barach talk.mab.final
TRANSCRIPT
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The Role of National Health Insurance in creating Safe,
Affordable, and High Quality Outcomes for Bahamians?
Paul Barach, MD, MPH
March 5, 2015 Medical Association of the Bahamas
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NHI: Key System Drivers
Health
Social Economic
Patient
Politics, regulations and agencies
2
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Vision of NHI
• The Government of The Bahamas is committed to transforming the healthcare systems into the safest, most effective and most compassionate provider of healthcare in the region.
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Wellness Model
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Slide: 5
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Mortality rates in PMH vary for public and private patients
263 deaths/
1781 admis
17 deaths
248 admis
270 deaths 9867
admis
6 deaths 1171
admis 15 deaths 2120
admis
0 deaths
44 admis
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• Lack of coordination, with providers in silos, fragmented service models
• Increasing Patient Expectations • Lack of active follow-up to ensure the best outcomes • Patients inadequately trained to manage their illnesses • Large variation in outcomes for patients • Very costly, unsustainable financial costs • Severe workforce issues • Lack of transparency of Outcomes and Scores • Discouraged, Unhappy Workforce
Bahamian Healthcare is challenged by:
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• “…the very first requirement in a Hospital [is] that it • should do the sick no harm.”
• – Notes on Hospitals, 1863
Florence Nightingale
It is all about the patient!
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Politics and medicine “Medicine is a social science and medicine is nothing but poli4cs on a grand scale”
Rudolf Virchow, (1821-‐1902) Prussian physician, one of the originators of the
cell theory, worked out the mechanism of pulmonary thromboembolism, wri4ng
about the 1848 typhus epidemic in Upper Silesia
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AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US
OVERALL RANKING (2013) 4 10 9 5 5 7 7 3 2 1 11
Quality Care 2 9 8 7 5 4 11 10 3 1 5
Effective Care 4 7 9 6 5 2 11 10 8 1 3
Safe Care 3 10 2 6 7 9 11 5 4 1 7
Coordinated Care 4 8 9 10 5 2 7 11 3 1 6
Patient-Centered Care
5 8 10 7 3 6 11 9 2 1 4
Access 8 9 11 2 4 7 6 4 2 1 9
Cost-Related Problem 9 5 10 4 8 6 3 1 7 1 11
Timeliness of Care 6 11 10 4 2 7 8 9 1 3 5
Efficiency 4 10 8 9 7 3 4 2 6 1 11
Equity 5 9 7 4 8 10 6 1 2 2 11
Healthy Lives
4 8 1 7 5 9 6 2 3 10 11
Health Expenditures/Capita, 2011** $3,800 $4,522 $4,118 $4,495 $5,099 $3,182 $5,669 $3,925 $5,643 $3,405 $8,508
COUNTRY RANKINGS
Top 2*
Middle
Bottom 2*
EXHIBIT ES-1. OVERALL RANKING
Notes: * Includes ties. ** Expenditures shown in $US PPP (purchasing power parity); Australian $ data are from 2010.Source: Calculated by The Commonwealth Fund based on 2011 International Health Policy Survey of Sicker Adults; 2012 International Health Policy Survey of Primary Care Physicians; 2013 International Health Policy Survey; Commonwealth Fund National Scorecard 2011; World Health Organization; and Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, Nov. 2013).
Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally
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Operations performed on Fridays were associated with a higher 30-day mortality rate than those performed on Mondays through
Wednesdays: 2.94% vs. 2.18%; Odds ratio, 1.36; 95% CI, 1.24–1.49)
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No system
beyond this point
10-2 10-3 10-4 10-5 10-6
Civil Aviation
Nuclear Industry
Railways
Chartered Flight
Drilling Industry
Chemical Industry (total)
Fatal risk
Anesthesiology ASA1
Innovative medicine (grafts, oncology …) ICU Trauma centers
Very unsafe Ultra safe
Professional fishing
Unsafe Safe
Hymalaya mountaineering
Combat A/C, war time
Medical risk (total)
Scheduled surgery Chronic care
Radiotherapy, Biology Blood transfusion
Finance Fire Fighting Food Industry
Processing Industry
Amalberti R. et al.: 5 System barriers to achieving ultra-safe health care. Ann Intern Med. 2005;142:756-764.
Average Rate per Exposure of Catastrophes and Associated Deaths in Various Industries and
Human Activities
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Assuming a system is 99.9% safe; How Safe is “Safe Enough” for surgery???
• 84 unsafe landings /day
• 1 major plane crash every 3 days
• 16,000 mail items lost/hr
• 37,000 bank transaction errors/hr
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14
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15
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IGNAZ SEMMELWEIS – USE OF CHLORINATED LIME HAND WASHING FOR PREVENTION OF PUERPERAL FEVER (THE MIDWIVES’ WARD LOWER THAN DOCTORS’)
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Semmelweis – the mortality rate in April 1847 was 18%; after hand washing was instituted in mid-May, the rate in July was 1%
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DR IGNAZ SEMMELWEIS’S FATE
Semmelweis was outraged by the indifference of the medical profession to pa4ent suffering and death ...
His contemporaries, including his wife, believed he was losing his mind, and in 1865 he was commiPed to an asylum..
