud, usamos las TICS para desarrollar soluciones que
contribuyan a mejorar los resultados de salud
• Somos un centro de difusión, formación y preservación de
conocimientos.
• Nuestros servicios son dirigidos a todos los actores del sistema
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2013
Agradecimientos y alcance
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2013
Agradecimientos y alcance
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2013
Agenda del día e invitados
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La triple meta . Qué es? Rafael Chaves OES
Papel regulador en la triple meta. Jose Luis Ortiz MSPS
Experiencia : Mejores resultados ambulatorios a menor costo. Carlos Tobar
JAVESALUD
Experiencia: Programa “Tu piel, mi piel” y su impacto en la experiencia del
paciente y su familia. Viviana Montenegro HUDN
Panel: Por dónde comenzamos?
Experiencia: Mejoramiento de la experiencia del paciente en el laboratorio
clínico. Lina Vallejos LABORATORIOS DEL VALLE
Experiencia: Beneficios del soporte nutricional en el paciente oncológico: Cómo
mejorar la atención del paciente. Mauricio Melo. ACODIN
Experiencia: Mejorando la experiencia del paciente a través del mejoramiento
institucional. Jaime Caicedo. HOSPITAL CIVIL DE IPIALES
Experiencia: Mejoramiento en el impacto de la disminución del riesgo del
componente materno infantil gracias al aprendizaje organizacional. Javier
Ruano. IDSN
La ética médica a través de la historia. Edgar Villota. UNIVERSIDAD SAN
MARTIN
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
Comentarios de inicio
• De donde sale esta iniciativa del foro regional
– IHI (Institute for health Care Improvement) y OES
– Encuentro latinoamericano de calidad y
seguridad
• Por qué es una que debemos perpetuar en el
tiempo?
– Crear una energía que aplauda el logro y
aprenda de él para la innovación y el
mejoramiento
• Cómo consolidar nuestro trabajo intersectorial?
• Busquemos la manera de crear una fuerza de
trabajo que se reúna cada año a mostrar logros
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
El liderazgo necesario de la
reforma de salud
Donald M. Berwick, MD
1st Annual Encuentro on Quality and Patient Safety
and
21st CGH International Forum
Cartagena, Colombia: June 20, 2012
Contexto Americano ? No será parecido
al nuestro?
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Presión económica de los actores
Polarización política
Pérdida de un diálogo auténtico
Confusión en el público
Incertidumbre del futuro
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Institute of Medicine: 2001
“Crossing the Quality Chasm”
“Between the health
care we have and the
care we could have
lies, not just a gap,
but a chasm.”
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The Institute of Medicine
Aims for Improvement
• Safety / Seguridad del paciente
• Effectiveness / Efectividad
• Patient-Centeredness / Enfoque
en el paciente
• Timeliness / Oportunidad
• Efficiency / Eficiencia
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Que tan peligrosa es la prestación de servicios de
salud?
(Professor Lucian Leape)
DANGEROUS
(>1/1000)
100.000
REGULATED
ULTRA-SAFE
(<1/100K)
HealthCare
Total lives lost per year
Driving
44,000 – 98,000
DEATHS PER YEAR
10.000
1.000
Scheduled
Airlines
100
Mountain
Climbing
Bungee
Jumping
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Chemical
Manufacturing
Chartered
Flights
European
Railroads
Nuclear
Power
1
1
10
100
1.000
10.000
100.000
Number of encounters for each fatality
1.000.000 10.000.000
Stages of Improvement
1. “The data are wrong.”
2. “The data are right, but it is not a
problem.”
3. “The data are right; it is a problem;
but, it’s not my problem.”
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“The First Law of Improvement”
Every system is perfectly
designed to achieve exactly
the results it gets.
-- Paul B. Batalden, MD
The Triple Aim: The Social imperative
Population
Health
Experience
of Care
Per Capita
Cost
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
Qué queremos lograr?
Cómo sabremos
que hay mejoramiento?
