![Page 1: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/1.jpg)
D e c e m b e r 9 , 2 0 1 3
I n s t i t u t e f o r H e a l t h c a r e I m p r o ve m e n t
O r l a n d o , F L
Vi ka s S a i ni , M .D.
Pres iden t , Lown Ins t i tu te
REMOVING WASTE FROM
HEALTH CARE: LESSONS FROM
CHOOSING WISELY AND THE
RIGHT CARE ALLIANCE
![Page 2: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/2.jpg)
� Origins in the Avoiding Avoidable Care conference 2012
� A newly established initiative of the Lown Institute
� Attempting to build a social movement within the medical
community and beyond for change in health care delivery
THE RIGHT CARE ALLIANCE
![Page 3: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/3.jpg)
Overuse is a pervasive cultural phenomenon.
Avoiding overuse and underuse is an ethical obligation.
Delivering the right care will result in the right amount of spending.
GETTING TO THE RIGHT CARE:
A POINT OF VIEW
![Page 4: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/4.jpg)
� Overuse is a target rich environment for Quality Improvement
� Choosing Wisely lists are clear, more or less uncontested, measurable, and subject to QI efforts
� Not a traditional error of the quality and safety movement
� Harms are colored by a presumption of benefit , casting any adverse event as a downstream target for improvement
GETTING TO THE RIGHT CARE: NOT SO
EASY
![Page 5: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/5.jpg)
� Placement of a PA catheter was not in and of itself a medical
error
� Indeed, it was an unofficial standard of care for over a decade
� One could systematically try to reduce the complication rate,
the infection rate, etc. of PA catheters placed…….
THE CASE OF PULMONARY ARTERY CATHETERS
![Page 6: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/6.jpg)
KAPLAN-MEIER SURVIVAL CURVES TO ONE YEAR
PA CATHETERS VS STANDARD CARE
Sandham, J. et al. N Engl J Med 2003;348:5-14
![Page 7: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/7.jpg)
� We will miss the question: is this even needed?
� That question is an upstream target for improvement
THE RISK OF NOT FOCUSING ON OVERUSE
![Page 8: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/8.jpg)
� Some core propositions:
� Unnecessary care increases risk of harm without net benefit
� Can violate patient preferences and cause “wrong patient error”
� For any test or treatment there is a population distribution of benefit and harm
� There is also a population distribution of risk tolerance and treatment preferences
� The right care is always to be found in this 2-D matrix.
OVERUSE IS A QUALITY AND SAFETY ISSUE
![Page 9: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/9.jpg)
� Appropriateness of clinical decision-making
is or should be a quality metric
� Degree of patient-centered decision-making
is or should be a quality metric
OVERUSE AS A QUALITY AND SAFETY ISSUE
![Page 10: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/10.jpg)
69 yo male lawyer told he needed CABG surgery
History of CHF, Afib, PAD
� 3 nuclear scans, 3 echos, 2 cardiac caths over 1 year
� No angina, good exercise tolerance, doesn’t want surgery
� AUC criteria of the American College of Cardiology:
Appropriate for Surgery
Lown opinion: defer surgery
A SECOND OPINION
![Page 11: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/11.jpg)
� Deferring surgery: Attending to the patient’s preference, but
within the doctor’s comfort zone of “OK and safe to do this”
� Regardless of the doctor’s comfort zone, if the patient makes
an informed decision and decides against a procedure, isn’t
that always the “right” decision?
GETTING TO THE RIGHT CARE: 2ND OPINION
CASE
![Page 12: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/12.jpg)
WHAT’S THE RIGHT RATE?
![Page 13: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/13.jpg)
� RCTs of Shared Decision Aids consistently show 20% drop in demand for procedures such as PCI or knee surgery
� 400,000 elective PCIs; 1-2% serious adverse events
� With SDM, 80,000 fewer PCIs; 800-1,600 harmed inappropriately?
� 1,015,000 hip knee arthroplasties; with SDM, 253,750 fewer; 17,500 harmed?
WRONG PATIENT ERROR*
*J. Wennberg and A. Mulley
Morgan, M.W., et al., J Gen Intern Med, 2000. 15(10): p. 685-93.
Arterburn, D., et al., Health Affairs, 2012. 31(9): p. 2094-104.
Feldman, D.N., et al., Am J Cardiol, 2006. 98(10): p. 1334-9; Boden, W.E., et al., N Engl J Med, 2007. 356(15): p. 1503-
16.
Cushner, F., et al., Am J Orthop, 2010. 39(9 Suppl): p. 22-8.
![Page 14: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/14.jpg)
� Paulo Borem, Unimed, Brazil
� Nadia Chambers, NHS, UK
ACHIEVING RIGHT CARE AROUND THE WORLD
![Page 15: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/15.jpg)
Promoting Healthier Moms and Babies by achieving
40% of Natural Child Birth among Unimed Jaboticabal’s
clients by August 2013
A Project Pilot to drive
the change for 20 million
clients
Quality Innovation Center UnimedPaulo Borem, MDIHI Improvement Advisor
![Page 16: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/16.jpg)
A Success
Story of
Mobilisation
![Page 17: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/17.jpg)
THE NHS’ RIGHT CARE CALL TO ACTION:
WHAT HAVE THEY ACHIEVED AND HOW?
Articulated an unacceptable situation
Agreed on a shared goal
Mobilised a constituency
Organised and Strategised
Measured Improvement
![Page 18: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/18.jpg)
� Developed systems that did not previously exist
� Audit demonstrated low diagnosis rates (30-40%)
� 72,000 people with a diagnosis of dementia on antipsychotics
� 80% had a clinical review
� National audit showed a 52% decrease in prescribing
� The Right Care Call to Action cited as making a significant contribution to achieving this.
DEMENTIA CARE – THE RIGHT PRESCRIPTION
OUTCOMES 2011-12
![Page 19: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/19.jpg)
�Reduce underuse, overuse, and misuse
�A renewed sense of purpose and
professionalism
�An alliance with the public
�Working together to change culture
GOALS OF THE RIGHT CARE ALLIANCE
![Page 20: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/20.jpg)
� Annual meetings
� Building a multispecialty, multi-professional network for taking action
� Medical Education Initiatives
� Designing a public engagement process
� Developing a research agenda
ACTIVITIES OF THE RIGHT CARE ALLIANCE
![Page 21: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/21.jpg)
� Choosing Wisely
� American Medical Students Association
� National Physicians Alliance
� Emerging International Contacts
COLLABORATIONS
![Page 22: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/22.jpg)
� www.rightcaredeclaration.
org
AN ORGANIZING TOOL
![Page 23: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/23.jpg)
� The lists we have are the tip of an iceberg of culture and a way of thought of “more is better”
� Long journey, many complexities
� Much required innovations of measurement, of intervention, and of assessment
� Primary responsibility lies with healthcare professions
A VAST LANDSCAPE OF CHALLENGES
![Page 24: REMOVINGWASTEFROM HEALTH CARE: …app.ihi.org/FacultyDocuments/Events/Event-2354/Presentation-9203/...REMOVINGWASTEFROM HEALTH CARE: LESSONS FROM ... For any test or treatment there](https://reader031.vdocuments.net/reader031/viewer/2022030718/5b036cba7f8b9ab9598f5736/html5/thumbnails/24.jpg)
“Customer expectations? Nonsense. All customer
expectations are only what you have led him to
expect. He knows nothing else.”
Last published interview of W. Edwards Deming, January 17,
1994; Industry Week magazine
PATIENT ROLE, PROVIDER ROLE