He died there of sep4caemia only 14 days later, possibly from the result of being severely beaten by guards
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HH: hand hygiene. OT: operating theatre. NSG: non-sterile gloves. SG: sterile gloves Annelot C Krediet, et al. Hygiene Practices in the Operating Theatre: An Observational Study., BJA, 2011
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Normalized Deviance • By a deviant organizational behavior, we refer to “an
event, activity or circumstance, occurring in and/or produced by a formal organization, that deviates from both formal design goals and normative standards or expectations, either in the fact of its occurrence or in its consequences.”
• Once a community normalizes a deviant organizational practice, it is no longer viewed as an aberrant act that elicits an exceptional response; instead, it becomes a routine activity that is commonly anticipated and frequently used.
Diane Vaughan, 1999: 273. ; Barach, Phelps 2013
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How does it start? • The normalization literature distinguishes
between factors that lead to the genesis of organizational deviance and factors that cause deviance to become routine, rather than idiosyncratic, behavior.
• A permissive ethical climate, an emphasis on financial goals at all costs, and an opportunity to act amorally or immorally, all contribute to managerial decisions to initiate deviance.
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NHI- Donabedian Causal Chain
Lilford R J et al. BMJ 2010;341:bmj.c4413
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“If an error is possible, someone will make it. The designer must assume that all possible errors will occur and design so as to minimize the chance of the error in the first place, or its effects once it gets made” Norman, The Design of Everyday Things, 2001
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Slide: 24
The 93% vs. 7% Rule
Organizational Design 93%
Knowing Violations
Human Error (People)
Reckless Conduct (People)
Negligent Conduct
(People)
(People)
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Reason – Complex Systems
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TeamSTEPPS--Model of Multi-disciplinary Care Teamwork
Mutual Trust
Shared Mental Models
Closed Loop Communication
Team Leadership
Team Orientation
Back-Up Behavior
Adaptability
THE CORE
Baker, D, Salas E, Barach P, 2006, 2007
Mutual Performance Monitoring
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Four building blocks towards towards a “high reliability” healthcare
organization
The definition of a high reliability organization extends beyond patient safety to encompass quality care – and ultimately value.
‘High reliability’ organizations:
27
After Berg M and KPMG Report
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Stages in the development of a safety culture
CALCULATIVE We have systems in place to
manage all hazards
PROACTIVE Safety leadership and values drive
continuous improvement
REACTIVE Safety is important, we do a lot every time we have an accident
PATHOLOGICAL Who cares as long as
we're not caught
GENERATIVE (High Reliability Orgs) HSE is how we do business
round here
After Ron Westrum
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The Five Dysfunctions of Teams
After Patrick Lencioni, 2007
30
Absence of trust
Fear of Conflict
Commitment
Accountability
Results
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PopulaIon Health Management System of Care
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Benefits Package Building
Health needs (BOD)
Required Health Interventions
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Criteria Results Group 1: Dr. Charles Group 2: Dr. Weech Group 3: Dr. Neymour
1 Safety Essential Effective / efficacy / Cost-efficiency
2 Burden of disease Effective / efficacy Value-added
3 Essential BoD BoD
4 Cost efficiency Value-added Culture / Language
5 Efficacy Efficient / cost effective Essential
6 Resource Impact on Health System
Safety Resource Impact
7 Value added Resource impact Safety
8
9 ?Education / Prevention
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Benefits Package Building
Health needs (BOD)
Required Health Interventions
Criteria Definition Inclusion/exclusion
Benefits Package Draft
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Benefits Package Building
Guidelines and Protocols
Quality Assurance
Health needs (BOD)
Required Health Interventions
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Protocol Building for The Bahamas
• World Health Organization • NICE National Health Institute for
Health and Care Excellence • National Guidelines Clearinghouse
• http://www.eguidelines.co.uk • http://www.ncbi.nlm.nih.gov • http://www.leitlinien.de • http://www.library.nhs.uk • http://www.guidelines.gov • http://www.nice.org.uk • http://medicine.ucsf.edu • http://www.cks.library.nhs.uk • http://www.guiasalud.es
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Protocol Building for The Bahamas
Hypertension
Initial Encounter
Primary Care Enrolment
Clinical Management Age, comorbidity, medication
Phatmaceuticals, Laboratories,
Allied
Primary Health Care
Hospitals
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TIMELINE
February 28
March 1 to 13 group
meetings
March 14 to April 15 BP draft definition
April 16 to 27 Presentation
and incorporation of
comments
April 27 to 30 Final
Draft Delivered
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Vision of NHI
• The Government of The Bahamas is committed to transforming the healthcare systems into the safest, most effective and most compassionate provider of healthcare in the region.
Slide: 40
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Next frontier -- Wicked Challenges
• Access to all • Healing Environments • Work sharing and team work • Infection prevention • Culture of safety • Transitions of care
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Conclusion
• Barriers to change-culture eats strategy for breakfast (Peter Drucker)
Slide: 42
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References • More on topic and references for talk
see https://www.linkedin.com/in/paulbarach
• Key research papers are downloadable at Research Gate athttps://www.researchgate.net/profile/Paul_Barach/publications/?pubType=article&ev=prf_pubs_art
• Email me at [email protected] or contact me at Tel: 242 4289817
Slide: 43