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Qué cambios podemos
Hacer que resulten en
mejores resultados?
Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
Why an Aim Statement?
Answers and clarifies “What are we trying
to accomplish? for the QI Project
Creates a shared language to
communicate about the project
Facilitates organizational conversations
and understanding
Provides a basis for developing the rest of
the project (measures and changes)
IHI, API, 2012
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Aim: What Are We Trying to Accomplish?
A team’s aim statement should include:
• What is expected to happen
• The system to be improved or the target
population
• Specific numerical goals
• Time frame
• Guidance for activities, such as strategies for
the effort, or limitations (include if appropriate)
IHI, API, 2012
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Aim Statement for Pain Management QI Team
Improve the pain management system for all
general surgical inpatients so that in seven
months:
• Patients’ experience of severe pain (as measured
by a pain intensity score of 7 to 10) is reduced by
25%
• 100% of patients will have their pain assessed
Guidance:
• Connect with the committee developing protocols
• Make education of patients and families a key
focus
IHI, API, 2012
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Population Segments
(Lynn J, Straube BM, Bell K, Jencks SF, Kambic RT
in Milbank Quarterly, Vol 85 No. 2, 2007, pp. 185-208)
Segment
% Population
% Costs
Healthy
52%
6.5%
Maternal & infant
3%
3%
Acutely ill mostly curable
4%
15%
Chronic condition, normal
function
36%
40%
Stable, significant disability
2%
14.5%
Short period of decline near
death
0.3%
2.5%
Organ system failure
0.7%
5%
Long, dwindling course
2%
13%
Population/Cost Segments
Source: Lynn J, Straube BM, Bell K, Jencks SF, Kambic RT in Milbank Quarterly, Vol 85 No. 2, 2007 (pp. 185-208)
Example Population Segments
• Everyone employed by your system (or some
other employer)
• Everyone in a particular health plan
• The population served by a medical home
• A capitated population, HMO, or potential ACO
population
• Broadly defined sub-populations, e.g.
– Elderly, working adults, individuals with medical and
social complexity, children
• Everyone in a particular geography (zip code,
county, state, HRR, etc.)
Qué queremos lograr?
Cómo sabremos
que hay mejoramiento?
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Qué cambios podemos
Hacer que resulten en
mejores resultados?
Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
Need for Measurement in
Improvement Efforts
Improvement is not about measurement. But
measurement plays an important role:
•Key measures are required to assess progress
on team’s aim
•Specific measures can be used for learning during
PDSA cycles
•Balancing measures are needed to assess whether
the system as a whole is being improved
•Data from the system (including from subjects and
staff) can be used to focus improvement and refine
changes
IHI, API, 2012
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Stages of Facing Reality:
Reaction to Data
“The data are wrong”
“The data are right, but it’s not a problem”
“The data are right; it is a problem; but it is not
my problem.”
“I accept the burden of improvement”
from Escape Fire, Don Berwick, (2002 Forum
Speech), page 287IHI, API, 2012
288
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Measurement principles:
a combination of art and science
The purpose of QI measurement is learning not
judgment.
Measures tell a story; goals give a reference point
Measures are one voice of the system. Hearing the voice
of the system gives us information on how to act with the
system
Measures should reflect the aim statement and make it
tangible
Seek usefulness, not perfection. Seek practicality rather
comprehensiveness.
IHI, API, 2012
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Potential Triple Aim Outcome Measures
11/09
Dimension
Measure
Population
Health
1. Health/Functional Status: single-question (e.g. from CDC HRQOL4) or multi-domain (e.g. SF-12, EuroQol)
2. Risk Status: composite health risk appraisal (HRA) score
3. Disease Burden: Incidence (yearly rate of onset, avg. age of onset)
and/or prevalence of major chronic conditions; summary of predictive
model scores
4. Mortality: life expectancy; years of potential life lost; standardized
mortality rates. Note: Healthy Life Expectancy (HLE) combines life expectancy
and health status into a single measure, reflecting remaining years of life in good
health. See http://reves.site.ined.fr/en/DFLE/definition/
Patient
Experience
1. Standard questions from patient surveys, for example:
-Global questions from US CAHPS or How’s Your Health surveys
-Experience questions from NHS World Class Commissioning or
CareQuality Commission
-Likelihood to recommend
2. Set of measures based on key dimensions (e.g., US IOM Quality
Chasm aims: Safe, Effective, Timely, Efficient, Equitable and Patient-centered)
Per Capita Cost 1. Total cost per member of the population per month
2. Hospital and ED utilization rate
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IHI, API, 2012
Data for a Monthly Measure
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Measure
83
80
81
84
83
85
68
87
89
92
91
IHI, API, 2012
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Family of Measures – Asthma Example
Use of appropriate
Anti-Inflammatory Meds
Written Action Plan
Symptom
Free Days
IHI, API, 2012
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Project Measure: Ambulatory Care
Sensitive Hospitalization Rate
Medicare Dual Eligible
Median T1 = 6.37
Median T2 = 5.37
Mann-Whitney test:
Time 1 vs. Time 2 p = .002
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Unit of measure is admissions per population per month
over time
System Measure: Overall Hospital
Utilization Rate
Central Tendency statistic = median
PCR = Primary Care Renewal, a Pt-Centered Medical Home
Transformation initiative led by CareOregon
Qué queremos lograr?
Cómo sabremos
que hay mejoramiento?
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Qué cambios podemos
Hacer que resulten en
mejores resultados?
Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
Developing a Change
Common problems when developing
changes:
1. More of the same – just try harder
with our current strategy
2. Utopia Syndrome – work to develop the
perfect strategy (paralysis of action)
IHI, API, 2012
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More of the Same Changes
•Trouble with meeting customer requirements –
add more resources
•Trouble with product … more inspections
•Trouble with variation in a process… make more
adjustments
•Trouble with adherence to procedure … add more
procedures or define more rigorously
•Trouble with discipline … add more restrictions
IHI, API, 2012
The Improvement
Guide, Chapter 6, p.
111
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Developing Changes
More of the Same
IHI, API, 2012
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What is Already in Your Portfolio?
• For your chosen population, what are you
doing now?
• Are there project goals that align with your
Triple Aim goals?
• Discuss at your tables for 5 minutes and
make some notes.
Building a TA Portfolio
Projects
Improved
Population Health
Achieving the
Triple Aim for
a Defined
Population
Enhanced
Experience of
Care
Reduced Per
Capita Cost
Building a TA Portfolio
Projects
Improved
Population Health
Achieving the
Triple Aim for
a Defined
Population
System
Measure
s
Enhanced
Experience of
Care
Reduced Per
Capita Cost
Project Measures
Building a TA Portfolio –
CareOregon Example
Building a TA Portfolio –
CareOregon Example
System
Measures:
•Total Cost
•Inpatient
Rates/Cost
•ED Rates/
Cost
Testing vs. Implementing
Testing – Trying and
adapting existing
knowledge on small scale.
Learning what works in
your system.
More Tests:
Including wide range
of conditionsdayshift/night shift
weekdays/weekends
different cultures
Implementation – Making this
change a part of the day-to-day
operation of the system in the
pilot site. (Usually after multiple
tests under a wide range of
conditions)
IHI, API, 2012
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Partipantes de proyectos en el mundo
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
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Propiedad intelectual OES - Organización para la Excelencia de la Salud ® Año 2012
Seven US Innovators
• HealthPartners
• Intel and Virginia Mason Medical Center
• CareOregon and Affiliated Clinics
• Blue Cross Blue Shield of Massachusetts
• Bellin Health
• University of Pittsburgh Medical Center
• Kaiser Permanente
NOS VEMOS EN 1AÑO CON SUS
PROYECTOS DEMOSTRATIVOS!
WWW.OES.ORG.CO
RCHAVES@OES.ORG.CO
Febrero 8 de 2013